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TYPE Systematic Review

PUBLISHED 26 September 2022
DOI 10.3389/fsurg.2022.1018511

Scalp block for postoperative

pain after craniotomy:
EDITED BY
Alessandro Di Rienzo,
Marche Polytechnic University, Italy
A meta-analysis of randomized
REVIEWED BY
Riccardo Paracino,
control trials
Hospital of Santa Maria della Misericordia in
Perugia, Italy Yanting Chen1†, Jianqiang Ni1†, Xiang Li2, Jialei Zhou2*
Bashar Alhani,
and Gang Chen *
2
University Hospitals Coventry and Warwickshire
NHS Trust, United Kingdom 1
Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China,
2
Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
*CORRESPONDENCE
Jialei Zhou
[email protected] Background: Postoperative pain after craniotomy is an important clinical
Gang Chen
concern because it might lead to brain hyperemia and elevated intracranial
[email protected]
†
pressure. Considering the side effects of opioid, several studies have been
These authors have contributed equally to this
conducted to investigate the effect of local anesthetics, especially the scalp
work
block, on postoperative pain. However, the strength of evidence supporting
SPECIALTY SECTION
this practice for postoperative pain after craniotomy was unclear and the
This article was submitted to Neurosurgery, a
section of the journal Frontiers in Surgery best occasion of scalp block was also not identified. Therefore, we
conducted a meta-analysis to evaluate the efficacy, safety, and the best
RECEIVED 13 August 2022
ACCEPTED 12 September 2022 occasion of scalp block for postoperative pain after craniotomy.
PUBLISHED 26 September 2022 Methods: PubMed, Embase, and the Cochrane Library databases from
CITATION database inception to October 10, 2021 were searched for all randomized
Chen Y, Ni J, Li X, Zhou J and Chen G (2022) controlled trials evaluating the effect of scalp block on postoperative pain
Scalp block for postoperative pain after after craniotomy. Data were assessed by StataMP 16 software.
craniotomy: A meta-analysis of randomized Results: A total of 12 studies were included. A random-effect model was used
control trials.
to analyze all data. Patients under scalp block earned fewer scores than the
Front. Surg. 9:1018511.
doi: 10.3389/fsurg.2022.1018511 non-scalp block group in visual analogue scale at the very early period
(MD = −1.97, 95% CI = −3.07 to −0.88), early period (MD = −1.84, 95% CI =
COPYRIGHT
© 2022 Chen, Ni, Li, Zhou and Chen. This is an −2.95 to −0.73) and intermediate period (MD = −1.16, 95% CI = −1.84 to
open-access article distributed under the terms −0.49). Scalp block could also significantly prolong the time of the first
of the Creative Commons Attribution License
request of rescue analgesia and reduce the use of additional analgesics
(CC BY). The use, distribution or reproduction in
other forums is permitted, provided the original without a significant difference in the incidence of complications. Subgroup
author(s) and the copyright owner(s) are analysis showed there was no significant difference in analgesia effect
credited and that the original publication in this
between pre-incision scalp block and post-incision scalp block in all periods.
journal is cited, in accordance with accepted
academic practice. No use, distribution or Conclusion: Scalp block could lead to lower pain intensity scores, more time of
reproduction is permitted which does not the first request of rescue analgesia, and fewer analgesic drugs applied in the
comply with these terms.
first 12 h after craniotomy. There was no significant difference between
pre-incision and post-incision scalp block in the occurrence and severity of
postoperative pain.

KEYWORDS

craniotomy, meta-analysis, nerve block, postoperative pain, visual analogue scale

Abbreviations
PRISMA, preferred reporting items for systematic reviews and meta-analyses; VAS, visual analogue scale;
MD, mean difference; OR, odds ratio; CI, confidence interval; SMD, standard mean difference

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Chen et al. 10.3389/fsurg.2022.1018511

