A Randomized, Double-Dummy, Emergency Department-Based Study of Greater Occipital Nerve Block With Bupivacaine vs Intravenous Metoclopramide for Treatment of Migraine.

BACKGROUND: Greater occipital nerve blocks (GONB) are used increasingly to treat acute migraine. OBJECTIVE: We conducted a randomized controlled trial to determine whether GONB was as effective as intravenous metoclopramide for migraine. METHODS: This was a double-dummy, double-blind, parallel-arm, non-inferiority study conducted in 2 emergency departments (EDs). Patients with migraine of moderate or severe intensity were randomized to receive bilateral GONB with each side administered 3 mL of bupivacaine 0.5% or metoclopramide 10 mg IV, the putative standard of care. The primary outcome was improvement in pain on a 0-10 scale between time 0 and 1 hour later. To reject the null hypothesis that metoclopramide would be more efficacious in relieving pain, we required that the lower limit of the 95% CI for the difference in pain improvement between those randomized to GONB vs those randomized to metoclopramide be >-1.3, a validated minimum clinically important difference. Secondary outcomes included sustained headache relief, defined as achieving and maintaining for 48 hours a headache level of mild or none without the use of additional analgesic medication, and the use of rescue medication in the ED. RESULTS: Over a 2.5-year study period, 1358 patients were screened for participation and 99 were randomized, 51 to GONB and 48 to metoclopramide. All of these patients were included in the primary analysis. Patients who received the GONB reported mean improvement of 5.0 (95% CI: 4.1, 5.8) while those who received metoclopramide reported a larger mean improvement of 6.1 (95% CI: 5.2, 6.9). The 95% CI for the between group difference of -1.1 was -2.3, 0.1. Sustained headache relief was reported by 11/51 (22%) GONB and 18/47 (38%) metoclopramide patients (95% CI for rounded difference of 17%: -1, 35%). Of the 51 GONB patients, 17 (33%) required rescue medication in the ED vs 8/48 (17%) metoclopramide patients (95% CI for rounded difference of 17%: 0, 33%). An adverse event was reported by 16/51 (31%) GONB patients and 18/48 (38%) metoclopramide patients (95% CI for (rounded) difference of 6%: -13, 25%). CONCLUSION: GONB with bupivacaine was not as efficacious as IV metoclopramide for the first-line treatment of migraine in the ED.

Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta-analysis.

INTRODUCTION: The treatment of cluster headache (CH) is challenging in view of the few evidence-based treatments. The authors aim to summarize the evidence of efficacy and safety of greater occipital nerve blocks (GONBs) in CH. AREAS COVERED: The authors included papers indexed in PubMed and Web of Science from the beginning of indexing to 5 May 2020. They included both observational and randomized studies referring to patients with episodic and/or chronic CH. The authors identified 12 studies on 365 patients. Five studies (two randomized controlled trials) could be included in the meta-analyses. The pooled proportion of pain-free subjects at 1 month was 50% (95% CI 24-76%) with considerable heterogeneity (I2 = 88%; P < 0.01). The pooled relative risk ratio of pain freedom at 1 month in active versus control groups in the two included randomized controlled trials was 4.86 (95% CI, 1.35-17.55) without statistical heterogeneity (I2 = 0%; P = 0.39). Three studies showed decreased attack intensity, frequency, and duration after GONBs. The studies reported mild and transient adverse events. EXPERT OPINION: Despite several limitations and considerable heterogeneity, the available data support the efficacy and safety of GONBs for the treatment of CH. Further large randomized trials are needed to confirm efficacy and establish optimal treatment protocols.

Great Auricular Neuralgia: Case Series.

