Child's Nervous System

https://doi.org/10.1007/s00381-020-04661-z

ORIGINAL ARTICLE

The scalp block for postoperative pain control in craniosynostosis

surgery: a case control study
Rossano Festa 1 & Federica Tosi 1 & Angela Pusateri 1 & Sonia Mensi 1 & Rossella Garra 1 & Aldo Mancino 1 &
Paolo Frassanito 2 & Marco Rossi 1,3

Received: 10 February 2020 / Accepted: 4 May 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose Postoperative analgesia after corrective surgery of pediatric craniosynostosis is crucial in terms of short- and long-term
outcomes. The objective of this observational study was to evaluate the effectiveness of an analgesic technique based on the scalp
block versus traditional pharmacological approach.
Methods Thirteen patients, aged between 3 months and 2 years, undergoing surgical correction of craniosynostosis, received
scalp nerve block before awakening (scalp block group). This group of patients was compared to a second group of 13 patients,
retrieved from our database, treated with the traditional pharmacological approach (control group). Pain scores, need of rescue
therapy, resumption of oral nutrition, degree of parent satisfaction at discharge, and length of stay in the Pediatric Intensive Care
Unit (PICU) and in the hospital were compared between the two groups.
Results Objective Pain Score values were significantly lower in patients treated with scalp block at 30 min and at 8 h after
extubation. The number of pharmacological interventions for the treatment of pain in PICU was significantly higher in Control
group. Children in Scalp block group started earlier oral feeding than in Control group, both for clear fluids and milk. Length of
stay in PICU was longer in Scalp block group than in Control group, though the difference between the mean data in the two
groups is about 3 . This difference does not seem significant from a clinical standpoint, since it seems more related to logistic
issues (e.g., availability of bed in the Pediatric Neurosurgery Unit, presence of a parent), rather than clinical problems
contraindicating the discharge from PICU. Indeed, the overall hospital length of stay was similar between the two groups.
Conclusion Scalp nerve block was effective for immediate postoperative pain control in patients younger than 2 years who
underwent cranioplasty for craniosynostosis. The best pain control compared to conventional therapy allowed to limit the need
for rescue analgesics in PICU and an earlier recovery time.
ClinicalTrials.gov Identification: NCT04133467

Keywords Craniosynostosis . Local anesthesia . Pain assessment . Personalized medicine . Postoperative pain . Scalp block

Introduction

Corrective surgery for craniosynostosis in infants includes a

variety of procedures, with different degree of invasiveness,
ranging from less invasive “stripping” procedures to open
* Paolo Frassanito
paolo.frassanito@gmail.com cranial remodeling ones [8, 9, 15, 26]. Several studies on the
anesthesiological management of craniosynostosis have been
1
published, the majority of them focusing on the perioperative
Anesthesia and Intensive care, Fondazione Policlinico Universitario
Agostino Gemelli IRCSS, Rome, Italy
management of blood loss and avoidance of hemorrhagic
2
shock. Other anesthetic issues are metabolic and electrolyte
Pediatric Neurosurgery, Fondazione Policlinico Universitario
Agostino Gemelli IRCSS, Largo Agostino Gemelli, 8,
disturbances [11, 25, 29]. On the other hand, the perioperative
00168 Roma, Italy management of pain is frequently under-evaluated, despite the
3
Dipartimento di Scienze dell’emergenza, anestesiologiche e della
extensive surgical manipulation of cranial structures. On these
rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy grounds, literature data concerning assessment and

