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DOI: 10.15190/d.2020.8
Regional Anesthesia in Neuroanesthesia Practice
REVIEW Article
Submitted: May 29, 2020; Revision: June 08, 2020; Accepted: June 08, 2020; Published: June 29, 2020
Citation: Kaushal A, Haldar R. Regional Anesthesia in Neuroanesthesia Practice. Discoveries 2020, 8(2):
e111. DOI: 10.15190/d.2020.8
ABSTRACT SUMMARY
Regional anesthesia has been an undervalued entity 1.Introduction
in neuroanesthetic practice. However, in the past few 2.Requirement of regional techniques in
years, owing to the development of more advanced neuroanesthesia
techniques, drugs and the prolific use of ultrasound 2.1. Blocks used in head and neck surgeries
guidance, the unrecognised potential of these 2.1.1 Scalp block
modalities have been highlighted. These techniques 2.1.2 Infraorbital block (IOB)
confer the advantages of reduced requirements for 2.1.3 Trigeminal Nerve Block
local anesthetics, improved hemodynamic stability 2.1.4 Cervical plexus block (CPB)
in the intraoperative period, better pain score 2.2. Blocks used for spinal surgeries
postoperatively and reduced analgesic requirements Erector Spinae Block (ESP)
in the postoperative period. Reduced analgesic 3. Conclusion
requirement translates into lesser side effects
associated with analgesic use. Furthermore, the 1. Introduction
transition from the traditional blind landmark-based
techniques to the ultrasound guidance has increased Neurosurgical Anesthesiology is a relatively modern
the reliability and the safety profile. In this review, subspecialty of anesthesiology, which focusses on
we highlight the commonly practised blocks in the the anesthetic management of patients undergoing
neuroanesthesiologist’s armamentarium and describe neurosurgical procedures. Maintenance of cerebral
their characteristics, along with their individual and spinal cord perfusion pressure is the foremost
particularities. consideration for neurosurgical procedure, which
depends upon the maintenance of hemodynamic
Keywords stability and changes in the pain intensity at different
Analgesics, anaesthetics, anaesthesia, carotid stages of surgery1. These procedures are usually
endarterectomy, cervical plexus block, neurosurgery. prolonged, thus maintaining the same surgical
position is difficult, even if the patient is awake or
Abbreviations
sedated with adequate analgesia. As the surgery is
Randomised control study (RCT); local anesthesia (LA); being conducted within narrow anatomical corridors
infraorbital block (IOB); trans-nasal trans-sphenoidal
and with high precision, slightest degree of
(TNTS); cervical plexus block (CPB); carotid
endarterectomy (CEA); erector spinae block (ESP);
movement by the patient is unacceptable and
general anesthesia versus local anesthesia for carotid potentially deleterious.
surgery (GALA); anterior cervical discectomy & fusion In the face of these concerns, maintenance of
(ACDF); general anesthesia (GA). general anesthesia with inhalational or intravenous
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Regional Anesthesia in Neuroanesthesia Practice
KEY POINTS
◊ Regional techniques in neuroanesthetic practice have not been widely explored
◊ Refinements in terms of techniques and drugs have increased their utilization in
neurosurgical practices, for smoother intraoperative course and improved
postoperative patient comfort
agents have been the traditional anesthetic modality stereotactic interventions, and endoscopic
for neurosurgical patients. Regional anesthesia procedures to increase surgical precision and
solely has not been proven adequate during minimize trauma to normal tissues is prioritized.
