Neurosurgery and Regional Anesthesia

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In this episode, we will explore the various regional anesthesia techniques used in neurosurgery, specifically focusing on blocks for head, neck, and spinal surgeries.

Segment 1: Blocks used in Head and Neck Surgeries

1. Scalp Block:

• The scalp block involves blocking six nerves that provide sensory innervation to the scalp.
• It is performed by subcutaneous infiltration of local anesthetics (such as bupivacaine, ropivacaine, or levobupivacaine) for each nerve.
• Ultrasound guidance has improved the precision of block administration.
• The main indication for a scalp block is awake craniotomy, but it is also used in other procedures like deep brain stimulation and cranioplasty surgery.
• Scalp block offers advantages such as accurate neurological evaluation, pre-emptive analgesia, and hemodynamic stability during surgery.
• It also reduces postoperative pain, the need for rescue analgesics, and pain scores in the early postoperative period.

1. Infraorbital Block (IOB):

• The infraorbital nerve block targets the infraorbital nerve, which supplies the skin and mucous membrane of the upper lip, lower eyelid, and cheek.
• The IOB can be performed using the classical landmark technique or ultrasound guidance.
• Ultrasound guidance provides real-time visualization and accurate needle placement.
• IOB combined with general anesthesia is beneficial for postoperative pain relief in procedures like endoscopic trans-nasal trans-sphenoidal (TNTS) approach for pituitary tumor excision.
• Other regional techniques like sphenopalatine ganglion block and maxillary nerve blocks have also been attempted for transsphenoidal surgeries.

1. Trigeminal Nerve Block:

• Trigeminal nerve block is used for patients unresponsive to medical management of trigeminal neuralgia.
• Traditionally performed using the paresthesia technique, ultrasound guidance allows real-time visualization and confirmation of local anesthetic spread.
• Ultrasound guidance helps locate the Gasserian ganglion and visualize the trigeminal ganglion, providing a safe and radiation-free procedure for pain relief.

Segment 2: Blocks used for Spinal Surgeries

1. Cervical Plexus Block (CPB):

• CPB is commonly used in carotid endarterectomy (CEA) and cervical spine surgery.
• Different levels of CPB can be performed depending on the depth of injection.
• Superficial CPB involves injecting local anesthetic superficially into the deep cervical fascia.
• Deep CPB requires depositing local anesthetic deep to the prevertebral fascia.
• CPB helps in monitoring cerebral blood flow during CEA and provides postoperative pain relief.
• Ultrasound guidance can be used for superficial CPB, ensuring accurate needle placement and local anesthetic spread.

1. Erector Spinae Block (ESB):

• ESB is used for pain control in spinal surgeries.
• It involves depositing local anesthetic in the plane between the erector spinae muscle and the transverse process.
• ESB provides effective postoperative analgesia and reduces opioid consumption.

Regional anesthesia techniques play a crucial role in neurosurgery, providing effective pain relief and improving patient outcomes. Blocks like scalp block, infraorbital block, trigeminal nerve block, cervical plexus block, and erector spinae block offer numerous advantages in specific procedures. Ultrasound guidance has enhanced the precision and safety of block administration. These techniques contribute to improved surgical outcomes and patient satisfaction in neurosurgical procedures.

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References Kaushal A, Haldar R. Regional Anesthesia in Neuroanesthesia Practice. Discoveries (Craiova). 2020 Jun 29;8(2):e111. doi: 10.15190/d.2020.8. PMID: 32637571; PMCID: PMC7332314.