Introduction patients scheduled for craniotomy. To avoid omissions, the

reference lists of all relevant articles were manually searched.
Craniotomy is an effective treatment of cerebral diseases
and injuries, and postoperative pain is an important clinical
concern. 86% of patients probably had the pain of somatic Inclusion and exclusion criteria
origin, with the involvement of soft tissues and pericranial
muscles (1). Elevated oxygen consumption and catecholamine Inclusion criteria were defined as follows: (1) Study type: only
release caused by postoperative pain lead to brain hyperemia randomized controlled trials; (2) Population: patients aged >18
and elevated intracranial pressure, which may predispose years; (3) Intervention: scalp block; (d) Studies that reported at
them to intracranial hematoma (2–4). Effective pain least one of the following outcome measures: pain intensity
management and prevention are important to avoid these measured by the visual analogue score, time of the first request
systemic changes and improve rehabilitation and long-term of rescue analgesia, additional analgesia requirement in the first
outcomes (5, 6). Besides, management of early postoperative 24 h, and adverse events in the first 24 h.
pain can prevent the development of central sensitization and Exclusion criteria were designed as follows: (1) Types of
chronic pain states caused by surgical tissue damage (7, 8). articles: reviews, case reports and retrospective studies; (2) Any
However, pain after a craniotomy is often treated study using methods other than placebo and systemic analgesia
insufficiently, because of the fear that the opioid-induced in the control group; (3) Any study had scalp block in all arms.
sedation and miosis will mask neurological pathology.
Therefore, several studies have been conducted to investigate
the effect of local anesthetics, especially the scalp block, on Data extraction
postoperative pain (9–12).
Scalp block was a common technique in craniotomy and was Two investigators extracted the following data from the
widely used to reduce the hemodynamic response and incisional included studies: (1) Number of patients; (2) occasion of scalp
pain during craniotomy procedure (13–15). Analgesia could be block; (3) Postoperative pain treatment modality (occasion and
achieved by blockade of the following nerves: greater and lesser the dosage); (4) Pain intensity for all time points; (5) Time of
occipital nerves, the supraorbital and supratrochlear nerves, the the first request of rescue analgesia; (6) Additional analgesia
zygomaticotemporal nerve, the auriculotemporal nerve, and the requirement in the first 24 h; (7) adverse events in the first
greater auricular nerve (16–18). However, the strength of 24 h. Data was recorded on a dedicated data extraction form.
evidence supporting this practice was unclear and the best
occasion of scalp block was also not identified (19–21).
Therefore, we conducted a meta-analysis to evaluate the
Outcome measures
efficacy, safety, and the best occasion of scalp block for
postoperative pain after craniotomy.
The primary outcome was pain intensity measured by the
visual analogue score within 48 h postoperative period. The
interval of 0 to 100 pain intensity of VAS was rescaled to a
Methods standard interval of 0 to 10. In this study, pain
level measurements were categorized into five time periods:
A meta-analysis was conducted according to the Preferred (1) very early: < 2 h; (2) early: ≥2 h but <6 h; (3)
Reporting Items for Systematic Reviews and Meta-Analyses intermediate: ≥6 h but <12 h; (4) late: ≥12 h but <24 h; (5)
(PRISMA) guidelines. As our study was based on published very late: ≥24 h but ≤48 h. When there were multiple
literature data, ethical approval or patient consent was not intervention groups, all relevant experimental intervention
required. Besides, only studies reporting ethical approval or groups or relevant control intervention groups were combined
patient consent were included in our meta-analysis. into one group. The average of their mean and standard
deviation had been calculated at the same time.

Search strategy
Subgroup analysis
In this meta-analysis, 2 investigators performed a systematic
literature search using keywords “scalp block” and “craniotomy” Subgroup analysis was conducted to evaluate efficacy in two
in PubMed, Embase, and the Cochrane Library databases from subgroups. According to the occasion of scalp block, subgroups
database inception to October 10, 2021, to identify randomized were classified as pre-incision scalp block and post-incision
clinical trials that reported scalp block vs. non-scalp block in scalp block.