neurosurgical procedure as compared to some other Outcome measures, such as quicker recovery,
surgical specialities and, therefore, has been often minimal perioperative morbidity, and reduced
disregarded or ignored. In this regard, application of hospital stay, are desired2. Spinal procedures are
regional nerve blocks when combined with general usually accompanied by neurophysiological
anesthesia during neurosurgery has been seen to monitoring, which curtails the type and dosage of
provide hemodynamic stability, to decrease general anesthetic drugs. Spinal surgeries are also
anesthetic requirement, as well as extend generally associated with intense pain in the
postoperative analgesia and, therefore, is desired. postoperative period, especially for the initial few
In this review article, we highlight the possible days. In this scenario, adequate pain management
types and techniques of regional anesthesia, which using regional anesthetic techniques correlates well
can be applied perioperatively as an adjunct to with improved functional outcome, early
general anesthesia and discuss their benefits when ambulation, early discharge, and preventing the
administered during various types of neurosurgical development of chronic pain3. Thus, appropriate
procedures. In addition to the authors own application of regional anesthetic modalities
experience, a systematic literature search and facilitates intraoperative conduct, as well as
analyses was performed by using search engines, improves the postoperative outcomes of
including the ones provided by PubMed, Google and neurosurgical patients. For the purpose of this
Google Scholar, with the use of the following single- review, we have broadly classified the different
text words and combinations: anesthesia/anaesthesia, modalities under the headings of blocks specific for
neurosurgery, regional anesthesia/anaesthesia, nerve head and neck surgeries and blocks utilized in spinal
blocks and other combinations of words, from the surgeries. Table 1 depicts the summary of different
year 2000 to 2020. The references of relevant studies related to regional neve blocks used for
articles were cross-checked and the articles neurosurgery.
containing all these keywords were thoroughly
studied for the development of this review. 2.1 Blocks used in head and neck surgeries
2. Requirement of regional techniques in 2.1.1 Scalp block: It consists of blocking six nerves
neuroanesthesia that provide the sensory innervation of the scalp, on
either side of the scalp, by subcutaneous infiltration
Neurosurgical procedures are broadly classified into of 2-3 ml local anesthetics (LA) for each nerve.
cranial and spinal procedures. Contemporary cranial These nerves are the supraorbital, supratrochlear,
procedures emphasise the use of functional and zygomaticotemporal, auriculotemporal, lesser
minimally invasive procedures, with high degree of occipital and greater occipital nerves. Usually
emphasis on availability of optimal operative bilateral blocks are placed. LA, such as bupivacaine,
conditions, preservation of neurocognitive function, ropivacaine or levobupivacaine, are commonly used.
minimizing interference with electrophysiological Though the landmark technique is popular, the
monitoring, and a rapid, high-quality recovery. advent of ultrasound guidance has increased the
Small craniotomies, intraoperative imaging, precision of block administration. Ultrasound
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Regional Anesthesia in Neuroanesthesia Practice
guidance can be used to locate the supraorbital notch severity14, which extends 6 hours after craniotomy15.
(for supraorbital nerve), pterygopalatine fossa (for A moderate reduction in opioid consumption in the
zygomaticotemporal nerve), superficial temporal 24 hours following craniotomy is also observed16.
artery (for auriculotemporal nerve) and occipital Additionally, it reduces the incidences of
artery (for greater occipital nerve). postoperative nausea and vomiting, which is usually
The main indication of scalp block is awake associated with opioid usage for analgesia15.
craniotomy. Other indications are deep brain
stimulation and stereotactic radiosurgery, burr hole 2.1.2 Infraorbital block (IOB): The infraorbital
drainage of chronic subdural haemorrhage and nerve is a pure sensory nerve and is a
cranioplasty surgery1. For other craniotomies, the terminal branch from the second maxillary division
promising advantage offered by scalp block is the of the trigeminal nerve that exits the skull through
capability to perform accurate neurological the foramen rotundum to enter the pterygopalatine
evaluation in postoperative period, as it does not fossa. It exits the cranium through the infraorbital
affect other motor or sensory systems and provides foramen in a caudal and medial direction and divides
pre-emptive analgesia. Benefits of an appropriately into several sensory branches: the inferior palpebral,
placed scalp block are present during all stages of the lateral nasal, and the superior labial nerves. It
the surgery. Preoperatively, scalp blockade blunts supplies the skin and mucous membrane of the
the hemodynamic response to cranial fixation4. upper lip and lower eyelid and the cheek between
Intraoperatively, scalp block (with bupivacaine) has them and to the lateral side of the nose.