management of postoperative pain in this particular surgical
setting is scarce [28].
Assessment of pain in infants is challenging and often re-
lies on clinical observation. To date, there are no evaluative
and therapeutic parameters universally accepted in this age
group [2]. Therefore, a degree of interaction between parents
on one side and medical and nursing staff on the other be-
comes essential, especially considering that these infants are
transferred after surgery to the Pediatric Intensive Care Unit
(PICU).
The analgesic drug of choice for postoperative pain treat-
ment is paracetamol, administered either rectally or orally. An
anti-inflammatory agent may be eventually added, even
though it could increase the risk of postoperative bleeding.
Other studies pointed out a possible role for opioids in con-
trolling postoperative pain [13, 30, 31], but over-sedation
should be avoided.
The scalp nerve block (SNB) is a regional anesthetic tech-
nique, performed for several years in children undergoing a
variety of procedures, from neurosurgery to eye-nose-throat
surgery [10].
This observational study sought to evaluate, in patients
undergoing surgical correction of craniosynostosis, the effec-
tiveness of an analgesic technique based on SNB compared to
the traditional pharmacological approach, in terms of im-
proved pain relief and outcomes.
Materials and methods
From January to June 2016, we enrolled 13 patients, aged
from 3 months and 2 years, undergoing surgical correction
of craniosynostosis. An informed consent was obtained from
both parents. Exclusion criteria were reported allergies to local
anesthetics and/or analgesics; specific drug therapies (pain
relievers, sedatives, and/or epileptic); denied consent to the
study; development of postoperative intracranial bleeding
and/or gastrointestinal bleeding; need of nasogastric tube;
and development of gastrointestinal infections.
All the 13 patients were subjected to SNB (group SB) with
levobupivacaine 0.125% (total dose 2 mg/kg) [19], performed
before awakening, in combination with intraoperative intrave-
nous acetaminophen (15 mg/kg if body weight > 10 kg,
7 mg/kg if body weight < 10 kg).
SNB technique
The SNB procedure was performed using the modified
Pinosky technique [4, 22], with levobupivacaine 0.125%. A
targeted infiltration of 0.75–2 ml of local anesthetic (LA) so-
lution was done at multiple sites with a 23G needle.
Firstly, the supraorbital and supratrochlear nerves were
blocked at their emergence from the orbit with LA infiltrated
Childs Nerv Syst
above the eyebrow. The auriculotemporal and great auricular
nerves were both blocked with LA injected anteriorly and
posteriorly to the ear at the level of the tragus, respectively.
The zygomaticotemporal nerve was blocked by an injection of
LA lateral to the orbit. Finally, the greater, lesser, and third
occipital nerves were blocked collectively with a single injec-
tion of LA along the superior nuchal line at the midpoint
between inion and mastoid process (Fig. 1).
Control group
A second group of 13 patients (group ST), operated on from
January to December 2015, was retrieved from our database.
All of them have been treated with the traditional pharmaco-
logical approach intraoperatively, based on intravenous acet-
aminophen according to the body weight, plus intravenous
tramadol 1 mg/kg.
Anesthetic management and surgical procedure
The anesthetic management was the same in both groups,
except for pain control. Inhalation induction was performed
with a mixture of sevoflurane and oxygen, while for the main-
tenance a balanced anesthesia with sevoflurane (MAC 1), ox-