BACKGROUND/OBJECTIVE: The great auricular nerve (GAN) arises from C2-C3 and provides innervation over the skin in the pre-auricular region, jaw angle, posteroinferior pinna, and mastoid. Although damage to the GAN has been reported following trauma or procedures nearby this nerve course, neuralgia of this nerve is uncommon with knowledge based on a handful of case reports in literature. The objective of this study is to describe the presentation, treatment, and outcome of 13 cases of GAN neuralgia. METHODS: Case series. Retrospecive review of charts from 1994 to 2018 with diagnoses: "auricular neuralgia," "auricular neuritis," or "auricular neuropathy." We included subjects with neuralgic pain within the distribution of the GAN, and excluded patients with atypical facial pain, GAN neuropathy, or unclear etiology. RESULTS: Of 79 charts, 13 patients met criteria (age at onset 11-59; 11 women, 2 men). Pain was most often described as paroxysmal stabbing provoked by: turning the head (n = 7), touching the neck (n = 5), neck position during sleep (n = 2), jaw movement (n = 2), and other (n = 2). Seven patients received GAN blocks: all noted dramatic improvement in pain, including 3 who continued to receive serial blocks at our institution successfully for the next 2 to 5 years. Two patients successfully transitioned from GAN blocks to GAN stimulators. One patient with GAN lymphoma had resolution of pain following GAN resection. CONCLUSION: GAN neuralgia should be considered in the differential for periauricular pain. GAN blocks or stimulators may be helpful for pain management.

Ultrasound-guided intermediate cervical plexus and additional peripheral facial nerve block for carotid endarterectomy : A prospective pilot study.

BACKGROUND AND OBJECTIVES: Ultrasound-guided intermediate cervical plexus block with perivascular local anesthetic infiltration is an established anesthetic procedure for carotid endarterectomy. In this prospective pilot study an additional subplatysmal block of the superficial ansa cervicalis is presented for the first time. The target structures are the anastomoses between the facial nerve (cervical and marginal mandibular branches) and cervical plexus. METHODS: An ultrasound-guided intermediate cervical plexus block (20 ml of ropivacaine 0.75%) was performed (n = 28). Then, depending on the individual sonoanatomy, 5 ml of prilocaine 1% was injected into the carotid sheath (group 1: no perivascular infiltration, n = 14, group 2: perivascular infiltration, n = 14). The third step was subplatysmal injection of 5 ml of prilocaine 1% between the medial edge of the sternocleidomastoid muscle and the submandibular gland (n = 28). The investigated parameters included the need for supplementation and block-related side effects. RESULTS: The requirement for supplemental local anesthetic infiltration in the skin incision area was minimal at mean (M) 1.1 ml (standard deviation (SD) ±2.4 ml). Perivascular infiltration in group 2 significantly decreased the total amount of local anesthetic supplemented: group 1 M = 4.2 ml (SD = ±3.1 ml), group 2 M = 1.7 ml (SD = ±2.0 ml) (p = 0.018). The incidence of block-related side effects was not significantly different between the two groups. CONCLUSION: This study presents an ultrasound-guided subplatysmal block of the superficial ansa cervicalis for the first time, with the aim of optimizing anesthesia quality during surgical interventions in the carotid triangle.

Ultrasound-Guided versus Fluoroscopy-Guided Deep Cervical Plexus Block for the Treatment of Cervicogenic Headache.

Objective. The aim of this study was to compare the efficacy of ultrasound-guided deep cervical plexus block with fluoroscopy-guided deep cervical plexus block for patients with cervicogenic headache (CeH). Methods. A total of 56 patients with CeH were recruited and randomly assigned to either the ultrasound-guided (US) or the fluoroscopy-guided (FL) injection group. A mixture of 2-4 mL 1% lidocaine and 7 mg betamethasone was injected along C2 and/or C3 transverse process. The measurement of pain was evaluated by patients' ratings of a 10-point numerical pain scale (NPS) before and 2 wks, 12 wks, and 24 wks after treatments. Results. The blocking procedures were well tolerated. The pain intensity, as measured by NPS, significantly decreased at 2 wks after injection treatment in both US and FL groups, respectively, compared with that of baseline (P < 0.05). The blocking procedures had continued, and comparable pain relieving effects appeared at 12 wks and 24 wks after treatment in both US and FL groups. There were no significant differences observed in the NPS before and 2 wks, 12 wks, and 24 wks after treatment between US and FL groups. Conclusions. The US-guided approach showed similar satisfactory effect as the FL-guided block. Ultrasonography can be an alternative method for its convenience and efficacy in deep cervical plexus block for CeH patients without radiation exposure.