been proven to be superior over control group (with In addition to infraorbital nerve that emerges on
saline) in terms of hemodynamic stability and to the face, the IOB also blocks anterior superior
decreased anesthetic requirement during cranial alveolar and middle superior alveolar nerves that
fixation5,6. Scalp block (with bupivacaine) has been originate within the infraorbital canal and supplies
found to be better compared to intravenous opioid the mucous membrane of the lateral wall, floor of
analgesic and bupivacaine infiltration at each pin the nasal cavity and also the nasal septum17,18.
insertion site in controlling hemodynamics during Endoscopic trans-nasal trans-sphenoidal
cranial fixation and for 3 minutes later. Lower levels (TNTS) approach is a commonly performed
of cortisol and adrenocorticotropic hormone at procedure for pituitary tumor excision. Although it
different time point after cranial fixation was also is a type of minimally invasive neurosurgery, due to
demonstrated in scalp block group7. Effect of scalp sub-mucosal nasal dissection and nasal packing,
block persists until the time of incision and until patient may experience significant pain and
dural opening. Scalp block was found superior over discomfort in the postoperative period. Bilateral
control group until dural opening, but following that, infraorbital nerve block combined with general
the scalp block was comparable to control group anesthesia is proved to be beneficial in rapid,
with respect of hemodynamic stability8. smooth, pain free emergence from anesthesia,
Scalp block’s effect extends into the facilitating quick neurological evaluation, in addition
postoperative period too and it has proved to to decreasing postoperative pain and discomfort19.
decrease the incidence and severity of postoperative The block can be applied using the classic
pain in patients undergoing supratentorial anatomical approach or the ultrasound guided
craniotomy9,10. It also reduces the incidence of approach. For the classical landmark techniques, two
requests for rescue analgesics, increases the duration approaches, either the intraoral or extraoral
between surgery completion and first demand of approaches, can be used. The important landmark is
analgesics, and reduces pain scores in the early the infraorbital foramen, which is located just below
postoperative period11. the orbital margin, at the junction of a vertical line
Adjuvants like opioids, dexmedetomidine12, drawn in line of the centre of the pupil and a
dexamethasone and magnesium sulphate13 have been horizontal line from the nasal alae. In intraoral
investigated by different investigators for their effect approach, the incisor and the first premolar are
on the improvement of the quality and duration of palpated. A 25-27-gauge needle is inserted into the
the block with varying results. Meta-analysis of buccal mucosa in the subsulcal groove at the level of
different randomised control studies (RCTs) have the canine or the first premolar and guided upward
demonstrated a consistent reduction of pain and outward into the canine fossa. Keeping a finger
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Regional Anesthesia in Neuroanesthesia Practice
over the infraorbital foramen to assess the suitable fossa have been traditionally performed using the
position of the needle tip and to prevent injury of the paresthesia technique, by positioning the needle
eyeball by unintentional cephalad progression of the under fluoroscopy or computed tomography. The
needle into the orbit, the needle is advanced20. Then, classical approach to access the Gasserian ganglion
after negative aspiration, 1–3 ml of local anesthetic is via the foramen ovale. Usually, X-ray guided
is administered. techniques, that rely on bony anatomical landmarks
In extraoral approach, the infraorbital foramen such as the maxilla, lateral pterygoid plate, and
is palpated, a 25-27-gauge needle is inserted foramen ovale, are utilized. They can be difficult and