ygen and air associated with intravenous fentanyl adminis-
tered in refracted doses, was chosen.
Concerning the surgical technique, patients with an early
diagnosis of scaphocephaly were operated with the
mininvasive technique conceived and routinely used by our
pediatric neurosurgery staff, which has been described else-
where [15]. Other craniosynostosis type was operated with
open cranial vault remodeling surgery [8].
Postoperative management and pain evaluation
At the end of surgery, all the patients enrolled in the study
were awoken, extubated, and subsequently admitted to the
PICU. All patients in both groups received fixed doses of
acetaminophen, 10 mg/kg every 8 h. If there was still pain,
the attending physician was allowed to administer tramadol at
1 mg/kg every 12 h or ketoprofene 1 mg/kg every 8 h [24].
The evaluation of pain intensity for pediatric surgery in our
institution is traditionally assessed by Objective Pain Score
(OPS) four items [18], with pain scores obtained at fixed times
in the postoperative record chart. OPS includes four pain be-
haviors (crying, movement, agitation, and verbalization) and
blood pressure change. For each of these categories, a score
from 0 to 2 is assigned, being 4 the threshold to start or adapt a
pain treatment.
In the present study, OPS was detected at the following
times:
& 30 min after extubation (T0),
Childs Nerv Syst
Fig. 1 Scalp nerve block using the Pinoski technique—supratrochlear
and supraorbital nerve block (a), auriculotemporal nerve block (b),
greater auricular nerve block (c), zygomaticotemporal nerve block (d),
& 2 h after extubation (T1),
& 4 h after extubation (T2),
& 8 h after extubation (T3),
& at discharge to the Pediatric Neurosurgery Unit (T4).
In the Pediatric Neurosurgery Unit, OPS was assessed by
the nurse at the beginning of each round, namely three times
per day, until the fifth day of hospitalization.
Postoperative administrations of an analgesic medication
for pain relief (paracetamol, tramadol, morphine) were decid-
ed by the medical staff according to patient need and subse-
quently recorded.
Other evaluated outcomes were:
– The timing to resume the oral nutrition and
– The degree of parent satisfaction at discharge using the
Quality of care Questionnaire by Arnetz and Arnetz [3,
32], which is always collected as institutional policy.
Statistical analysis
The data was processed with GraphPad Prism 7.0 for MacOs.
lesser occipital nerve block (e), greater occipital nerve block (f), third
occipital nerve block (g)
The resumption of nutrition, the length of stay in PICU, and
the length of stay in hospital were analyzed with the
Kolmogorov-Smirnov test; OPS variations between the two
groups (expressed as median and interquartile ranges) were
compared with the Mann Whitney test.
The Mann Whitney test was used to assess differences in
the approval ratings expressed by family members at dis-
charge, between the two groups.
All tests are double-tail with a significance of 5%.
We calculate that a sample size of 13 patients in each group
would have 80% power at a 5% significant level to detect a
difference in OPS at extubation of 2 among groups, assuming
that in our database OPS was 4 (IQR 3–6) in patients treated
with standard therapy.
Results
The two groups were homogeneous for gender (group ST 6
females and 7 males vs group SB 5 females and 8 males) and
other demographic data. Moreover, type of craniosynostosis,
type of surgical procedure, and duration of surgery showed no
significant differences between the two groups. In particular, 7
out of 13 patients underwent mininvasive procedure for
 Childs Nerv Syst

