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Nerve blocks of the scalp, neck, and trunk: Techniques

Meg A Rosenblatt, MD
Yan Lai, MD, MPH
Section Editor
Lisa Warren, MD
Deputy Editor
Marianna Crowley, MD


Nerve blocks of the scalp, neck, thorax, and abdomen are used for operative anesthesia and/or postoperative analgesia for a variety of surgeries. This topic will discuss the innervation of these anatomic areas, techniques and drugs used for these blocks, and complications specific to these blocks. Indications, contraindications, comparison of techniques relevant to all peripheral nerve blocks, equipment, and complications common to all nerve blocks are discussed separately. Nerve blocks for airway anesthesia for awake intubation and infraorbital and mental nerve blocks are also discussed separately. (See "Overview of peripheral nerve blocks" and "Flexible scope intubation for anesthesia", section on 'Airway anesthesia' and "Assessment and management of facial lacerations", section on 'Facial nerve blocks'.)


Individualized, targeted nerve blocks of the scalp have evolved to become sophisticated and effective techniques compared with traditional local anesthetic (LA) infiltration [1-4]. Scalp nerve blocks are useful for awake and routine craniotomies, deep brain stimulation, stereotactic procedures, craniosynostosis repair in pediatric patients, and for chronic pain syndromes of the head and neck [1-3].

Scalp blocks are performed for craniotomy in order to blunt the hemodynamic response to skull pinning and to reduce postoperative pain [4-6]. Preoperative scalp block can reduce intraoperative opioid requirement, which can facilitate early postoperative neurologic assessment [5-7]. As an example, a 2013 meta-analysis of seven trials with 320 patients found a reduction in pain scores up to 12 hours after craniotomy and a reduction in cumulative opioid requirements over the first 24 postoperative hours with the use of scalp nerve blocks [1]. (See "Anesthesia for craniotomy", section on 'Surgical steps'.)

Anatomy — Four branches of the trigeminal nerve and two branches of the cervical nerve roots C2 and C3 provide innervation to the anterior and posterior scalp (figure 1) [2,3]. The supraorbital and supratrochlear nerves are sensory nerves that innervate the forehead and upper eyelids. They are derived from the ophthalmic division of the trigeminal nerve (V1). The zygomaticotemporal nerve comes from the maxillary division (V2) and supplies a small area lateral to the outer canthus of the eye. The auriculotemporal nerve is a branch of the mandibular division (V3) and provides sensation to the area in front of and above the ear. The greater occipital nerve comes from the dorsal ramus of C2 and ascends through the posterior scalp medial to the occipital artery. The lesser occipital nerve originates from the ventral rami of C2 and C3 and courses upward from the posterior neck to innervate the scalp behind the ear (figure 2) [2,3].

Scalp block technique — Six nerves are blocked on each side for complete scalp block. This block is performed with long-acting LA (eg, bupivacaine 0.25 or 0.5%, or ropivacaine 0.2 or 0.5%) using a 1.5-inch, 25- or 27-gauge needle, using the following techniques (figure 3):

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Literature review current through: Nov 2017. | This topic last updated: Feb 21, 2017.
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