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Chen et al. 10.3389/fsurg.2022.1018511

Risk of bias outcomes as mean difference (MD) or the odds ratio

(OR) using a 95% confidence interval (CI) separately.
Reviews Manager 5.4 software was used to evaluate the risk of Standard mean difference (SMD) was used for additional
bias in each study. Two investigators used the uniform criteria of analgesia requirements in first 24 h because the specific
the Cochrane collaboration for assessing the risk of bias, drug and route of administration varied among trials.
including selection bias, performance bias, detection bias, Heterogeneity was classified as moderate (I 2 = 25%–50%),
reporting bias, performance bias, detection bias, attrition bias, substantial (I 2 = 50%–75%) or considerable (I 2 ≥ 75%)
reporting bias, and other potential biases. The result of each (22). Owing to the degree of heterogeneity found, a
aspect was divided into low risk, high risk, or unknown risk. random-effect model was used (23). Subgroup analysis
was performed to investigate the stability of the
consolidated results. P-value <0.05 was considered as
Statistical analysis and data synthesis significant. To determine the source of heterogeneity and
assess the influence of every single study on the final
Data were assessed by StataMP 16 software. We results, we excluded one study in sequence through
defaulted to analyzing continuous or dichotomous sensitivity analysis.

FIGURE 1
Study flow chart (as per PRISMA guideline).

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Chen et al. 10.3389/fsurg.2022.1018511

Results
Study selection

A total of 225 articles from PubMed, Embase, and Cochrane

Library databases were identified. 182 records were removed
because of duplication or irrelevance to the study. 31 other
records were excluded because they were comments (1
record), reviews (19 records), meta-analyses (5 records), and
conference abstracts (6 records). The entire process of study
search, selection, and inclusion are shown in Figure 1. The
overall risk of bias in studies included is presented in Figure 2.

Study characteristics

Details of the included studies are shown in Table 1. Full

information on included studies could be accessed in the
supplement. 8 trials (24–31) were analyzed for pain intensity
outcome, 9 trials (4, 24–29, 32, 33) for additional analgesia
outcome, and 5 trials (4, 25, 29, 33, 34) for adverse events
outcome. Four trials had a three-arm design and two trials
had a four-arm design. Data from all doses of scalp block in
the same trial were combined as one experimental
intervention group (28, 34). Several drugs were used for
rescue analgesia, including ketorolac, paracetamol, pethidine,
morphine, dezocine, hydromorphone, fentanyl, pethidine,
morphine, and codeine phosphate.

Outcomes

The summary of the meta-analysis results was in Table 2.

Visual analogue scale

There was lower pain intensity in patients receiving scalp
block at the very early period (MD = −1.97, 95% CI = −3.07
to −0.88), early period (MD = −1.84, 95% CI = −2.95 to
−0.73) and intermediate period (MD = −1.16, 95% CI =
−1.84 to −0.49) than the non-scalp block group (Figure 3,
Supplementary Figures S1–S2). No significant reduction in FIGURE 2
Risk of bias assessment summary.
reported pain scores associated with scalp bock was found at
late or very late period (Supplementary Figures S3–S4).

Rescue analgesia Adverse events

Six studies reported the time of the first request of rescue Nausea and vomiting odds ratio in the first 24 h related to
analgesia and there was an overall increment associated with scalp block was 0.61 (95% CI = 0.23 to 1.67) as shown in
scalp bock (MD = 164.65, 95% CI = 65.28 to 264.01). Scalp Figure 4. None of the included trials reported any
block led to a notably decrease on additional analgesia significant difference in the incidence of other
requirement in first 24 h (SMD = −0.88, 95% CI = −1.62 to complications such as local hematoma, infection, or nerve
−0.13). injury (24, 26–28, 30–32).

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TABLE 1 Characteristics of included trials.

Study Year Participants Study SB NSB Occasion Scale Pain score Rescue
type assessments analgesia
(h)