scaphocephaly in group SB and 6 out of 13 in group ST Table 2 Pain scores in PICU

(Table 1). The two groups of patients received similar Pain evaluation in PICU (median, IQR)
amounts of fentanyl intraoperatively (group ST 26.8 ±
11.4 Jg vs group SB 29.2 ± 8.3 Jg, n.s.). Group ST Group SB p value U value η2 value
Highly statistically significant lower OPS values were ob-
OPS (T0) 4 [3–6] 0 [0–2] < 0.001 15.000 0.545
served in patients treated with SNB at T0 (group SB 0 [CI
OPS (T1) 3 [0–4.5] 0 [1–1.5] 0.11 56.500 0.108
0.07–1.72] vs group ST 4 [CI 3.19–5.58], U = 15.000, η2 =
OPS (T2) 3 [0–4.5] 3 [0–4] 0.85 80.500 0.002
0.545, p < 0.001). Lower OPS was observed also at T3 (group
OPS (T3) 3 [0–5.5] 0 [3–3.5] 0.05 49.000 0.153
SB 0 [CI 0.02–2.60] vs group ST 3 [CI 1.73–4.73], U =
OPS(T4) 3 [0–4] 0 [0–3] 0.19 60.500 0.070
49.000, η2 = 0.153, p = 0.05) (Table 2).
OPS values collected in the Pediatric Neurosurgery Unit T0 30 min after extubation, T1 2 h after extubation, T2 4 h after
did not differ significantly between the two groups, though a extubation, T3 8 h after extubation, T4 discharge from PICU
lower trend was observed in group SB (Table 3).
The number of pharmacological interventions for the treat-
ment of pain in PICU was higher in group ST (4 [CI 2.73–
5.73]) than in group SB (3 [CI 1.55–3.22]) (U = 47.500, η2 = group ST 12.8 h [CI 9.4–16.1]; Z = 2.157, η 2 = 0.204,
0.148, p = 0.05), though this difference did not reach statistical p < 0.01) (Fig. 2).
significance. The need for additional analgesics during hospi- Finally, no differences were found between the two groups
talization in the Pediatric Neurosurgery Unit did not show regarding the parent satisfaction at discharge (Table 4).
significant differences (group ST 6 [CI 5.44–8.10] vs group
SB 5 [CI 4.55–6.37], p = 0.08). In all cases but two, tramadol
1 mg/kg was the chosen analgesic. Discussion
The length of stay (LOS) in PICU showed a weak evidence
of being longer in group SB (21.1 [CI 19.5–22.8]) than in In the last years, the Enhanced Recovery After Surgery
group ST (18.1 [CI 15.8–20.4]), Z = 1.373, η2 = 0.075, p = (ERAS) approach has been proposed. This approach is based
0.04, while the hospital LOS was comparable between the on a combination of evidence-based perioperative items, in-
two groups (group ST 104.1 [CI 94.5–113.6] vs group SB cluding a multimodal, opioid-sparing postoperative analgesia,
(107.5 [CI 87.6–127.5]), Z = 0.588, η2 = 0.014, p = 0.87. aiming to allow a fast recovery and a return to the preoperative
Additionally, no episode of vomiting was detected in group quality of life as early as possible [5, 6]. These aspects are
SB, in comparison with two patients in group ST. Patients in fairly attainable in adult patients undergoing surgery, whereas
group SB demonstrated a strong evidence of an earlier oral it is not always easy to identify appropriate outcome parame-
feeding than in group ST, for both clear fluids (group SB 2.6 h ters to define optimal postoperative recovery for pediatric pa-
[CI 2.1–3.1] vs group ST 8.9 h [CI 4.8–12.9]; Z = 1.961, η2 = tients. Dealing with very young patients, the communication
0.154, p = 0.001) and milk (group SB 3.7 h [CI 2.8–4.6] vs limits are fair, so the detection of pain is usually given through
parental assessment and the use of analgesic drugs is some-
times conditioned by fear, lack of knowledge, and of “evi-
Table 1 Demographic data and types of craniosynostosis dence-based” guidelines [2], with obvious risk of under- as
Group ST (n.13) Group SB (n.13) well as over-treatment of pain.
In infants affected by craniosynostosis, these aspects are
Gestational age (weeks ± SD) 38.5 ± 3.8 39.8 ± 1.0 strikingly evident.
Age (months ± SD) 6 ± 3.4 7.8 ± 7.2 Furthermore, the difficult evaluation of pain in this age
Weight (kg ± SD) 7.6 ± 1.9 8.5 ± 2.5 group may partly explain why literature data on pain care after
Duration of surgery (min ± SD) 119 ± 33 130 ± 59 surgical correction of craniosynostosis are scarce.
Type of craniosynostosis, n (%) In the traditional approach of these patients, after a bal-
Scaphocephaly 6(46.2) 8(61.5) anced anesthesia, the use of acetaminophen with an
Trigonocephaly 3(23) 2(15.4) analgesic/anti-inflammatory agent is usually required. An im-
Right anterior plagiocephaly 2(15.4) 1(7.7) portant issue is to avoid over-sedation after the extubation,
Left anterior plagiocephaly 0(0) 1(7.7) although some studies used the morphine or other strong opi-
Complex craniosynostosis 2(15.4) 1(7.7) oids [24, 30, 31]. A recent retrospective survey of 57 children
Type of corrective surgery, n (%) scheduled for surgical repair of primary craniosynostosis
Mininvasive procedure 6(46.2) 7(53.8) showed that a parent-/nurse-controlled analgesia during the
Open cranial remodeling 7(53.8) 6(46.2) first 24 h with fentanyl and a rectal transition with oxycodone
in the first two postoperative days provided a good pain
Childs Nerv Syst

Table 3 Pain scores in Pediatric

Neurosurgery Unit Pain evaluation in Pediatric Neurosurgery Unit (OPS: median, IQR)