[Combined anaesthesia in reconstructive operations on carotid arteries].

MATERIAL AND METHODS: The authors analysed the protocols of anaesthesia in a total of 100 patients operated on carotid arteries. Depending upon the method of anaesthesiological management, the patients were subdivided into 4 groups comparable by age, gender, physical status, and the scope of the intervention. Group One patients received only propofol-fentanyl total intravenous anaesthesia (TIVA). Group Two, Three and Four patients received combined anaesthesia which was as follows: in Group Two - TIVA based on propofol and fentanyl with superficial cervical plexus block (SCPB), in Group Three - combined anaesthesia based on sevoflurane in a combination with SCPB, and in Group Four - combined anaesthesia based on isoflurane and fentanyl in a combination with SCPB. Analysing the results, we assessed the parameters of arterial pressure, BIS values, also calculating the doses of the anaesthetics and demand for narcotic analgesics during anaesthesia. The quality of the postoperative period was evaluated according to the 5-point vertebral rating scale (VRS). RESULTS: Comparing the need in fentanyl for maintaining general anaesthesia revealed considerably higher doses thereof in Group One patients. Analysing the dynamics of the parameters of mean arterial pressure showed their higher stability in Groups 2, 3 and 4, which was conditioned by better antinociceptive protection with SCPB added. The degree of the postoperative pain syndrome within 48 hours according to the VRS in Group One patients was higher as compared with that in Groups Two, Three and Four patients who additionally received SCPB. CONCLUSION: TIVA based on propofol and fentanyl combined with SCPB provides better analgesia in the area of the operation and decreases the demand for narcotic analgesics. Combined anaesthesia provides better stability of the haemodynamic parameters at the stages of surgery, also decreasing the degree of postoperative pain.

Addition of dexmedetomidine to ropivacaine improves cervical plexus block.

OBJECTIVE: To investigate the sensory block onset time, duration time, and side effects of adding dexmedetomidine to ropivacaine for cervical plexus block. METHODS: Forty American Society of Anesthesiologists (ASA) Class I or II adult patients who were scheduled to undergo thyroid surgery were randomly allocated to the following groups to receive cervical plexus block: 30 mL of 0.375% ropivacaine combined with 1 µg kg(-1) of dexmedetomidine; 30 mL of 0.375% ropivacaine combined with saline (control). The sensory block onset time, duration of analgesia, mean arterial pressure (MAP), heart rate (HR), and the incidences of side effects, such as hypotension, bradycardia, and hypoxemia were recorded. RESULTS: The addition of dexmedetomidine to ropivacaine (Group D) shortened the sensory block onset time compared with the ropivacaine group (Group C) (95% confidence interval [CI] 4.18-5.26; p < 0.05). The duration of analgesia of cervical plexus block in Group D was significantly longer than that in Group C (95% CI 295.96-311.12; p < 0.05). The Ramsay sedation score at 5, 10, 20, 40, 60, 90, and 120 minutes after local anesthetic administration in Group D was significantly higher than that in Group C (p < 0.05). MAP level and HR level in Group D were significantly lower than that in Group C (p < 0.05). CONCLUSION: The addition of 1 µg kg(-1) dexmedetomidine to ropivacaine for cervical plexus block could shorten the sensory block onset time and extend the duration of analgesia, and increased the quality of analgesia, with the patients being sedated and arousable.

[Effect of electroacupuncture combined with cervical plexus block on stress responses in patients undergoing thyroid surgery].

