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Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 266-267

Bilateral ultrasound-guided continuous cervical erector spinae plane block in suboccipital craniotomy

1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
3 Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India

Correspondence Address:
Ajeet Kumar
Room no 502, B-Block, OT complex, AIIMS, Patna - 801 507, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.sja_699_21

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Date of Submission29-Sep-2021
Date of Decision02-Oct-2021
Date of Acceptance03-Oct-2021
Date of Web Publication17-Mar-2022

How to cite this article:
Kumar A, Kumar A, Sinha C, Jha VC, Sagdeo GD. Bilateral ultrasound-guided continuous cervical erector spinae plane block in suboccipital craniotomy. Saudi J Anaesth 2022;16:266-7

How to cite this URL:
Kumar A, Kumar A, Sinha C, Jha VC, Sagdeo GD. Bilateral ultrasound-guided continuous cervical erector spinae plane block in suboccipital craniotomy. Saudi J Anaesth [serial online] 2022 [cited 2022 Sep 28];16:266-7. Available from:

The midline suboccipital craniotomy is the preferred approach of exposure for cerebellar vermis, posterior inferior pontine and medullary, foramen magnum, midline cerebellum, and pineal regions. Major portion of the posterior scalp is innervated by greater occipital nerve (GON), which arises from the posterior ramus of the second cervical nerve (C2) root and to a lesser extent from fibers of the third cervical nerve (C3).[1],[2] The GON innervates the skin of the back of the scalp up to the vertex of the skull.[2] Third occipital nerve is a superficial medial branch of the dorsal ramus of the C3 spinal nerve and innervates the region of the skin below the superior nuchal line after innervating the semispinalis capitis.[1] Here, we have described our experience of continuous bilateral upper cervical erector spinae plane (ESP) block to provide perioperative analgesia in a 14-year-old male patient scheduled for midline suboccipital craniotomy. Written and informed consent for publication was taken from parents.

Anesthesia was induced with injection fentanyl 2 μg/kg, propofol 2 mg/kg, and vecuronium 0.08 mg/kg. After securing the airway, the patient was placed in the prone position with Mayfield head fixation; US-guided (US machine M-Turbo, Fujifilm Sonosite Edge II, Inc, Bothell, WA, United States) ESP block was given at C2-axis vertebra. The probe was kept transversally in a midline position at the level of the target cervical vertebra. After identification of the spinous process and transverse process, the probe was slid to ipsilateral side. Epidural Tuohy needle (B. Braun, Melsungen, Germany, 18G) was inserted in-plane to target the the lateral edge of the transverse process [Figure 1] below the erector spinae muscle. After confirming the needle tip position by hydro-dissection, 10-ml LA solution (0.2% ropivacaine) was injected bilaterally [Figure 1]. Epidural catheter of 20 G was threaded on both sides. The catheter was tunnelled to secure it [Figure 1]. Patient's trachea was extubated after overnight ventilation. Ten-ml volume of 0.2% ropivacaine was given through both catheter every 8 hours during postoperative period. The patient was assessed at 24, 48, and 72 hours postoperatively with numerical rating scale (NRS) being 1/10, 2/10, and 1/10.
Figure 1: Sonoanatomy of transverse approach to the cervical ESP block, and an in-plane approach to catheter placement

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The possible mechanism of increased postoperative pain in suboccipital craniotomy could be extended muscle damage during resection of posterior cervical muscles.[3] Regional analgesia techniques to ameliorate post-craniotomy pain includes scalp nerve block and scalp infiltration with local anesthesia (LA).[4] Greater occipital nerve block have been used for awake craniotomy to cover posterior component of scalp block. Generally, this block was given by injecting local anaesthetic medial to the occipital artery along the superior nuchal line.[5] However, this site is not appropriate for continuous GON block because of nearby suboccipital craniotomy incision site. In this case report, we have targeted the greater occipital nerve and third occipital nerve at extracranial region (posterior ramus of C2 and C3 nerve) by bilateral upper cervical ESP block. The continuous catheter technique of this block could provide opioid-sparing regimen of pain management in suboccipital craniotomy.

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There are no conflicts of interest.

  References Top

Choi I, Jeon SR. Neuralgias of the head: Occipital neuralgia. J Korean Med Sci 2016;31:479-88.  Back to cited text no. 1
Kemp WJ, Tubbs RS, Cohen-Gadol AA. The innervation of the scalp: A comprehensive review including anatomy, pathology, and neurosurgical correlates. Surg Neurol Int 2011;2:178.  Back to cited text no. 2
[PUBMED]  [Full text]  
Gottschalk A, Berkow LC, Stevens RD, Mirski M, Thompson RE, White ED, et al. Prospective evaluation of pain and analgesic use following major elective intracranial surgery. J Neurosurg 2007;106:210-6.  Back to cited text no. 3
Akcil EF, Dilmen OK, Vehid H, Ibısoglu LS, Tunali Y. Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration. Clin Neurol Neurosurg 2017;154:98-103.  Back to cited text no. 4
Burnand C, Sebastian J. Anaesthesia for awake craniotomy. Contin Educ Anaesth Crit Care Pain 2014;14:6-11.  Back to cited text no. 5


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