Anaesth Intensive Care 2006; 34: 224-227

Effect of Scalp Block on Postoperative Pain Relief in

Craniotomy Patients
I. Bala*, B. Gupta*, N. Bhardwaj*, B. Ghai*, V. K. Khosla**
Department of Anaesthesiology and Intensive Care, and Department of Neurosurgery, Postgraduate Institute of Medical
Education and Research, Chandigarh, India

SUMMARY
The efficacy of scalp nerve block using 0.5% bupivacaine with adrenaline for postoperative pain relief in ­craniotomy
patients was evaluated in 40 ASA I or II adult patients undergoing supratentorial craniotomy. A standard ­general
anaesthesia technique was followed. Patients were randomly divided into two groups. Group B received 0.5%
­bupivacaine with 1:400,000 adrenaline and group S received normal saline with 1:400,000 adrenaline, both after
skin closure. Postoperative pain was assessed at 30 seconds and 1, 2, 4, 6, 8 and 12 hours using a numerical ­rating
scale. Diclofenac IM was administered as rescue analgesia if patients reported a numerical rating scale of 40 or
more. Tramadol IV was administered as second rescue analgesia. Sixty per cent of patients in group S experienced
moderate to severe pain (numerical rating scale of 40 or more) at some time during the first 12 postoperative hours
in comparison to 25% patients in group B. Median pain scores were significantly lower in group B for up to 6 hours.
Significantly more patients were pain free up to four hours in group B. Median duration for the requirement of first
dose of diclofenac was longer in group B compared to group S (360 min vs 30 min, P<0.01). The number of doses
of diclofenac (5 vs 19) was significantly lower in group B compared to group S (P<0.01). Tramadol was required
by six patients in group S only. Scalp nerve block using 0.5% ­bupivacaine with 1:400,000 adrenaline decreases the
incidence and severity of postoperative pain in patients undergoing ­supratentorial craniotomy.
Key Words: supratentorial craniotomy, scalp block, bupivacaine, postoperative analgesia

Postoperative pain is common in neurosurgical of regional anaesthesia on postoperative pain after

patients and is often undertreated for the fear of
masking neurosurgical pathology or depressing
ventilation1. Opioids like morphine2, tramadol3 and
codeine4 have been utilized for pain relief. However,
they are associated with side-effects. A regional
anaesthesia technique might be a better choice for
pain relief in these patients, as side-effects associated
with the systemic drugs can be avoided.
The scalp is densely innervated by C fibres and the
main cause of postoperative pain in patients follow-
ing craniotomy is the skin incision and reflection
of muscles during the operation rather than brain
manipulation and resection5. Blockade of nerves that
supply the scalp will anaesthetize both superficial
and deep layers of the scalp. Studies of the effect
* M.D., Department of Anesthesiology & Intensive Care, Postgraduate
Institute of Medical Education and Research.
** M.S., M.Ch., Department of Neurosurgery, Postgraduate Institute of
Medical Education and Research.
Address for reprints: Dr Babita Ghai, Department of Anesthesiology
and Intensive Care, Teacher Flat No. 3, Sector-12, PGIMER, Chandigarh
(160012), India.
Accepted for publication on December 1, 2005.
intracranial surgery are scarce. Wound infiltration6,7
and superficial cervical plexus block8 with local
anaesthetic have been used to decrease postoperative
pain after craniotomy. Only one previous study with
ropivacaine has examined the effect of scalp block on
post-craniotomy pain9.
We planned this prospective double-blind ran­
domized study to assess the efficacy of scalp block
using 0.5% bupivacaine with 1:400,000 adrenaline for
postoperative pain relief after craniotomy.
MATERIALS AND METHODS
After institutional ethics committee approval and
informed patient consent, 40 ASA I and II patients,
aged 18 to 50 years undergoing elective supratentorial
craniotomy were included in the study. Patients with
a Glasgow Coma Score (GCS) less than 15, those
with documented allergy to bupivacaine, and those
undergoing emergency procedures were excluded.