OBJECTIVE: To observe the effect of electroacupuncture (EA) combined with cervical plexus block (CPB) on the stress response of patients undergoing thyroid surgery. METHODS: Forty thyroidectomy patients were randomly divided into sham EA plus CPB group (sham group) and EA+CPB group (20 cases in each group). For patients of the sham group, deep cervical plexus block (25% ropivacaine hydrochloride + 1% lidocaine hydrochloride) was performed first, followed by inserting acupuncture needles into bilateral Hegu (LI 4) and Neiguan (PC 6) separately without needle manipulation and then connecting the output wires of the EA therapeutic instrument to the handles of the acupuncture needles but without electric current output. For patients of the EA+CPB group, deep cervical plexus block was performed first followed by EA stimulation [10 Hz, (6 +/- 2) mA] of the bilateral LI 4 and PC 6 for 20 min. Systolic blood pressure (SBP), heart rate (HR) and breathing frequency were detected using a multipurpose monitor. Plasma adrenocorticotropic hormone (ACTH) and cortisol (Cor) contents were determined using chemiluminescence method, plasma epinephrine (E) level was detected by enzyme-linked immunosorbent assay, glucose (Glu) assayed by oxidase method, and plasma C-reactive protein (CRP) level detected using immumofluorescence technique. RESULTS: (1) During surgery, the patients' SBP and HR of both sham and EA groups were increased significantly compared with their basic values (P < 0.05), but the levels of the increased SBP and HR of the EA group were obviously lower than those of the sham group (P < 0.05). (2) The levels of plasma ACTH during surgery and at the immediate time after surgery, Cor level at the immediate time after surgery, plasma E and Glu contents during surgery, at the immediate time and on day 1 after surgery, and plasma CRP at the immediate time, and on day 1 and 3 after surgery in the sham group were upregulated considerably (P < 0.05), while the levels of plasma ACTH, Cor, E, Glu and CRP in the above-mentioned time-points of the EA group were all remarkably lower than those of the sham group (P < 0.05). CONCLUSION: EA combined with cervical plexus block significantly reduces peri-operative cardiovascular stress responses and inhibits abnormal increases of plasma stress hormones and inflammatory reaction in patients undergoing thyroid surgery.

Combination of high-resolution ultrasound-guided perivascular regional anesthesia of the internal carotid artery and intermediate cervical plexus block for carotid surgery.

All previously documented regional anesthesia procedures for carotid artery surgery routinely require additional local infiltration or systemic supplementation with opioids to achieve satisfactory analgesia because of the complex innervation of the surgical site. Here, we report a reliable ultrasound-guided anesthesia method for carotid artery surgery. High-resolution ultrasound-guided regional anesthesia using a 12.5-MHz linear ultrasound transducer was performed in 34 patients undergoing carotid endarterectomy. Anesthesia consisted of perivascular regional anesthesia of the internal carotid artery and intermediate cervical plexus block. The internal carotid artery and the nerves of the superficial cervical plexus were identified, and a needle was placed dorsal to the internal carotid artery and directed cranially to the carotid bifurcation under ultrasound visualization. After careful aspiration, local anesthetic was spread around the internal carotid artery and the carotid bifurcation. In the second step, local anesthetic was injected below the sternocleidomastoid muscle along the previously identified nerves of the intermediate cervical plexus. The necessity for intra-operative supplementation and the conversion rate to general anesthesia were recorded. Ultrasonic visualization of the region of interest was possible in all cases. Needle direction was successful in all cases. Three to five milliliters of 0.5% ropivacaine produced satisfactory spread around the carotid bifurcation. For intermediate cervical plexus block, 10 to 20 mL of 0.5% ropivacaine produced sufficient intra-operative analgesia. Conversion to general anesthesia because of an incomplete block was not necessary. Five cases required additional local infiltration with 1% prilocaine (2-6 mL) by the surgeon. Visualization with high-resolution ultrasound yields safe and accurate performance of the block. Because of the low rate of intra-operative supplementation, we conclude that the described ultrasound-guided perivascular anesthesia technique is effective for carotid artery surgery.

Randomized controlled trial on the efficacy of bilateral superficial cervical plexus block in thyroidectomy.