Skutulienė 2021 141 RCT 0.25% bupivacaine, 1% Paracetamol 1 g and Post-incision VAS 1, 3, 6, 24 Ketorolac,
et al. lidocaine and ketoprofen 2 mg/ (0–100) paracetamol and
1:200,000 kg intravenous pethidine
epinephrine
Carella et al. 2021 60 RCT 0.33% levobupivacaine Placebo Pre-incision VAS 1, 3, 6, 24, 48 Morphine
(0–10)
Yang et al. 2020 88 RCT 0.2%, 0.33% or 0.5% Placebo Pre-incision VAS 2, 4, 6, 24 Dezocine
ropivacaine (0–10)
Rigamonti 2019 89 RCT 0.5% bupivacaine with Placebo Post-incision VAS 1, 2, 4, 8, 12, 18, Hydromorphone
et al. 1:200,000 (0–100) 24, 48
epinephrine
Hussien 2020 30 RCT 0.5% bupivacaine, 2% Fentanyl intravenous Pre-incision VAS 0.5, 1, 2, 4, 8, 16, Fentanyl or
et al. lidocaine and (0–10) 24 ketorolac
1:200,000
epinephrine
Dudko et al. 2015 120 RCT 0.25% bupivacaine, 1% Paracetamol 1 g and Post-incision VAS 1, 3, 6, 24 Ketorolac,
lidocaine and ketoprofen 2 mg/ (0–100) paracetamol and
1:20,0000 adrenaline kg intravenous pethidine
Dudko et al. 2014 75 RCT 0.25% bupivacaine, 1% Paracetamol 1 g and Post-incision VAS 1, 3, 6, 24 Ketorolac,
lidocaine and ketoprofen 2 mg/ (0–100) paracetamol and
1:200.000 adrenaline kg intravenous pethidine
Tuchinda 2010 60 RCT 0.5% or 0.25% Placebo Pre-incision VAS 1, 1.5, 2, 6, 12, 24 Morphine
et al. bupivacaine with (0–10)
1:200,000 adrenaline
Gazoni 2008 30 RCT 0.5% ropivacaine Standard treatment Pre-incision VAS 1, 2, 4 Morphine
et al. (0–10)
Ayoub et al. 2006 50 RCT 2% lidocaine and 0.5% Placebo Post-incision NRS 1, 2, 4, 8, 12, 16, Codeine phosphate
bupivacaine (0–10) 24
Zhang et al. 2003 60 RCT 0.75% ropivacaine Placebo Post-incision VAS 4, 8, 12, 16, 20, N/A
(0–10) 24, 48
Nguyen 2001 30 RCT 0.75% ropivacaine Placebo Post-incision VAS 4, 8, 12, 16, 20, N/A
et al. (0–10) 24, 48

Abbreviation: SB, scalp block; NSB, non-scalp block; RCT, randomized controlled trial; VAS, visual analogue scale; NRS, numerical rating scale; N/A, not available in
report.

Subgroup analysis Study bias assessment

According to the occasion of scalp block, patients were
divided into pre-incision scalp block group and post- Egger’s publication bias plot was used to assess the potential
incision scalp block group. Pre-incision scalp block was risk of publication bias Supplementary Figure S7) and no
significantly effective at the very early and early period, significant funnel plot asymmetry was observed. Results of
whereas pre-incision scalp block showed a significant “leave-one-out” sensitivity analysis are provided in
reduction in pain scores at early and intermediate period Supplementary Figures S8–S15.
after surgery (Figure 3, Supplementary Figures S1–S4).
There was no significant difference in the time of the first
request of rescue analgesia between pre-incision scalp block
and post-incision scalp block (Supplementary Figure S5). Discussion
Besides, a significant reduction in the usage of analgesia
requirement was found in the post-incision scalp block This meta-analysis of 12 randomized controlled trials
group (Supplementary Figure S6). reviewed the available evidence to evaluate the efficacy and

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TABLE 2 Summary of meta-analysis results.

