Needles for Neurosurgery: Do preoperative skull blocks improve post-operative pain scores?

Interestingly, not the primary endpoint studied in this article. While the study was adequately powered to detect the hemodynamic endpoint, the same is not true for the post-operative pain scores. The aggregate 1-4h data do suggest a trend towards improvement in post-op pain scores that is statistically significant.

All in all, a nicely written article worth reading. Especially enjoyed the well-written and appropriately researched discussion.

J Neurosurg. 2008 Jul;109(1):44-9
Effect of ropivacaine skull block on perioperative outcomes in patients with supratentorial brain tumors and comparison with remifentanil: a pilot study.
Gazoni FM, Pouratian N, Nemergut EC.

Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia 22908-0710, USA.

OBJECT: Skull blockade for craniotomy may result in the reduction of sympathetic stimulation associated with the application of head pins (“pinning”), improvement in intraoperative hemodynamic stability, and a decrease in intraoperative anesthetic requirements. Postoperative benefits may include a decrease in pain, in analgesic requirements, and in the incidence of nausea and vomiting. The authors examined the potential benefits of a skull block in patients in whom a maintenance anesthetic consisting of sevoflurane and a titratable remifentanil infusion was used. In other studies examining the ability of a skull block to improve perioperative outcomes, investigators have not used remifentanil. METHODS: Thirty patients presenting for resection of a supratentorial tumor were prospectively enrolled. Patients were randomized into 2 groups as follows: 14 patients (skull block group) received a skull block with 0.5% ropivacaine at least 15 minutes prior to pinning, whereas the remaining 16 patients (control group) did not. RESULTS: Patients in the skull block group did not have a significant increase in blood pressure or heart rate with placement of head pins, whereas patients in the control group did. Nevertheless, there was no difference in blood pressure variability between the groups. The mean intraoperative concentration of sevoflurane (1.0% in both groups, p = 0.703) and remifentanil (0.163 microg/kg/min compared with 0.205 microg/kg/min, p = 0.186) used was similar in both groups. During the postoperative period, there was no difference in the 1-, 2-, or 4-hour visual analog scale scores; in the need for postoperative narcotic analgesia (0.274 morphine equivalent mg/kg compared with 0.517 morphine equivalent mg/kg, p = 0.162); or in the incidence of nausea or vomiting. CONCLUSIONS:Prospective analysis of perioperative skull blockade failed to demonstrate significant benefit in patients treated with a remifentanil infusion.