BACKGROUND AND OBJECTIVE: As thyroid surgery is being performed as an ambulatory procedure, recent studies concerning post thyroidectomy analgesia have focused on regional techniques such as bilateral superficial cervical plexus block (BSCPB) and bilateral combined superficial and deep cervical plexus block. But, data regarding the efficacy of BSCPB are controversial. Hence we compared the efficacy of BSCPB with 0.25% bupivacaine with and without clonidine in thyroidectomy, as preventative analgesia. METHODS: Patients (n = 60) undergoing thyroidectomy were randomized into 3 groups (n = 20 each) to receive BSCPB using 15 mL of 0.25% bupivacaine (group B) or 0.25% bupivacaine with 1 µg/kg clonidine (group BC) or 0.9% normal saline (group S) on each side after induction. Intraoperative (fentanyl) and postoperative (morphine) analgesic requirements were assessed. Postoperative pain scores, nausea, vomiting, and sedation were assessed for 24 hours. RESULTS: Intraoperative fentanyl requirement was significantly lesser in groups B and BC (P = 0.012). Postoperative pain scores were significantly lower in group BC (compared to S) at 2 (P = 0.002), 4 (P = 0.016), and 8 (P = 0.012) hours. First analgesic requirement time (min) was significantly higher in groups B and BC (P = 0.002), and postoperative morphine requirement was significantly lower in groups B and BC (P = 0.001). Incidence of postoperative vomiting was significantly reduced in group BC (P = 0.022). CONCLUSION: BSCPB with 0.25% bupivacaine with or without clonidine is effective in reducing both intraoperative and postoperative pain and analgesic requirements in thyroidectomy, and adding clonidine to bupivacaine reduces postoperative vomiting.

Ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in oral and maxillofacial surgery.

OBJECTIVES: We examined the application of an ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in patients undergoing oral and maxillofacial surgery. METHODS: A total of 19 patients receiving ultrasound-guided combined intermediate and deep cervical plexus anaesthesia followed by neck surgery were examined prospectively. The sternocleidomastoid and the levator of the scapula muscles as well as the cervical transverse processes were used as easily depicted ultrasound landmarks for the injection of local anaesthetics. Under ultrasound guidance, a needle was advanced in the fascial band between the sternocleidomastoid and the levator of the scapula muscles and 15 ml of ropivacaine 0.75% was injected. Afterwards, the needle was advanced between the levator of the scapula and the hyperechoic contour of the cervical transverse processes and a further 15 ml of ropivacaine 0.75% was injected. The sensory block of the cervical nerve plexus, the analgesic efficacy of the block within 24 h after injection and potential block-related complications were assessed. RESULTS: All patients showed a complete cervical plexus nerve block. No patient required analgesics within the first 24 h after anaesthesia. Two cases of blood aspiration were recorded. No further cervical plexus block-related complications were observed. CONCLUSIONS: Ultrasound-guided combined intermediate and deep cervical plexus block is a feasible, effective and safe method for oral and maxillofacial surgical procedures.

Regional anesthesia for carotid endarterectomy: a comparison between ropivacaine and levobupivacaine.

BACKGROUND: This study compares ropivacaine and levobupivacaine when administered for cervical plexus block. The authors therefore compared the arterial pressure profile and the incidence of hypotension between drugs. METHODS: Forty-eight patients scheduled for carotid artery surgery (American Society of Anesthesiologists [ASA] 2-3) were randomly assigned to receive levobupivacaine or ropivacaine (24 patients each). Neurological status, arterial pressure profile and control of postoperative pain were the main observed parameters. All patients had severe carotid stenosis (>80%) and/or had suffered transient ischemic attacks (TIAs) or preoperative strokes. The same team performed anesthesia and surgery for carotid endarterectomy; the cervical block was performed according to Moore's technique.Arterial pressure, heart rate and S(a)O(2p) were monitored continuously with particular regard to T0 (baseline), T1 (immediately before carotid clamping), T2 (immediately before declamping) and T3 (at the end of the procedure). Hypotension was defined as the fall of arterial systolic pressure 30% below baseline or less than 100 mmHg. RESULTS: Arterial pressure fell significantly in both groups at T1 with respect to T0 (P<0.0001). Levobupivacaine patients showed higher mean arterial pressure on T0 (112+/-12 mmHg versus 103+/-7 mmHg; P<0.05), thus suggesting a more pronounced vasodilator effect, as confirmed by the larger drop of arterial diastolic pressure (P=0.007). An absolute 6% difference of hypotension-related drug was recorded with levobupivacaine (19%) as compared with ropivacaine (13%) (P=0.28). CONCLUSIONS: Levobupivacaine has a greater vasodilatory effect than ropivacaine. Its higher incidence of hypotension, although not statistically significant, suggests ropivacaine as the drug of choice for cervical plexus block.

