BRIEF REPORT
Does Bilateral Superficial Cervical Plexus Block Decrease
Analgesic Requirement After Thyroid Surgery?
Zeynep Eti, MD, Pınar Irmak, MD, Bahadır M. Gulluoglu,
and F. Yılmaz Gogus, MD
Departments of Anesthesiology and General Surgery, Breast and Endocrine Surgery Unit, Marmara University School of
Medicine, Istanbul, Turkey
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In this randomized, double-blind and controlled study
we evaluated and compared the analgesic efficacy of
bilateral superficial cervical plexus block and local an-
esthetic wound infiltration after thyroid surgery. Forty-
five patients were assigned to 3 groups. After general
anesthesia induction, bilateral superficial cervical
plexus block with 0.25% bupivacaine 15 mL in each side
was performed in Group I, and local anesthetic wound
infiltration with 0.25% bupivacaine 20 mL was performed
in Group II. In Group III (control) no regional block was
A
lthough thyroid surgery is a short-stay proce-
dure, most patients require effective postopera-
tive analgesia. It has been reported that the
mean postoperative pain score was 6.9 on a visual
analog scale (VAS) from 0 to 10 and 90% of the pa-
tients required morphine during the first postopera-
tive day (1). However, nausea and vomiting are the
most frequent side effects of opioids and in one study
the incidence of postthyroidectomy nausea-vomiting
was reported to be 54% (2). Therefore the most recent
studies concerning postthyroidectomy analgesia are
focused on the efficacy of regional techniques. Local
anesthetic wound infiltration (LWI), bilateral superfi-
cial cervical plexus block (BSCPB), and bilateral com-
bined superficial and deep cervical plexus block were
reported to reduce postoperative opioid requirements
(1,3–5). However the risk-benefit ratio of these re-
gional blocks differs and the analgesic efficacy of these
techniques after thyroid surgery has not been
compared.
The aim of this double-blind, randomized and con-
trolled study was to evaluate and compare the effects
Accepted for publication December 6, 2005.
Address correspondence and reprint requests to Zeynep Eti, MD,
Marmara University Hospital, Anesthesiology Department,
Tophanelioğlu Cad. No: 13-15, 34662 Altunizade, İstanbul, Turkey.
Address e-mail to emineeti@superposta.com.
DOI: 10.1213/01.ane.0000202383.51830.c4
1174 Anesth Analg 2006;102:1174–6
MD, Manuk N. Manukyan, MD,
administered. Intravenous patient-controlled analgesia
was used to evaluate postoperative analgesic require-
ment. Neither visual analog scale scores nor total patient-
controlled analgesia doses were different among groups.
We concluded that bilateral superficial cervical plexus
block or local anesthetic wound infiltration with 0.25%
bupivacaine did not decrease analgesic requirement after
thyroid surgery.
(Anesth Analg 2006;102:1174 –6)
of LWI and BSCPB on postoperative opioid require-
ments and side effects after thyroid surgery.
Methods
After Institutional Ethics Committee approval and pa-
tients’ written consent, 45 patients ASA physical sta-
tus I–II, aged 20 –70 yr and scheduled for elective
thyroid surgery under general anesthesia were en-
rolled in the study. Thyroid surgery was performed by
the same surgeon with a similar surgical technique
and surgical drains were used in a consistent fashion.
All patients were euthyroid at the time of surgery.
Patients were randomized by using sealed envelopes
into 3 groups (15 patients in each group).
