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Local anaesthetic scalp block
A comparison between scalp nerve block and morphine showed no relevant differences in
any analgesic parameters (Ayoub et al, 2006 Level II). Scalp infiltration was also no more
effective that IV fentanyl (Biswas & Bithal, 2003 Level II).
However, comparisons of scalp blocks with bupivacaine or ropivacaine and placebo showed
better analgesia with the local anaesthetic blocks in a number of trials (Bloomfield et al, 1998
Level II; Nguyen et al, 2001 Level II; Law‐Koune et al, 2005 Level II; Bala et al, 2006 Level II; Gazoni et al,
2008 Level II; Batoz et al, 2009 Level II). Scalp infiltration with ropivacaine also reduced the
incidence of persistent pain 2 months after craniotomy, from 56% to 8 % (Batoz et al, 2009
Level II).
A comparison between SC local anaesthetic infiltration and occipital/supraorbital nerve block
showed no difference between groups in the postoperative period, but nerve blocks were less
painful than infiltration analgesia (Watson & Leslie, 2001 Level II).
Adjuvant drugs
Clonidine did not improve analgesia after supratentorial craniotomy (Stapelfeldt et al, 2005
Level II).

Key messages
1. Morphine is more effective than codeine and tramadol for pain relief after craniotomy (N)
(Level II).
2. Local anaesthetic infiltration of the scalp provides early analgesia after craniotomy and
reduces incidence of subsequent chronic pain (N) (Level II).
3. Craniotomy leads to significant pain in the early postoperative period (N) (Level IV), which
is however not as severe as pain from other surgical interventions (N) (Level III‐2).
4. Craniotomy can lead to significant chronic headache (N) (Level IV).

9.2 ACUTE PAIN FOLLOWING SPINAL CORD INJURY

Acute pain following spinal cord injury (SCI) is common, with over 90% of patients
experiencing pain in the first 2 weeks following injury (Siddall et al, 1999 Level IV); however the CHAPTER 9
range of described prevalence varies between 26% and 96% (Dijkers et al, 2009 Level IV). Acute
pain may also develop during the rehabilitation phase due to intercurrent disease (eg renal
calculus) or exacerbation of a chronic pain syndrome.
Pain associated with SCI usually falls into two main categories: neuropathic pain, either at or
below the level of the injury, and nociceptive pain, from somatic and visceral structures (Siddall
et al, 2002). Neuropathic pain associated with a lesion of the central (somatosensory) nervous
system is termed central pain (Loeser & Treede, 2008). Phantom pain and complex regional pain
syndromes may also develop in patients with SCI.

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