All patients were examined on the evening before
surgery and familiarized with the numerical rating
scale (NRS)11 for pain assessment. Patients were
advised to select a number from 0 to 100 to describe
the intensity of their postoperative pain. Zero in­
Anaesthesia and Intensive Care, Vol. 34, No. 2, April 2006
 Scalp Block for Craniotomy Patients
dicated no pain and 100 indicated the worst possible
pain. Baseline blood pressure and heart rate were
recorded. All patients were premedicated with oral
diazepam 5 mg the night before surgery and 5 mg in
the morning on the day of surgery.
A standard anaesthetic technique was followed.
After preoxygenation for three minutes, anaesthesia
was induced with thiopentone 5 mg/kg. Vecuronium
was used to provide muscle relaxation. Anaesthesia
was maintained with 66% nitrous oxide in oxygen and
isoflurane 0.5-1% supplemented with intravenous
morphine 0.15 mg/kg IV. At the end of the pro­
cedure, neuromuscular blockade was reversed with
neostigmine 0.05 mg/kg and atropine 0.02 mg/kg.
Patients were extubated when they were able to obey
simple commands.
After skin closure, the scalp block was performed
using aseptic precautions. Patients were randomly
divided into two groups using a computer generated
random number chart. Group B received scalp block
with 0.5% bupivacaine and adrenaline 1:400,000,
whereas group S received scalp block using normal
saline with 1:400,000 adrenaline. The neurosurgeon,
the anaesthetist performing the scalp block and the
patients were blinded to the drug being administered.
The anaesthetist performing the block did not
participate in the postoperative pain assessment.
The scalp block was performed as described by
Pinosky et al12. The following nerves were blocked
bilaterally: the supraorbital and supratrochlear
nerves were blocked as they emerge from the orbit
with 2 ml of solution using a 23G needle introduced
above the eyebrow perpendicular to the skin; the
auriculotemporal nerves were blocked with 2 ml of
solution injected 1.5 cm anterior to the ear at the level
of tragus (the 23G needle was introduced perpen-
dicular to the skin and injection was made deep to the
fascia and superficially as the needle was withdrawn);
the zygomatico-temporal nerves were blocked mid-
way between the supraorbital and auriculo-temporal
nerves by using 2 ml of solution with a 23G needle;
the postauricular branches of the greater auricular
nerves were blocked by 2 ml of solution using a 23G
needle between the skin and bone 1.5 cm posterior
to the ear at the level of tragus; the greater, lesser
and third occipital nerves were blocked with 2 ml of
solution using a 22G spinal needle with infiltration
along the superior nuchal line, approximately halfway
between the occipital protuberance and mastoid
process. The total volume of solution used was 20 ml
in all patients.
Postoperative analgesia was assessed using NRS at
time intervals of 30 minutes and 1, 2, 4, 6, 8 and 12
hours postoperatively. Other parameters recorded
Anaesthesia and Intensive Care, Vol. 34, No. 2, April 2006
225
were blood pressure, heart rate, respiratory rate,
GCS and sedation score. Sedation was assessed using
four point scale: i.e. 1. awake and communicative;
2. asleep, responds to normal speech; 3. asleep, re­
sponds to shaking; 4. deeply sedated. Patients having
an NRS≥40 were treated with diclofenac 75 mg IM as
first rescue analgesic. Tramadol 50 mg IV was used
as second rescue analgesic if the NRS remained at
40 in spite of receiving diclofenac. The time interval
between the end of surgery and the first requirement
of rescue analgesic was noted for each patient. Total
dose and frequency of rescue analgesics administered
was also noted.
Sample size calculation was performed, based on
the assumption that scalp block will decrease the
incidence of moderate to severe postoperative pain
(NRS≥40) by 50% (from 80 to 40%). With a of 0.05
and power of 80%, 19 patients in each group were
required. Therefore we chose 20 patients per group
in the study.