Postoperative day Detection Group ST Group SB p value U value η2 value

#1 #1 3 [1–3.5] 1 [0–3] 0.068 48.000 0.284
#2 4 [3–5] 3 [2–3.5] 0.271 62.500 0.101
#3 4 [1.5–4.5] 3 [0–3.5] 0.153 56.500 0.166
#2 #1 4 [2–5] 2 [1–4] 0.069 48.500 0.276
#2 1 [0–5.5] 0 [0–4] 0.364 66.500 0.067
#3 0 [0–4.5] 0 [0–0] 0.135 54.500 0.191
#3 #1 1 [0–3] 0 [0–0] 0.092 51.000 0.239
#2 0 [0–2] 0 [0–0] 0.465 64.000 0.045
#3 0 [0–0] 0 [0–0] 0.190 53.500 0.142
#4 #1 0 [0–0] 0 [0–0] 0.303 40.000 0.087
#2 0 [0–0] 0 [0–0] 0.412 10.000 0.056
#3 0 [0–0] 0 [0–0] 0.927 15.000 < 0.001

control without affecting the recovery time [14]. Other studies
showed a tendency for opioid avoidance, but nausea and
vomiting still represent an important challenge in the postop-
erative care. Intravenous administration of non-narcotic drugs
seems to be a good choice for an effective full dose delivery
and less vomiting episodes. In our experience, tramadol could
represent an effective and safe combination for these patients,
thanks to its two mechanisms of action, namely serotonin
reuptake inhibition and weak J receptors agonism.
Accordingly, it was routinely used in combination with acet-
aminophen in our traditional approach (control group).
The present study shows that the implementation of SNB in
the anesthetic management of infants undergoing surgery for
craniosynostosis may warrant a better pain control in the first
postoperative hours and subsequently after the discharge from
PICU to the Pediatric Neurosurgery Unit. OPS values, in fact,
was reduced from the median value of 4, which represent the
starting point for an analgesic treatment, to a median value of
0 in the experimental group, which corresponds to pain ab-
sence. The better pain control was confirmed by a minor need
for additional analgesics and resulted in an earlier resumption
of oral feeding.
This may obviously minimize the stress of the patient,
aiming to enhance his recovery after surgery.
The SNB is an underutilized technique, which has the ad-
vantages to be easy to perform, minimally invasive, and asso-
ciated to minimal adverse effects [12]. We used the modified
“extended” technique, blocking also the third occipital nerve
[3, 22], aiming to offer the most complete pain coverage of the
posterior scalp after the surgical correction.
The block was performed with levobupivacaine without
epinephrine. Although the procedure is not considered innoc-
uous [1], no complication was observed in our experience.
SNB was performed after surgery and before extubation, in
the operating room. This timing was chosen in order to allow
better local anesthetic absorption and minor dispersion in the
surgical field, thus warranting the longer lasting of pain relief
effect after surgery and minimizing the need for additional
analgesics. Indeed, a previous literature experience using a
preoperative block in a population of 32 young patients sched-
uled for craniosynostosis repair did not allow to avoid mor-
phine requirements in 82% of them at awakening from anes-
thesia [20]. Similarly, preoperative SNB reduced the intraop-
erative remifentanil requirement but failed to reduce the use of

Fig. 2 Recovery of oral feeding

in the two groups (* = statistically
significant)
 Childs Nerv Syst

Table 4 Parent satisfaction at

discharge Arnetz&Arnetz Quality of care questionnaire

Group ST Group SB p value U value η2 value

Information—illness 3 [3–3] 3 [3–3] 0.756 78.000 0.008

Information—routines 4 [2.5–4] 4 [3–4] 0.718 77.000 0.011
Accessibility 0 [0–0] 0 [0–0] 0.976 84.500 < 0.001
Medical treatment 4 [3.5–4] 4 [3–4] 0.833 80.000 0.003
Caring processes 8 [8–8] 8 [8–8] 0.779 78.500 0.007
Staff attitudes 8 [8–8] 8 [8–8] 0.976 84.500 < 0.001
Participation 4 [4–4] 4 [4–4] 0.976 84.500 < 0.001
Staff work environment 7 [7–8] 8 [7–8.5] 0.575 73.000 0.026