perpendicularly in upward and medial direction often a challenge to interpret. Ultrasound guided
toward the foramen, until bony resistance is felt. A needle placement allows real-time visualization of
finger is continuously positioned at the level of the soft tissue and surrounding vasculature in addition to
infraorbital foramen. Then, after negative aspiration, the appearance of bony structures. The image
1–3 ml of the local anesthetic is administered. guidance permits delicate adjustment of the needle
The same block can be attempted under tip and direct observation of the injectate and, in
ultrasound guidance. Using a 6-13 Hz linear probe doing so, confirm the local anesthetic spread at the
placed on the cheek just lateral to the nose intended region. The lateral pterygoid plate, the
horizontally and moving from medial to lateral maxillary artery, and the pterygopalatine fossa can
direction, until a disruption is appreciated in the be easily ultrasonographically identified. The
hyperechoic line which represents the infraorbital placement of the injectate anterior to the lateral
foramen. The relationship of the nerve with pterygoid plate, below the lateral pterygoid muscle,
infraorbital artery is confirmed using the Doppler can be visualized in real time. This approach allows
mode. A 23-25 G block needle is inserted using in access to the pterygopalatine fossa and its contents,
plane approach from the caudal edge of the probe including the sphenopalatine ganglion and the
and advanced until foramen is reached. After superficial and deep petrosal nerves27. In addition, as
aspiration and confirmation of no intravascular previously demonstrated using fluoroscopy, because
injection, 1 ml of local anesthetics is the volume of the pterygopalatine fossa is small,
administered21,22. placing 2 ml of contrast in this space produces a
A previous case report has demonstrated the retrograde passage to reach the middle cranial fossa
successful use of bilateral infraorbital nerve blocks and allows visualization of the trigeminal ganglion28.
combined with general anesthesia for better Thus, ultrasound guidance makes it a safe and
perioperative analgesia in a paediatric patient radiation free percutaneous procedure to provide
undergoing a transsphenoidal resection of a sustained pain relief in patients unable to get relief
suprasellar tumour23. In one prospective randomized by conservative measures from trigeminal neuralgia.
study, application of bilateral infraorbital block with
0.5% bupivacaine for transsphenoidal pituitary 2.1.4 Cervical plexus block (CPB): Most common
surgery has resulted in a significant increase for first indication of deep and superficial cervical plexus
demand to analgesia and significant decrease of block (CPB) in neurosurgery is carotid
analgesic consumption, whereas patient satisfaction endarterectomy (CEA), in which an awake patient
for postoperative analgesia was found to be good18. can self-monitor the sufficient cerebral blood flow
Other regional techniques have also been attempted, throughout cross-clamping of the carotid artery. In
which include bilateral sphenopalatine ganglion recent years other indications of cervical plexus
block24 and bilateral maxillary nerve blocks25. These block is cervical spine surgery. For the superficial
have been shown to suppress the intraoperative cervical plexus block, local anesthetic is
sympathetic stimulation and hemodynamic superficially injected to the deep cervical fascia. In
responses during transsphenoidal surgeries. intermediate cervical plexus block, the injection is
made between the investing layer of the deep
2.1.3 Trigeminal Nerve Block: Patients who are cervical fascia and the prevertebral fascia, whereas
unresponsive to medical management of trigeminal for the deep cervical plexus block, local anesthetic is
neuralgia require injection of local anaesthetics26. deposited deep to the prevertebral fascia.