Pain and sedation scores were compared using
Wilcoxon test. The numbers of pain free patients at
different time intervals were compared using chi square
test or Fisher’s exact test. The time interval between
the end of surgery and the first administration of
diclofenac was compared using Mann Whitney U test.
Dose requirement of diclofenac was compared using
chi square test and that of tramadol was compared
using Fisher exact test between the groups. A P value
<0.01 was considered significant.
RESULTS
The demographic characteristics and duration of
surgery are provided in Table 1. The indications for
craniotomies performed for each group are given
in Table 2. Sixty per cent of patients in group S
experienced moderate to severe pain (NRS≥40) at
some time during the first 12 postoperative hours in
comparison to 25% patients in group B. The median
pain scores were significantly lower up to six hours
postoperatively in group B (Table 3). More patients
in group B were pain free compared to group S at all
time intervals. However, the difference was significant
only until four hours (Table 4).
Table 1
Patients characteristics and duration of surgery
Group B Group S
(n=20) (n=20)
Age (years, mean±SD) 36.8±8.5 40.1±9.3
Weight (kg, mean±SD) 63±10.1 62.2±12.4
Sex ratio (M:F) 10: 10 15: 5
ASA I:II 12:8 10:10
Glasgow Coma Score 15 15
Duration of surgery (min, mean±SD) 230±54 221±59
226 I. Bala, B. Gupta et al
Table 2
Indications for craniotomies
Indication Group B (n=20) Group S (n=20)
Frontoparietal glioma 12 11
Temporoparietal glioma 2 3
Sphenoid meningioma 4 3
Craniopharyngioma 2 3
Table 3
Postoperative pain scores
Time Group B Group S P value
interval (n=20) (n=20)
Hours Median IQR Median IQR
0.5 0 2.5 20 40 0.001
1 0 2.5 22.5 12.5 0.001
2 0 5 22.5 10 0.00003
4 2.5 10 25 10 0.0007
6 10 12.5 20 10 0.037
8 15 10 20 12.5 0.105
12 20 11.2 22.5 10 0.138
IQR=Interquartile range.
Table 4
Number of patients remaining pain free (%)
Time interval Group B (n=20) Group S (n=20) P value
hours
½ 15 (75) 6 (30) 0.004
1 15 (75) 3 (15) <0.001
2 14 (70) 2 (10) <0.001
4 10 (50) 2 (10) 0.006
6 5 (25) 2 (10) 0.212
8 2 (15) 2 (10) 0.633
12 3 (15) 2 (10) 0.633
The median (range) time interval between the end
of surgery and the first administration of diclofenac
was longer in group B than group S [360(60-480) min
vs 30(30-240), P<0.001)]. The number of patients
requiring rescue analgesia (5 vs 19) was lower in
group B compared to group S (P<0.001). Second
rescue analgesic tramadol was required by six patients
in group S only (Table 5).
Most of the patients were awake or easily arousable
in the immediate postoperative period. All patients
were extubated on the operating table once they
followed verbal commands. Sedation scores were
comparable between the groups at all time intervals.
Table 5
Postoperative rescue analgesia
Group B Group S P value
Time of first request of rescue
analgesia [min, median
(range)] 360 (60-480) 30 (30-240) 0.011
Total number of diclofenac
doses 5 19 <0.001
Total number of tramadol
doses 0 6 <0.001
No arrhythmia or hypotension was noted during block
administration or in the postoperative period.
DISCUSSION
The conventional wisdom that most neurosurgical
patients experience minimal postoperative pain and
require little analgesia has been challenged. In contrast
to the standard teaching that pain is not a significant
problem in craniotomy patients13, recent studies
have reported that 60 to 84% of patients experience
moderate to severe pain after craniotomy5,10.
The scalp is densely innervated by sensory nerves.