Patients were premedicated with midazolam
0.07 mg/kg IM. The surgeon routinely marked the
intended cervical incisional line before the patients are
delivered to the operation room. General anesthesia
was induced with 5 mg/kg thiopental and 0.1 mg/kg
vecuronium IV. After endotracheal intubation, in
Group I, BSCPB with 0.25% bupivacaine 15 mL in each
site and in Group II, LWI with 20 mL 0.25% bupiva-
caine were performed by the same anesthesiologist. In
Group III (control) no regional block was adminis-
tered. BSCPB was performed with a 22-gauge needle
inserted at the midpoint of the lateral border of the
sternocleidomastoid muscle. Ten mL of solution was
injected in both cranial and caudal directions along the
©2006 by the International Anesthesia Research Society
0003-2999/06
ANESTH ANALG BRIEF REPORT 1175
2006;102:1174–6

Table 1. Demographic Characteristics and Duration of Table 2. Visual Analog Scale (VAS) Scores of Patients
Surgery
BSCPB LWI Control
BSCPB LWI Control (n ⫽ 15) (n ⫽ 15) (n ⫽ 15)
(n ⫽ 15) (n ⫽ 15) (n ⫽ 15)
1h 23.0 ⫾ 19.3 23.6 ⫾ 21.1 20.7 ⫾ 13.3
Age (yr) 47⫾15 45 ⫾ 13 42 ⫾ 14 2h 20.5 ⫾ 16.5 12.7 ⫾ 15.5 18.5 ⫾ 15.1
Weight (kg) 66 ⫾ 9 69 ⫾ 6 69 ⫾ 12 4h 17.6 ⫾ 13.6 12.7 ⫾ 9.0 14.2 ⫾ 8.5
Male:female (n) 3:12 2:13 3:12 6h 11.5 ⫾ 13.4 8.1 ⫾ 10.7 12.1 ⫾ 8.9
Duration of surgery 130 ⫾ 41 131 ⫾ 40 128 ⫾ 37 8h 6.9 ⫾ 9.4 6.3 ⫾ 6.7 7.8 ⫾ 8.0
(min) 12 h 10.7 ⫾ 9.5 3.6 ⫾ 6.7 5.7 ⫾ 6.4
16 h 5.3 ⫾ 8.7 8.1 ⫾ 9.8 7.1 ⫾ 9.9
Values are mean ⫾ sd.
BSCPB ⫽ bilateral superficial cervical plexus block; LWI ⫽ local anesthetic 20 h 3.8 ⫾ 5.0 10.0 ⫾ 12.6 7.1 ⫾ 9.1
wound infiltration. 24 h 5.0 ⫾ 6.4 5.4 ⫾ 8.2 5.0 ⫾ 7.5
Values are mean ⫾ sd (mm).
lateral border of the muscle and 5 mL was injected BSCPB ⫽ bilateral superficial cervical plexus block; LWI ⫽ local anesthetic
wound infiltration. There were no differences among groups in VAS scores.
horizontally above the muscle in each site. LWI was
performed with a 22-gauge needle inserted along the
preoperatively marked incision line and 20 mL of The incidence of nausea and vomiting was similar
solution was injected in subcutaneous layers of the in all groups (P ⬎ 0.05) (Table 3).
incision line. The patients, surgeon, and the anesthe-
siologist responsible for follow-up of patients in the
postoperative period were blinded as to group alloca-
tion. General anesthesia was maintained with oxygen Discussion
in 70% nitrous oxide and 1.5%–2% sevoflurane. No In this study, neither LWI nor BSCPB decreased opi-
opioids were administered intraoperatively. oid requirements or pain scores after thyroid surgery.
In the postanesthesia care unit, the first analgesic LWI is a simple technique used for postoperative an-
requirement time (VAS ⬎ 30) was recorded and IV algesia. However, the literature is confusing, with nu-
patient-controlled analgesia (PCA) with meperidine merous reports supporting the value of this approach
(10 mg/mL, bolus dose 1.5 mL and lockout time 8 and a similar number disputing the beneficial effect
min) was started after a bolus dose of meperidine (1,3,6,7). LWI has been used in different types of sur-
sufficient to obtain a VAS score of 30. On the ward, gery with different doses of local anesthetics and the
VAS scores were recorded at 1, 2, 4, 8, 12, 16, 20, and opioid requirement was assessed with different meth-
24 h postoperatively. The incidence of nausea and ods, such as on-demand administration or PCA. For
vomiting and total meperidine dose during the 24-h postthyroidectomy analgesia, Gozal et al. (1) infil-
postoperative period were also recorded. trated the wound with 10 mL 0.5% bupivacaine at the
The main outcome measure of this study was a 30% end of surgery and found that the 24-h morphine
decrease in postoperative opioid requirement. Group requirement and the mean pain scores were signifi-
size was selected by using proportions sample size cantly less in the treatment group. We could not dem-
estimates (␣ ⫽ 0.05, ␤ ⫽ 0.085). Values are reported as onstrate any difference in pain scores, or the 24-h
mean ⫾ sd. VAS scores were compared with two-way meperidine consumption, of patients whose wounds
repeated measures of analysis of variance, and post hoc were infiltrated with bupivacaine, when compared
statistical testing was performed according to Tukey with those of the control group. The possible explana-
Kramer test. Student’s t-test for unpaired data and tion for our contradictory result could be the differ-
Fisher’s exact test for the incidence of nausea and ences in study design and pain management. The
vomiting were performed. study of Gozal et al. (1) was not double-blind and their
postoperative pain medication included morphine IV
or IM as needed. We used IV-PCA, which is a more
Results objective and sensitive method for assessing the post-
Demographic characteristics and the duration of sur- operative opioid demand. However, we cannot ex-
gery were not different among the groups (P ⬎ 0.05) clude the possibility of obtaining better results with a
(Table 1). larger concentration of bupivacaine (0.5%) because a
There were no differences in VAS scores among the significant dose-response relationship was reported
groups at all time intervals (P ⬎ 0.05) (Table 2). The when a larger concentration of local anesthetic caused
total amount of PCA consumption (10 mg/mL meper- the most pronounced effect (7,8). There is also the
idine) was not different among the groups (P ⬎ 0.05) possibility of a longer duration with 0.25% bupiva-
(Table 3). The first analgesic requirement time in caine with epinephrine. Further studies are needed to
Group I was significantly longer than for the control evaluate the ideal volume and drug concentration for
group (P ⬍ 0.05) (Table 3). LWI.