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate

1. Very early VAS 6 446 Mean Difference (IV, Random, 95% CI) −1.97 [−3.07, −0.88]
1.1 Pre-incision scalp block 4 331 Mean Difference (IV, Random, 95% CI) −2.03 [−3.53, −0.53]
1.2 Post-incision scalp block 2 135 Mean Difference (IV, Random, 95% CI) −1.87 [−3.92, 0.18]
2. Early VAS 7 456 Mean Difference (IV, Random, 95% CI) −1.84 [−2.95, −0.73]
2.1 Pre-incision scalp block 4 229 Mean Difference (IV, Random, 95% CI) −1.87 [−3.51, −0.23]
2.2 Post-incision scalp block 3 227 Mean Difference (IV, Random, 95% CI) −1.67 [−3.05, −0.29]
3. Intermediate VAS 7 331 Mean Difference (IV, Random, 95% CI) −1.16 [−1.84, −0.49]
3.1 Pre-incision scalp block 3 139 Mean Difference (IV, Random, 95% CI) −0.88 [−2.23, 0.46]
3.2 Post-incision scalp block 4 192 Mean Difference (IV, Random, 95% CI) −1.31 [−2.03, −0.59]
4. Late VAS 5 430 Mean Difference (IV, Random, 95% CI) −0.98 [−2.13, 0.17]
4.1 Pre-incision scalp block 2 89 Mean Difference (IV, Random, 95% CI) −0.45 [−1.35, 0.46]
4.2 Post-incision scalp block 3 341 Mean Difference (IV, Random, 95% CI) −1.39 [−3.32, 0.53]
5. Very late VAS 7 523 Mean Difference (IV, Random, 95% CI) −1.09 [−2.22, 0.04]
5.1 Pre-incision scalp block 3 189 Mean Difference (IV, Random, 95% CI) −0.70 [−2.06, 0.67]
5.2 Post-incision scalp block 4 334 Mean Difference (IV, Random, 95% CI) −1.45 [−3.47, 0.57]
6. Time of the first request of rescue analgesia 5 313 Mean Difference (IV, Random, 95% CI) 164.65 [65.28, 264.01]
6.1 Pre-incision scalp block 2 89 Mean Difference (IV, Random, 95% CI) 46.69 [−75.61, 168.98]
6.2 Post-incision scalp block 3 224 Mean Difference (IV, Random, 95% CI) 282.48 [67.17, 497.79]
7. Additional analgesia requirement in first 24 h 7 354 Std. Mean Difference (IV, Random, 95% CI) −0.88 [−1.62, −0.13]
7.1 Pre-incision scalp block 4 169 Std. Mean Difference (IV, Random, 95% CI) −1.58 [−2.92, −0.24]
7.2 Post-incision scalp block 3 185 Std. Mean Difference (IV, Random, 95% CI) −0.13 [−0.71, 0.45]
8. Nausea and vomiting in first 24 h 5 344 Odds Ratio (M-H, Random, 95% CI) 0.61 [0.23, 1.67]
8.1 Pre-incision scalp block 2 115 Odds Ratio (M-H, Random, 95% CI) 0.47 [0.04, 5.65]
8.2 Post-incision scalp block 3 229 Odds Ratio (M-H, Random, 95% CI) 0.75 [0.25, 2.22]

Abbreviation: VAS, visual analogue scale; CI, confidence interval. Numbers in bold indicate a significant treatment effect (P < 0.05).

safety of scalp block for postoperative analgesia after craniotomy. This finding might be explained by the
craniotomy. Combining all studies, we found scalp block was preemptive analgesic effect. When scalp block is administered,
effective in reducing short-term pain without increasing the it blocks the C fiber as well as prevents part of the
risk of associated complications, no matter whether it was inflammatory cascade, which could reduce or even eliminate
used before or after incision. the pain hypersensitivity.
Postoperative pain after craniotomy is mainly localized in Rescue analgesia is usually applied when the pain score is
the incision and surrounding soft tissues and is less likely to above a certain value, or the pain is unbearable. The longer
be a widespread headache. The pathophysiological time of first request of rescue analgesia (MD = 164.65, 95%
mechanisms of postoperative pain involve different pathways CI = 65.28 to 264.01) and the less usage of additional
of injury perception. The effects of different analgesic analgesics (SMD = −0.88, 95% CI = −1.62 to −0.13) were
techniques acted on these injury perception pathways. To found in our study. The fewer additional analgesics used
block the scalp innervation and to anesthetize both the postoperatively, the associated side effects like gastrointestinal
superficial layers of the scalp, local anesthetic infiltration has bleeding caused by NSAIDs or ventilation depression caused
been accepted by many neurosurgeons, but the effect is short- by opioids are less likely to occur.
lived. A study conducted by Akcil et al. (35) found anesthetic Concerns about postoperative pain management revolved
infiltration could provide effective anesthesia only in the first around the side effects of sedation, miosis, nausea, and
10 min postoperatively, compared with systemic anesthesia. vomiting, which could probably mask some crucial clinical
Our study showed a significant mean reduction in pain score symptoms. Expect for a trial of Gazoni et al. (29), none of the
at up to 12 h after craniotomy and the analgesic effect other trials included reported any significant difference in the
decreased over time. In general, the effect of local anesthetic incidence of complications. Analysis of 5 randomized
lasts no more than 6 h. The effect of scalp block seemed to controlled trials including a total of 190 participants
persist longer than expected, considering the duration of demonstrated that no significant variation could be found in

