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• W2077761709 abstract "Sir: For the majority of scalp lesions, local anesthesia is adequate. In patients with more advanced lesions and who thus require sacrifice of a larger area of skin, general anesthesia is required but might be risky because of comorbid illness and/or advanced age, and surgery is sometimes abandoned. In cases with posterior scalp location, we suggest greater occipital nerve block–assisted resection. Since its first description by Bogduk,1 greater occipital nerve block has been used in neurosurgery as a part of anesthesia for supratentorial craniotomies, for chronic cluster headache,2 and to reduce postoperative occipital headache and posterior neck pain after thyroid surgery.3 To the best of our knowledge, greater occipital nerve block has not been systematically suggested for major oncologic scalp surgery. Eight patients were treated with the greater occipital nerve block–assisted resection of five infiltrating malignant and three benign huge lesions of the posterior scalp (Fig. 1). Five of the patients were American Association of Anesthesiologists class III. In these patients, a cranial bone milling/resection was performed because tumors were infiltrating. The blocks were performed with 8 ml of 1% ropivacaine for both sides from 2 cm lateral and 2 cm inferior to the external occipital protuberance in all cases. If needed, mepivacaine 1% was infused to the anterior margin of resection. Five minutes after injection, anesthesia in the distribution of the injected nerve was evaluated with the pinprick test. In case the patient experienced major discomfort, propofol could be infused at a mean dose of less than or equal to 0.7 mg/kg/hour. The analgesic level was measured by use of an 11-point numerical rating scale and a five-point verbal rating scale. Every 10 minutes, we asked the patients to quantify the level of comfort according to a five-point verbal rating scale.Fig. 1.: A patient with infiltrating squamocellular carcinoma of the posterior scalp.Surgical resections were performed with success in every patient (Fig. 2), as previously planned, lasting 45 minutes to 1 hour. No complaint of pain during excision, bone milling, or reconstruction was reported. When complete anesthesia of the greater occipital nerve area was achieved, 0 points were registered for the numerical and verbal rating scales, and all patients reported a verbal rating scale score of 1. After the third hour, pain increased in a progressive way for a couple of hours, but the numerical rating scale score was always 2 or less and the verbal rating scale score was always 1 or less. At hour 16 ± 1.73, paresthesia was reported by patients. Every patient was discharged the day after surgery and asserted that they would have undergone the same anesthetic technique.Fig. 2.: The same patient as shown in Figure 1, demonstrating the postoperative result after greater occipital nerve block–assisted resection and reconstruction.Patients requiring oncologic surgery of the scalp are often elderly, with comorbid illness, so that general anesthesia is not always recommended,4,5 and sometimes surgery has to be abandoned in favor of radiotherapy. The outcome of the elder patient after general anesthesia is very unpredictable, and they often report consciousness disorder for some days. We think that in these cases, greater occipital nerve block–assisted surgery is a valid technical option that gives a long-lasting effect (16 hours), is accepted by patients, and is easy to perform. Gabriele Finco, M.D. Department of Anesthesiology and Resuscitation Matteo Atzeni, M.D. Section of Plastic Surgery Department of Surgery Mario Musu, M.D. Department of Anesthesiology and Resuscitation Sara Maxia, M.D. Diego Ribuffo, M.D. Section of Plastic Surgery Department of Surgery Cagliari University Hospital Monserrato, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this article." @default.
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• W2077761709 date "2010-02-01" @default.
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• W2077761709 title "Greater Occipital Nerve Block for Surgical Resection of Major Infiltrating Lesions of the Posterior Scalp" @default.
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• W2077761709 doi "https://doi.org/10.1097/prs.0b013e3181c72457" @default.
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