1176 BRIEF REPORT
Table 3. Total Patient-Controlled Analgesia Consumption, First Analgesic Requirement Time, Incidence of Nausea
and Vomiting
BSCPB (n ⫽ 15)
Total PCA consumption (mg)
First analgesic requirement time (min)
Incidence of nausea (%)
Incidence of vomiting (%)
BSCPB ⫽ bilateral superficial cervical plexus block; LWI ⫽ local anesthetic wound infiltration; PCA ⫽ patient-controlled analgesia.
Meperidine was the opioid used for PCA.
* P ⬍ 0.05 compared with control group.
BSCPB was found to reduce pain intensity scores
and the amount of cumulative morphine doses after
thyroidectomy in the study of Dieudonne et al. (4).
They performed BSCPB with 20 mL bupivacaine
0.25% with 1:200,000 epinephrine at the end of surgery
and found lower pain intensity scores in the early
postoperative period in the treatment group. How-
ever, we used 30 mL bupivacaine 0.25% for BSCPB
and could not demonstrate any beneficial effect on
postoperative opioid demand or pain scores. The main
difference in their study was in pain assessment inter-
vals and the manner in which a nurse evaluated the
patient’s numeric rating scale (NRS)-11 score every
4 h; 5 mg morphine was administered subcutaneously
if the pain score was 4 or higher. In our study we
evaluated the 24-h opioid demand with IV PCA and
pain scores in 2-h intervals during the first 8 h. Dieu-
donne et al. (4) concluded that BSCPB did not provide
optimal pain relief because 65% of patients needed
additional analgesics and the reduced opioid con-
sumption was less clinically relevant, as it did not
result in reduced side effects. It seems that the de-
crease in morphine consumption was not enough to
have an impact on the morphine-related side effects
and this would weaken the clinical relevance of
opioid-sparing.
Bilateral deep cervical plexus block (9) or combined
superficial and deep cervical plexus block (5) were
also found to be effective for decreasing postoperative
thyroidectomy pain. However, deep cervical plexus
block has been reported to cause hemidiaphragmatic
dysfunction in 61% of patients (10). We suggest that
bilateral deep cervical block can produce significant
respiratory dysfunction and should not be encouraged
for postoperative pain management.
In our study, the only beneficial effect of BSCPB was
the prolonged first analgesic requirement time, which
was about 15 min. This result was statistically signif-
icant but of no clinical significance.
A likely explanation for the lack of beneficial effects
of BSCPB or LWI on postthyroidectomy analgesia is
ANESTH ANALG
2006;102:1174–6
LWI (n ⫽ 15) Control (n ⫽ 15)
440.1 ⫾ 210.2 400.0 ⫾ 160.8 370.2 ⫾ 250.8
29.6 ⫾ 17.8* 25.7 ⫾ 11.5 13.5 ⫾ 6.3
53.3 53.3 73.3
13.3 20.0 26.6
that pain arising from areas that cannot be blocked by
a superficial approach is of greater significance than
that from cutaneous, subcutaneous, and muscular lay-
ers after thyroid surgery. Intraoperative neck position
and wound drainage are also important components
of postthyroidectomy pain.
In conclusion, BSCPB or LWI with 0.25% bupiva-
caine did not decrease opioid requirement or pain
scores after thyroid surgery.
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