longer-acting opiate in craniosynostotic surgery [23]. In a
more recent study on craniosynostosis surgery, preoperative
SNB has been compared to local anesthetic infiltration before
skin incision with no clear superiority of one option over the
other. Moreover, the need for morphine in the early recovery
period was significant with both options (almost half of the
patients with local anesthetic infiltration and two thirds of
patients with SNB) [7].
It is worth to note in group SB the quite complete pain
relief 30 min after the awakening, which lasted for the first 8
postoperative hours. Pain scores remained lower in children
with SNB during the first 2 postoperative days, although this
difference did not result statistically significant.
The better pain relief, the decreased need of analgesics in
group SB, and the absence of vomiting in the postoperative
period could all together explain the faster resumption of oral
feeding in these patients, in comparison with the group treated
with tramadol.
Moreover, a good pain control is associated to a reduced
risk of chronic post-surgical pain in adult patients, according
to recent literature data [6, 27]. Although we may not roughly
draw similar conclusions in the pediatric patients, this issue
deserves further investigations.
Pain was assessed by OPS four items, which is validated
for children younger than 12 months [24]. It incorporates four
pain behaviors (crying, movement, agitation, and verbaliza-
tion) and blood pressure change. Previous experiences used
other scores, such as the Children Hospital of Eastern Ontario
Pain Scale (CHEOPS) [16] or the Face, Legs, Activity, Cry,
Consolability scale (FLACC scale), the latter specific for pain
assessment for children with age ranging from 2 months to
7 years [17]. It is very difficult to assess pain intensity in very
young children, such as those enrolled in the present study,
because they lack the necessary verbal and cognitive skills. A
correct pain assessment mainly relies on observation and par-
ent cooperation. All these aspects may result in under- as well
as over-treatment of pain. We chose the OPS scale because it
is easy to detect and is based on direct and objective
observation by the health caregivers, though it shares the same
limitations of the other available methods. In fact, specific
behaviors in pediatric patients, such as cry and agitation, do
not necessarily relate to pain, and a physical discomfort can be
caused by fear or hunger.
The longer stay in PICU of the patients treated with
SNB is an unexpected observation and does not seem to
fit with the other findings. However, the difference be-
tween the mean data in the two groups is about 3 h. This
difference does not seem significant from a clinical stand-
point, since it seems more related to logistic issues, namely
the availability of bed in the Pediatric Neurosurgery Unit,
rather than clinical problems contraindicating the dis-
charge from PICU. Indeed, the overall hospital LOS was
similar between the two groups.
Further studies with a larger sample would hopefully allow
to clarify the impact of SNB on the length of stay of patients
undergoing surgery for craniosynostosis.
Another variable included in the study is the degree of
parental satisfaction at discharge, since the satisfaction indica-
tor is nowadays considered an important marker to evaluate
the QoL of the surgical patients [21]. The parent wishes for a
postoperative course without complications and especially
pain freedom is an important outcome, which should be eval-
uated along with the surgical outcome of the correction.
Actually, both groups showed similar degrees of parental sat-
isfaction. We hypothesize that this is mainly related to the
good outcome of surgery and the discharge of patients as
scheduled at the admission, while the better pain management
has been probably overlooked by parents.
The main limitation of the present study is its observational
nature. Furthermore, no hemodynamic data were analyzed in
the present study, since SNB was not performed before sur-
gery. Moreover, the young age of patients enrolled in the
study may represent a major concern, but at the same time it
offered us the possibility to evaluate the effectiveness of a
multimodal pain control approach in a challenging and poorly
explored setting, thus strengthening the value of our results.
Childs Nerv Syst
In conclusion, this study showed that the multimodal ap-
proach with SNB in combination with acetaminophen was
effective for immediate postoperative pain control in patients
younger than 2 years who underwent cranioplasty for cranio-
synostosis. The better pain control compared to conventional
therapy with acetaminophen and tramadol allowed to limit the
need for rescue analgesics in PICU and an earlier recovery
time. Future studies would focus on the best timing of the
block and the better combination of local agents, as well as
the more reliable scale for scoring postoperative pain in young
children, and reliable indicators for the child’s quality of life
and the work of the caregivers.
Funding Information The authors received no funding for this research.
Compliance with ethical standards
Conflict of interest Authors declare no conflict of interests.
Ethics approval The study protocol was approved by the institutional
Ethics Committee: Prot. 14,138/18 (3258/19), ID: 2024.
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