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Reviews on Recent Clinical Trials


ISSN (Print): 1574-8871
ISSN (Online): 1876-1038

Clinical Trial

Bilateral Superficial Trigeminal Nerve Blocks are not More Effective than a Placebo in Abolishing Post-operative Headache Pain in Pituitary Transsphenoidal Neurosurgery: A Prospective, Randomized, Doubleblinded Clinical Trial

Author(s): Una Srejic*, Erik Litonius, Seema Gandhi, Pekka Talke, Oana Maties, Claas Siegmueller, Avic Magsaysay, Daniel Hasen, Sandeep Kunwar, Rahul Seth, Lizbeth Gibson and Philip Bickler

Volume 18, Issue 3, 2023

Published on: 15 June, 2023

Page: [228 - 237] Pages: 10

DOI: 10.2174/1574887118666230227113217

open access plus


Background: Pituitary neurosurgery executed via the transsphenoidal endonasal approach is commonly performed for pituitary adenomas. Reasons for prolonged hospital stay include postoperative headache and protracted nausea with or without vomiting. Bilateral superficial trigeminal nerve blocks of the supra-orbital V1 and infra-orbital V2 (SION) nerves performed intra-operatively as a regional anesthetic adjunct to general anesthesia were hypothesized to decrease 6 hours postoperative morphine PCA (patient-controlled analgesia) use by patients.

Methods: Forty-nine patients, following induction of general anesthesia for their transsphenoidal surgery, were prospectively randomized in a double-blinded fashion to receive additional regional anesthesia as either a block (0.5% ropivacaine with epi 1:200,000) or placebo/sham (0.9% normal saline). The primary endpoint of the study was systemic morphine PCA opioid consumption by the two groups in the first 6-hours postoperatively. The secondary endpoints included (1) pain exposure experienced postoperatively, (2) incidence of postoperative nausea and vomiting, and (3) time to eligibility for PACU discharge.

Results: Of the 49 patients that were enrolled, 3 patients were excluded due to protocol violations. Ultimately, there was no statistically significant difference between morphine PCA use in the 6 hours postoperatively between the block and placebo/sham groups. There was, however, a slight visual tendency in the block group for higher pain scores, morphine use p=0.046, and delayed PACU discharge. False discovery rate corrected comparisons at each time point and then revealed no statistically significant difference between the two groups. There were no differences between the two groups for secondary endpoints.

Conclusion: It was found that a 6-hour postoperative headache after endoscopic trans-sphenoidal pituitary surgery likely has a more complicated mechanism involving more than the superficial trigeminovascular system and perhaps is neuro-modulated by other brain nuclei.

Keywords: Pituitary neurosurgery, superficial trigeminal nerve blocks, regional anesthesia of head and neck, supraorbital and infraorbital nerve block, migraine headache, supra-orbital V1.

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Cousins MJ, Bridenbaugh PO. Neural blockade in clinical anesthesia and management of pain Neural blockade for pediatric surgery. (3rd ed.). Philadelphia, PA: Lippincott-Raven 1998; pp. 605-37.
Goadsby PJ, Edvinsson L. The trigeminovascular system and migraine: Studies characterizing cerebrovascular and neuropeptide changes seen in humans and cats. Ann Neurol 1993; 33(1): 48-56.
[] [PMID: 8388188]
Lauritzen M. Cerebral blood flow in migraine and cortical spreading depression. Acta Neurol Scand Suppl 1987; 113: 1-40.
[] [PMID: 3324620]
Zagami AS, Goadsby PJ, Edvinsson L. Stimulation of the superior sagittal sinus in the cat causes release of vasoactive peptides. Neuropeptides 1990; 16(2): 69-75.
[] [PMID: 2250767]
Ilhan Alp S, Alp R. Supraorbital and infraorbital nerve blockade in migraine patients: results of 6-month clinical follow-up. Eur Rev Med Pharmacol Sci 2013; 17(13): 1778-81.
[PMID: 23852904]
Mariano ER, Watson D, Loland VJ, et al. Bilateral infraorbital nerve blocks decrease postoperative pain but do not reduce time to discharge following outpatient nasal surgery. Can J Anaesth 2009; 56(8): 584-9.
McAdam D, Muro K, Suresh S. The use of infraorbital nerve block for postoperative pain control after transsphenoidal hypophysectomy. Reg Anesth Pain Med 2005; 30(6): 572-3.
[] [PMID: 16326343]
Michael TL, Scott AS, Robert AS, Matthew JJ, Richard E. Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med 1994; 1: 514-9.
[] [PMID: 7600397]
Brigid CF, Edward C. Postoperative nausea and vomiting and pain after trans-sphenoidal surgery: A review of 877 patients. Anesth Analg 2006; 103: 162-7.
[] [PMID: 16790646]
Matthew SR, Robertson CE, Kaplan E, Ailani J, Charleston LIV, Kuruvilla D, et al. The sphenopalatine ganglion: Anatomy, pathophysiology, and therapeutic targeting in headache. Headache 2016; 56(2): 240-58.
Dodick DW. A phase-by-phase review of migraine pathophysiology. Headache 2018; 58: 4-16.
Binfalah M, Alghawi E, Shosha E, Alhilly A, Bakhiet M. Sphenopalatine ganglion block for the treatment of acute migraine headache. Pain Res Treat 2018; 2018: 1-6.
[] [PMID: 29862074]
Ashgan RA, Sameh AS, Rahman ASMA, Ashgan RA. Bilateral sphenopalatine ganglion block as adjuvant to general anesthesia during endoscopic trans-nasal resection of pituitary adenoma. Egypt J Anaesth 2010; 26: 273-80.
Hill JN, Gershon N, Gargiulo PO. Total spinal blockade during local anesthesia of the nasal passages. Anesthesiology 1983; 59(2): 144-6.
[] [PMID: 6869874]

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