Deep cervical plexus block for the treatment of cervicogenic headache.

BACKGROUND: Cervicogenic headache descriptors include its unilateral nature, "signs and symptoms linking it to the neck," and trauma of the neck. Since the pain often occurs over the C2 or C3 nerve root, we used a modification of the deep cervical block technique for treatment of this refractory type headache. OBJECTIVE: To determine the efficacy of a modified deep cervical block for treatment of cervicogenic headache. DESIGN: Prospective case study. METHODS: Thirty-nine patients referred to our pain clinic participated in this study. All patients had undergone extensive screening/diagnostic testing. The blocks were performed unilaterally, without inducing a risk of invading the neural foramen, and repeat injection of the contra-lateral side occurred at >1 week after initial injection. Patients were followed for a 6-month period using a pain diary and questionnaire. Pain was assessed pre- and post-injection and 3 and 6 months post treatments. RESULTS: The mean treatment period was 59 +/- 61 days. The mean values for pre- and post-injection series pain scores (0-10 pain scale) were 9.54 +/- 1.53 and 6.75 +/- 3.23 respectively (p <0.001). Thirty-three percent (33%) of the patients reported pain scores of < or = 4 on the 0-10 pain scale after their last treatment. Effectiveness of the therapy following the injection procedure was rated to be 42% effective for all first injections and 40% effective for last injections (p =NS). Six months evaluations showed that return of moderate to severe pain took 6.62 +/- 8.1 weeks. At the 3 and 6 months follow up evaluations, mean pain scores had returned to 8.41 +/- 2.96 and 8.83 +/- 2.78, respectively. Ten patients (24%) had pain scores < or = 4 at the 3-month evaluation while 7 of the patients (18%) had pain scores < or = 4 at the 6-month evaluation. CONCLUSIONS: These results showed that for some patients this series of blocks provided effective pain relief for 3 months post treatment but by 6 months the pain had returned to pre-treatment levels. This block technique significantly diminished pain after the initial as well as the last treatment. These clinically significant changes in pain relief suggest that more aggressive selective therapy targeting these nerve routes might provide longer lasting relief.

Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: a case series.

Persistent occipital neuralgia can produce severe headaches that are difficult to control by conservative or surgical approaches. We retrospectively describe a series of six patients with severe occipital neuralgia who received conservative and interventional therapies, including oral antidepressants, membrane stabilizers, opioids, and traditional occipital nerve blocks without significant relief. This group then underwent occipital nerve blocks using the botulinum toxin type A (BoNT-A) BOTOX Type A (Allergan, Inc., Irvine, CA, U.S.A.) 50 U for each block (100 U if bilateral). Significant decreases in pain Visual Analog Scale (VAS) scores and improvement in Pain Disability Index (PDI) were observed at four weeks follow-up in five out of six patients following BoNT-A occipital nerve block. The mean VAS score changed from 8 +/- 1.8 (median score of 8.5) to 2 +/- 2.7 (median score of 1), while PDI improved from 51.5 +/- 17.6 (median 56) to 19.5 +/- 21 (median 17.5) and the duration of the pain relief increased to an average of 16.3 +/- 3.2 weeks (median 16) from an average of 1.9 +/- 0.5 weeks (median 2) compared to diagnostic 0.5% bupivacaine block. Following block resolution, the average pain scores and PDI returned to similar levels as before BoNT-A block. In conclusion, BoNT-A occipital nerve blocks provided a much longer duration of analgesia than diagnostic local anesthetics. The functional capacity improvement measured by PDI was profound enough in the majority of the patients to allow patients to resume their regular daily activities for a period of time.