Scalp Nerve Block, Local Anesthetic Infiltration, and Postoperative Pain After Craniotomy: A Systematic Review and Network Meta-analysis of Randomized Trials

Abstract

The most efficacious methods for controlling postoperative pain in craniotomy remain unknown. A systematic review and network meta-analysis were performed to compare the efficacies of different strategies of scalp nerve block (SNB), scalp infiltration (SI), and control in patients undergoing craniotomy. MEDLINE, Embase, and CENTRAL databases were searched for randomized controlled trials. The primary outcome was postoperative 24-hour pain score, and the secondary outcome was opioid consumption within the first 24 hour after surgery. The effect was estimated using the between-group mean difference and ranked using the surface under the cumulative ranking curve (SUCRA) score. Twenty-four randomized trials were identified for inclusion. SNB using ropivacaine reduced postoperative 24-hour pain score when compared with control (mean difference [95% credible interval], -2.04 [-3.13, -0.94]; low quality), and when compared with SI using ropivacaine (-1.77 [-3.04, -0.51]; low quality) or bupivacaine (-1.96 [-3.65, -0.22]; low quality). SNB using ropivacaine was likely the most efficacious method for pain control (SUCRA, 91%), and also reduced opioid consumption within the first postoperative 24 hours as compared with control (mean difference [95% credible interval], -11.91 [-22.42, -1.4]; low quality). SNB using bupivacaine, lidocaine, and epinephrine combined, and SNB using ropivacaine, were likely the most efficacious methods for opioid consumption reduction (SUCRA, 88% and 80%, respectively). In summary, different methods of SNB / SI seem to have different efficacies after craniotomy. SNB using ropivacaine may be superior to other methods for postcraniotomy pain control; however, the overall quality of evidence was low.

Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2023

“…5 Luo et al conducted a systematic review and meta-analysis of 24 randomized controlled trials (RCTs) (1,361 patients) comparing the efficacies of different strategies (scalp nerve block [SNB] and scalp infiltration [SI]) in postoperative pain in patients undergoing craniotomy. 5 6 SNB using ropivacaine was found to be the most efficacious method for pain control (success rate of 91%) and reduced postoperative opioid consumption in the first 24 hours compared with control (mean difference [MD] = − 11.91, 95% CI [–22.42, –1.4]; low quality). SNB using ropivacaine reduced postoperative (24-hour) pain score when compared with control (mean difference [MD] = − 2.04, 95% CI [–3.13, –0.94]; low quality), and when compared with SI using ropivacaine (MD= –1.77, 95% CI [–3.04, –0.51]; low quality) or bupivacaine (MD = –1.96, 95% CI [–3.65, –0.22]; low quality).…”