The forehead and front of the scalp are supplied by
the supraorbital and supratrochlear nerves (branches
of ophthalmic division of trigeminal) the temple by
auriculotemporal (branch of mandibular division of
trigeminal) and zygomatico-temporal nerves (branch
of maxillary division of trigeminal). Posteriorly the
greater occipital and third occipital nerves (posterior
rami of C2 and C3 respectively) extend to the vertex
and posterior scalp respectively. The lesser occipital
(anterior ramus of C2) supplies the skin behind the
ear.
In a few prospective studies carried out to assess
the incidence and severity of postcraniotomy pain,
it was observed that 60 to 84% patients reported
moderate to severe or even excruciating pain during
the first 24 hours5,10. In our study, 60% of patients
in our saline group experienced moderate to severe
pain at some time during the first 12 postoperative
hours. Hence, ours is another study that indicates
that moderate to severe pain is common in patients
following craniotomy.
We found that blockade of the main sensory
nerves of the scalp with bupivacaine and adrenaline
was effective in decreasing postoperative pain in
patients who underwent supratentorial craniotomy.
Only 25% patients in group B had moderate to
severe pain during the first 12 hours. Patients in
group B had lower pain scores for up to six hours
postoperatively.
The duration of pain relief in our study corres-
ponded with the expected duration of action of
bupivacaine with adrenaline. This is in contrast with a
previous study by Nguyen et al9 who used ropivacaine
0.75% for scalp nerve block for postcraniotomy pain
relief. They observed that the duration of pain relief
was much longer than the expected duration of action
of ropivacaine (three to four hours). Their average
pain scores in the ropivacaine groups were signifi-
cantly lower compared to the saline group up to
24 hours and the analgesic effect seemed to persist
for at least 48 hours postoperatively. The authors
Anaesthesia and Intensive Care, Vol. 34, No. 2, April 2006
 Scalp Block for Craniotomy Patients
attributed this unexpected long-lasting analgesia to
pre-emptive analgesic effect. No such phenomenon
was observed in our study.
The time interval between the end of the surgery
and demand of first dose of rescue analgesic was
significantly longer in group B compared to the
group S. The number of doses and the total dose of
diclofenac required was also significantly less in group
B. This is not consistent with the observations of
Nguyen et al9. They observed that although there was
a trend towards a longer time interval between the
end of surgery and the first dose of rescue analgesia
(codeine) in the ropivacaine group, it did not reach
statistical significance. The total dose of codeine
administered was also not significantly different
between the groups. The difference between their
study and our study results could be because of the
analgesic regimen chosen. Nguyen et al9 used codeine
phosphate (0.5-1.0 mg/kg) at a fixed interval of three
to four hours as requested by the patients in both the
groups despite lower visual analogue scores in their
ropivacaine group. However, we administered rescue
analgesia only if the NRS was ≥40. In our study, the
choice of diclofenac as first rescue analgesic and
tramadol as second rescue analgesic was based on
the regimen being followed by our neurosurgeon
colleagues.
Scalp infiltration with local anaesthetic is another
technique that has been studied for postoperative
pain after craniotomy. Bloomfield et al6 infiltrated
the scalp both before incision and after scalp closure
with 0.25% bupivacaine with 1:200,000 adrenaline.
Their study was limited to only one hour in the
immediate postoperative period and showed that
wound infiltration decreases pain scores on admission
to PACU up to one hour. In a more recent study,
Biswas and Bithal7 observed that although preincision
scalp infiltration with bupivacaine did not have
any significant effect on postcraniotomy pain and
analgesic requirement, it delayed the need for rescue
analgesia.
We chose bupivacaine because of its longer
duration of action. Adrenaline 1:400,000 was added
to further prolong its action and reduce the risk of
toxicity. Bupivacaine with adrenaline has been used
previously for scalp infiltration without any increase in
mean arterial pressure or heart rate14. We also did not
observe any change in heart rate or blood pressure.