Blockade of the branches of the trigeminal nerve The efficacy of superficial and deep cervical
(V2 and V3) in the pterygopalatine or infratemporal plexus block for CEA is the same. However,
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Regional Anesthesia in Neuroanesthesia Practice
vertebrae, disks, ligaments, dura, facet joint, muscle, process, the transducer is kept about 3 cm lateral to
fascia, subcutaneous and cutaneous tissues3. the spinous processes in a longitudinal parasagittal
Although, the majority of the spinal procedures are alignment. Transverse process is identified as flat,
commonly performed under general anesthesia, sole squared-off acoustic shadows, whereas ribs are
regional anesthesia may be an option for one- or visualized as rounded acoustic shadows (if the
two-level lumbar laminectomy or disc surgery39. transducer is placed too laterally) and thoracic
The major advantages of regional anesthesia laminae are identified as flat hyperechoic lines (if
(spinal and epidural anesthesia, intrathecal injection the transducer is placed too medial). After correct
of opioids and cervical plexus block) for spine identification of the transverse process, an 18-gauge
surgery are hemodynamic stability, decreased echogenic needle is inserted with an in-plane,
postoperative pain, nausea vomiting and analgesic cranial-to-caudad direction to touch the bony
requirement in postoperative period40-42. shadow of the transverse process by the tip deep to
Epidural analgesia is considered as the gold the fascial plane of the erector spinae muscle. The
standard for postoperative analgesia in lumbar spine accurate location of the needle tip is established by
surgeries, but the catheters may interfere with administrating 1-2 ml of normal saline and noticing
surgery. Also, there is chance of intrathecal spread of fluid lifting the erector spinae muscle
penetration of local anesthetic if dura mater damage above transverse process. Now, either longer acting
occurs during surgical procedure43,44. local anesthetics can be administered in bolus dose
In addition to the cervical CPB previously or a catheter can be placed through the needle for
described for cervical spine surgeries, bilateral continuous drug infusion, for longer duration. The
ultrasound guided erector spinae plane block, a simple aspects in the acceptance of this block are
relatively newer plane block, was first defined by easy sonographic identification of landmarks and a
Forero et al. in 2016. This block has been shown to minor complication ratio compared to the
have comparable analgesic properties to epidural paravertebral block and its alternatives50. The exact
block45. The site of ESPB administration is deep into mechanism of action is not fully known. An
the erector spinae muscle and superficial to the tips interfascial spread toward the dorsal rami of spinal
of the thoracic transverse processes, distant from the nerves is possibly the key mechanisms of
pleura and major blood vessels. Pneumothorax has action. These rami carry visceral motor, somatic
been stated as one of the major complications of this motor, and sensory information to and from the skin
procedure. ESP block has been used as successful and deep muscles of the back. The extent of the
postoperative analgesic treatment method in block and its analgesic effect is variable due to the
abdominal, thoracic, and breast surgeries46-49. variability in the craniocaudal spread of the drug50.
Additionally, ESP blocks have also been used for Different studies compared ESP block group with
postoperative analgesia in spinal surgery and control group for post-operative analgesia in patients
published as case reports41-43. undergoing elective lumber surgery and concluded
The erector spinae include several muscles, that there was decreased pain score at different time
such as the iliocostalis, longissimus, and spinalis points after surgery, decreased 24-hour postoperative
muscles. They extend bilaterally from skull to sacral cumulative opioid requirements, time to first
region longitudinally and from spinous to transverse analgesic requirement was significantly longer, as
process up to ribs horizontally. This block is well as more favourable patient satisfaction scores in
performed post induction, after making patient ESP group of patients51,52. Another retrospective
prone, although it can also be performed in a sitting study concluded that the ESP block for patients
or lateral decubitus positions. As with the majority undergoing lumbar laminoplasty provides more
of the other plane blocks, this block is also effective analgesia, which persists until the morning
performed under ultrasound guidance. After strict of the second postoperative day53.
aseptic precaution, a high-frequency (10–15 MHz)
linear-array ultrasound transducer (offers a higher- 3. Conclusion
resolution image) is needed, although a low-
frequency curvilinear probe is beneficial in obese Application of regional anesthetic techniques in the
patients where the transverse processes is situated at domain of neurosurgery had conventionally been an
a depth more than 4 cm. To visualize the transverse overlooked clinical area. Perioperative pain
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Regional Anesthesia in Neuroanesthesia Practice
management in neurosurgical patients has been awareness of pain management in general, along
traditionally reliant on intravenous and oral with advances in understanding of pain modulation
analgesics. Apart from the reasons previously and pathophysiology, has led to improved practice
mentioned, regional techniques had concerns of and perioperative care of patients, leading to
motor blockade, failure and infection, which resurgence in regional techniques. This has resulted
restricted their widespread usage. However, better in better operative conditions and parameters, along
visualization with ultrasound, refinements in with an increased patient satisfaction, in terms of
techniques and development of LA with lower analgesia, mobility and early recovery. Since the
propensity of motor blockade has revitalized their area is still relatively unexplored, with a vast
role in intraoperative management neurosurgical potential for improvements in terms of new
procedures and the postoperative pain, which has strategies and techniques, it is worthwhile to
been usually inconsistently recognized and undertake further studies and investigations in this
inadequately treated. Simultaneously, an increased regard.