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FIGURE 3
Forest plot summarizing meta-analysis of studies reporting very early pain score. Notes: The black solid rhombuses indicate the estimated mean
difference for each randomized controlled trial and the extending lines indicate the estimated 95% CI of mean difference for each randomized
controlled trial; The black hollow rhombuses indicate the estimated mean difference (95% CI) for patients in each subgroup or all patients
included; Weights are from a random-effects analysis. Abbreviation: SB, scalp block; NSB, non-scalp block; CI, confidence interval.

FIGURE 4
Forest plot summarizing meta-analysis of studies reporting nausea and vomiting in first 24 h. Notes: The black solid rhombuses indicate the
estimated odds ratio for each randomized controlled trial and the extending lines indicate the estimated 95% CI of odds ratio for each
randomized controlled trial; The black hollow rhombuses indicate the estimated odds ratio (95% CI) for patients in each subgroup or all patients
included; Weights are from a random-effects analysis. Abbreviation: SB, Scalp Block; NSB, non-Scalp Block; CI, confidence interval.

the complications, with substantial heterogeneity. We believed We conducted a subgroup analysis to figure out the
that scalp block was equally safe compared to traditional advantages and disadvantages of the different occasion of
analgesic methods. scalp block and found that there was no significant difference

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Chen et al. 10.3389/fsurg.2022.1018511

in analgesia effect between pre-incision scalp block and post- Author contributions
incision scalp block. However, we found different periods of
postoperative analgesia: pre-incision scalp block was effective YC (First Author): Conceptualization, Methodology,
for analgesia at very early and early periods, but post-incision Software, Investigation, Formal Analysis, Writing - Original
scalp block was better at the early and intermediate periods. Draft. JN (First Author): Conceptualization, Methodology,
Considering the same duration of effect of scalp block, it’s Software, Investigation, Formal Analysis, Writing - Original
important to allow effective time to cover the most critical Draft. XL: Data Curation, Writing - Original Draft. JZ
periods. When only considering the postoperative analgesic (Corresponding Author): Visualization, Supervision, Writing -
effect, performing scalp block postoperatively was Review &; Editing. GC (Corresponding Author):
recommended. However, pre-incision scalp block might also Conceptualization, Supervision, Writing- Review &; Editing.
have the advantage of blunting the hemodynamic response to All authors contributed to the article and approved the
noxious stimuli such as cranial stapling, skin dissection, and submitted version.
flap stripping, which is of great importance when patients are
scheduled for awake craniotomies. In general, the occasion of
scalp block should be determined upon which purpose the
neurosurgeons want to achieve. We believed that pre-incision Conflict of interest
scalp block should be applied when better intraoperative
analgesia was needed, otherwise post-incisional scalp block The authors declare that the research was conducted in the
was more reliable. absence of any commercial or financial relationships that could
Overall, Scalp block is a safe and reliable technique that can be construed as a potential conflict of interest.
effectively reduce patients’ pain in the first 12 h after
craniotomy, and the results of our study supported its use in
postoperative analgesia after craniotomy.
Several limitations were objectively included in this study. Publisher’s note
First, only 12 randomized controlled studies were included in
the study and no more data were available to support our All claims expressed in this article are solely those of the
conclusions. Secondly, there were also methodological authors and do not necessarily represent those of their
differences among the included trials, such as different types affiliated organizations, or those of the publisher, the editors
and doses of local anesthetics. Thirdly, we did not focus on and the reviewers. Any product that may be evaluated in this
the relevance between the duration of craniotomy and the article, or claim that may be made by its manufacturer, is not
effect of scalp block on postoperative pain after craniotomy. guaranteed or endorsed by the publisher.
We hope more trials and studies related to scalp block could
be conducted in the future to support our conclusion.

Supplementary material
Data availability statement
The Supplementary Material for this article can be found
The raw data supporting the conclusions of this article will online at: https://www.frontiersin.org/articles/10.3389/fsurg.
be made available by the authors, without undue reservation. 2022.1018511/full#supplementary-material.

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