Scalp Blocks

Head & Neck
Written By John Hagen
 
 
 
 
 

Distribution: Four branches of the trigeminal nerve (1-4) and two branches of the cervical nerve roots C2 and C3 (5-6) provide innervation to the anterior and posterior scalp

Indications: Awake craniotomy; Craniosynostosis

Complications:

  • Intravascular injection:  when mixed with a vasoconstrictor, could cause hypertension, LAST

  • Facial nerve palsy: proximity of the facial nerve to nerves being blocked makes this a potential side effect

  • Inadvertent subarachnoid injection

Supratrochlear

  • It innervates the forehead and the anterior part of the scalp.

  • Just medial to the supraorbital nerve injection site, above the eyebrow line; after (-) aspiration inject LA medially

  • Can either be blocked as it emerges above the eyebrow or can be involved by a medial extension of the supraorbital block.

Supraorbital

  • It innervates the forehead, anterior part of the scalp, and top part of the head.

  • Palpate the supraorbital notch, insert the needle perpendicularly, after (-) aspiration inject.

Zygomaticotemporal

  • It innervates a small area of the forehead and the temporal area. 

  • Infiltration begins at the lateral edge of the supraorbital margin and continues to the distal aspect of the zygomatic arch. While palpating the posterolateral aspect of lateral orbital rim, the needle is walked down the bone until at the level of the lateral canthus.

 

Auriculotemporal

  • It innervates the temporal areas, auricle, and the scalp above the auricle. Inject local anaesthetic about 1 cm anterior to the auricle, above the level of the temporomandibular joint. The nerve generally runs deep to the superficial temporal artery, which can typically be appreciated (and historically cannulated!) on palpation. After (-) aspiration, inject LA.

  • This nerve crosses over the root of the zygomatic process of the temporal bone and lies deep to the superficial temporal artery, which should be palpated to avoid intra-arterial injection.

 

Greater & Lesser Occipital

 
 

Greater Occipital

  • It arises from the first and second cervical vertebrae. It ascends to innervate the skin along the posterior part of the scalp. It may also innervate the scalp at the top of the head and over the auricle. It is located by initially palpating the occipital artery, which is found lateral to the external occipital protuberance along the superior nuchal line. Once the artery is identified, inject the local anaesthetic medial to the occipital artery.

  • Ultrasound technique (pending)

 

Lesser Occipital

  • It innervates the scalp in the lateral area of the head posterior to the auricle.

  • The lesser occipital nerve can be blocked by infiltration along the superior nuchal line, lateral to the greater occipital nerve block

Bracho, G.F.P., de Souza Neto, E.P., Grousson, S., Mottolese, C. and Dailler, F., 2014. Opioid consumption after levobupivacaine scalp nerve block for craniosynostosis surgery. Acta Anaesthesiologica Taiwanica, 52(2), pp.64-69.

Okuda, Y., Matsumoto, T., Shinohara, M., Kitajima, T. and Kim, P., 2001. Sudden unconsciousness during a lesser occipital nerve block in a patient with the occipital bone defect. European journal of anaesthesiology, 18(12), pp.829-832.

Osborn, I. and Sebeo, J., 2010. “Scalp block” during craniotomy: a classic technique revisited. Journal of neurosurgical anesthesiology, 22(3), pp.187-194.

Pinosky ML, Fishman RL, Reeves ST, et al. The effect of bupivacaine skull block on the hemodynamic response to craniotomy. Anesth Analg. 1996;83:1256–1261

Suresh S, Wagner AM. Scalp excisions: getting ‘‘ahead’’ of pain. Pediatr Dermatol. 2001;18:74–76.

Suresh S, Voronov P. Head and neck blocks in children: an anatomical and procedural review. Paediatr Anaesth. 2006;16: 910–918.

Eichenberger, U., Greher, M., Kapral, S., Marhofer, P., Wiest, R., Remonda, L., Bogduk, N. and Curatolo, M., 2006. Sonographic Visualization and Ultrasound-guided Block of the Third Occipital Nerve: Prospective for a New Method to Diagnose C2–C3 Zygapophysial Joint Pain. Anesthesiology: The Journal of the American Society of Anesthesiologists, 104(2), pp.303-308.

Greher, M., Moriggl, B., Curatolo, M., Kirchmair, L. and Eichenberger, U., 2010. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. British journal of anaesthesia, 104(5), pp.637-642.

Geze, S., Yilmaz, A.A. and Tuzuner, F., 2009. The effect of scalp block and local infiltration on the haemodynamic and stress response to skull-pin placement for craniotomy. European Journal of Anaesthesiology (EJA), 26(4), pp.298-303.

Kissoon, N.R., O'Brien, T.G., Bendel, M.A., Eldrige, J.S., Hagedorn, J.M., Mauck, W.D., Moeschler, S.M., Olatoye, O.O., Pittelkow, T.P., Watson, J.C. and Pingree, M.J., 2022. Comparative Effectiveness of Landmark-guided Greater Occipital Nerve (GON) Block at the Superior Nuchal Line versus Ultrasound-guided GON Block at the Level of C2: A Randomized Clinical Trial (RCT). The Clinical Journal of Pain.

Abo-Zeid, M.A., Elmaddawy, A.E.A., El-Fahar, M.H. and El-Sabbagh, A.H., 2018. Selective scalp nerve block: a useful technique with tissue expansion in postburn pediatric alopecia. Annals of plastic surgery, 80(2), pp.113-120.

Festa, R., Tosi, F., Pusateri, A., Mensi, S., Garra, R., Mancino, A., Frassanito, P. and Rossi, M., 2020. The scalp block for postoperative pain control in craniosynostosis surgery: a case control study. Child's Nervous System, 36(12), pp.3063-3070.

John Hagen
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