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Regional Anesthesia in Neuroanesthesia Practice
Table 1. Continued
Study Type of Type of surgery Regional Intervention Findings
study nerve
block
Bala et al.9 RCT Supratentorial Scalp 40 patients were randomized in Significant decrease in
2006 craniotomy block study group (skull block with 0.5% incidence and severity of
bupivacaine with 1:400,000 postoperative pain, as well as a
adrenaline) vs. control group (skull decrease in analgesic
block with normal saline with requirement in scalp nerve
1:400,000 adrenaline), both after block group of patients.
skin closure.
Nguyen A et RCT Supratentorial Scalp 30 patients were randomly divided Postoperative scalp block
al.10 craniotomy block into two groups: ropivacaine (scalp decreases the severity of pain
2001 block with ropivacaine 0.75%) and after craniotomy 4, 8, 12, 16,
saline (scalp block with 0.9% 20, 24, and 48 h.
saline).
Jose R et RCT Supratentorial Scalp 90 patients were randomized in Addition of dexamethasone as
al.12 craniotomy block study group (skull block with local an adjuvant to local anesthetics
2017 anesthetics and 8 mg of in scalp nerve blocks in the
dexamethasone) vs. control group setting of perioperative steroid
(skull block with local anesthetics therapy does not appear to
and 2 ml of normal saline) soon provide any additional benefit
after induction of general with respect to prolongation of
anesthesia. the duration of the block
Yasser M. et RCT Awake Scalp 40 patients were randomly Use of either 8 mg
al.13 craniotomy block allocated into 4 equal scalp block dexamethasone, or 500 mg
2020 groups. Group I (bupivacaine MgSO4, or both, as adjuvant to
0.25%+lidocaine 1% with bupivacaine-lidocaine for scalp
1:200,000 epinephrine) Group II block improves efficacy of the
(same as Group I + 8 mg block.
dexamethasone) Group III (same
as Group I + 500
mgMgSO4) Group IV (same as
Group I + 8 mg dexamethasone +
500 mgMgSO4).
Guilfoyle Meta- Supratentorial Scalp 7 RCTs with a total recruitment of Meta-analysis shows a
MR et al.14 analysis craniotomy block 320 patients evaluating the effect consistent finding of reduced
2013 of regional scalp block on postoperative pain.
postoperative pain after
craniotomy.
Wardhana A Meta- Supratentorial Scalp A total of 10 RCTs (551 patients) Scalp block might be effective
et al.15 analysis craniotomy block evaluating the effect of scalp block at <6 h post craniotomy with
2019 on post craniotomy pain compared very-low quality evidence. It
to no-scalp block. also shows moderate effect on
reducing total 24 h opioid
consumption.
Ayoub C et RCT Supratentorial Scalp Fifty craniotomy patients were Quality of analgesia and
al.16 craniotomy block randomized into two groups: postoperative hemodynamic
2006 morphine (morphine 0.1 mg/kg IV profile was similar in both
after dural closure and scalp block groups.
with 0.9% saline at the end of
surgery) and block (0.9% saline
after dural closure and scalp block
with a 1:1 mixture of bupivacaine
0.5% and lidocaine 2% at the end
of surgery).
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Regional Anesthesia in Neuroanesthesia Practice
Table 1. Continued
Study Type of Type of surgery Regional Intervention Findings
study nerve
block
Jonnavithula RCT Transsphenoidal Infraorbital 20 patients were randomized In addition to postoperative
N et al.18 hypophysectomy block into two groups: group I analgesia infraorbital block useful
2011 (bilateral infraorbital block in providing rapid, smooth, pain
with 0.5% bupivacaine) vs free emergence from anesthesia,
group II (no block). facilitating prompt neurological
assessment; provides effective
postoperative analgesia and
relieves discomfort of nasal
packing.