It has been observed by Castello et al15 that scalp
block with ropivacaine (mean dose 3.6 mg/kg) used
for awake craniotomies, was associated with rapid rise
in plasma levels of ropivacaine which peaked at about
15 minutes after injection. Despite this rapid rise,
Anaesthesia and Intensive Care, Vol. 34, No. 2, April 2006
227
no signs of cardiovascular or central nervous toxicity
were observed. Although blood levels of bupivacaine
were not measured in our study, no patient had signs
or symptoms of bupivacaine toxicity.
In conclusion, this study demonstrates that scalp
block using 0.5% bupivacaine with adrenaline de­-
creases both the incidence and severity of postopera-
tive pain in patients undergoing supratentorial
craniotomy.
REFERENCES
1. Cousins MJ, Umedaly HS. Postoperative pain management in
neurosurgical patients. Int Anesthesiol Clin 1996; 34:179-193.
2. Goldsack C, Scuplak SM, Smith M. A double-blind comparison
of codeine and morphine for postoperative analgesia following
intracranial surgery. Anaesthesia 1996; 51:1029-1032.
3. Jeffrey HM, Charlton P, Mellor DJ, Moss E, Vucevic M.
Analgesia after intracranial surgery: a double-blind, prospec-
tive comparison of codeine and tramadol. Br J Anaesth 1999;
83:245-249.
4. Stoneham MD, Walters FJ. Postoperative analgesia for
­craniotomy patients: current attitudes among neuroanaes­
thetists. Eur J Anaesthesiol 1995; 12:571-575.
5. Quiney N, Cooper R, Stoneham M, Walters F. Pain after
­craniotomy. A time for reappraisal? Br J Neurosurg 1996;
10:295-299.
6. Bloomfield EL, Schubert A, Secic M et al. The influence of
scalp infiltration with bupivacaine on hemodynamics and
postoperative pain in adult patients undergoing craniotomy.
Anesth Analg 1998; 87:579-582.
7. Biswas BK, Bithal PK. Preincision 0.25% bupivacaine scalp
infiltration and post craniotomy pain: A randomized double-
blind, placebo controlled study. J Neurosurg Anesthesiol 2003;
15:234-239.
8. Niijima K, Malis LI. Preventive superficial cervical plexus block
for postoperative cervicocephalic pain in neurosurgery. Neurol
Med Chir Tokyo 1993; 33:365-367.
9. Nguyen A, Girard F, Boudreault D et al. Scalp nerve blocks
decrease the severity of pain after craniotomy. Anesth Analg
2001; 93:1272-1276.
10. De Benedittis G, Lorenzetti A, Migliore M et al. Postoperative
pain in neurosurgery: A pilot study in brain surgery. Neuro­
surgery 1996; 38:466-470.
11. Jensen MP, Karoly P, Braver S. The measurement of clinical
pain intensity: a comparison of six methods. Pain 1986; 27:117-
126.
12. Pinosky ML, Fishman RL, Reeves ST et al. The effect of
bupivacaine skull block on the hemodynamic response to
­craniotomy. Anesth Analg 1996; 83:1256-1261.
13. Atkinson RS, Rushman GB, Davies NJH: Surgical operations
and choice of anesthetic, Lee’s synopsis of anesthesia, 11th
edition. Edited by Atkinson RS, Rushman GB, Davies NJH.
Oxford, Butterworth Heinemann Publishers, 1993, pp 444-
602.
14. Hartley EJ, Bissonnette B, St-Louis P, Rybczynski J, McLeod
ME. Scalp infiltration with bupivacaine in pediatric brain
­surgery. Anesth Analg 1991; 73:29-32.
15. Costello TG, Cormack JR, Hoy C et al. Plasma ropivacaine
levels following scalp block for awake craniotomy. J Neurosurg
Anesthesiol 2004; 16:147-150.