Mariano ER RCT Nasal surgery Infraorbital 40 patients were randomly Compared to group NS, subjects
et al.19 block assigned to receive bilateral in group IOB did experience a
2009 infraorbital injections with reduction in postoperative pain.
either 0.5% bupivacaine
(group IOB) or normal
saline (group NS) using an
intraoral technique.
McAdam D Case Transsphenoidal Infraorbital Bilateral infraorbital nerve Patient didn’t need additional
et al.23 Report hypophysectomy block blocks were performed analgesia in postoperative period.
2005 using an intraoral approach
in an 11-year old after
induction and repeated at the
conclusion of surgery.
Wang H et RCT Anterior cervical Cervical 356 patients who underwent Group A patients had better
al. 34 discectomy and plexus 1-level ACDF for cervical intraoperative hemodynamic
2017 fusion (ACDF) block spinal myelopathy were stability with no intraoperative
assigned to receive general pain. However, it requires longer
anesthesia (group A) and surgery and anesthesia time, and
cervical plexus block (group need more postoperative analgesic
B). & anesthesia cost.
Lewis SC et Multicenter Carotid Cervical Multicenter RCT of 3526 The two groups did not
al.35 RCT endarterectomy plexus patients with symptomatic significantly differ for quality of
(GALA block or asymptomatic carotid life, length of hospital stay in the
TRIAL) stenosis from 95 centers in prespecified subgroups of age,
2008 24 countries. Participants contralateral carotid occlusion,
were randomly assigned in and baseline surgical risk.
equal number to carotid
endarterectomy
under general or local
anesthesia.
Mariappan RCT Anterior cervical Cervical 46 patients were randomized Preoperative SCPB is an effective
et al 36 discectomy and plexus to receive either a strategy for improving the early
2015 fusion (ACDF) block superficial cervical plexus quality of recovery in patients
block (SCPB) (0.25% undergoing single- or two-level
bupivacaine, 10 mL) or no ACDF.
block for elective single- or
two-level ACDF.
Melvin JP et Case series Lumbosacral Erector Bilateral erector spinae All patients had minimal
al.49 spine surgery, spinae block blocks at the T10 or postoperative pain and very low
2018 lumbar block T12 level in six patients. postoperative opioid
decompressions, (ESP) requirements.
sacral
laminoplasties &
coccygectomy
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Regional Anesthesia in Neuroanesthesia Practice
Table 1. Continued
Study Type of Type of surgery Regional Intervention Findings
study nerve
block
Yayik AM RCT Lumbar Erector 60 patients undergoing open Significant postoperative
et al 52 decompression spinae lumbar decompression surgery pain control, decreased
2019 surgery block were randomly assigned to 2 analgesic requirement and
groups. The ESP group increased time to first
received ultrasound guided analgesic requirement in
bilateral erector spinae block ESP group.
with 0.25% bupivacaine.
In the control group, no
intervention was performed.
Ueshima H Retrospective Lumbar spinal Erector 41 patients undergoing lumbar The ESP block provides
et al 53 study surgery spinae spinal surgery were effective postoperative
2019 block retrospectively analyzed. Of analgesic effect for 24 hours
these, 23 received only general in patients undergoing
anesthesia (G group), whereas lumbar spinal surgery.
the other 18 patients received
the ESP block in addition to
general anesthesia (E group).
Singh et al RCT Lumbar Erector 40 adults were randomly Significant decrease in
54
spine surgery spinae assigned to the control group- postoperative pain control
2019 block no preoperative ESP block, or and analgesic requirement in
ESP block group-preoperative ESP block group.
bilateral ultrasound-guided ESP Patient satisfaction scores
block. were more favourable within
the block group.
RCT – randomised control study
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Regional Anesthesia in Neuroanesthesia Practice
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