Skip to main content

Ultrasound-guided bilateral superficial cervical block and preemptive single-dose oral tizanidine for post-thyroidectomy pain: a randomized-controlled double-blind study

Journal of Anesthesia volume 32, pages 219–226 (2018)Cite this article

Abstract

Purposes

The postoperative analgesic effect of tizanidine has not yet been evaluated sufficiently. The role of bilateral superficial cervical plexus block (BSCPB) for postoperative analgesia after thyroidectomy remains questionable. We aimed to evaluate the analgesic effect of combined use of BSCPB and a single-dose oral tizanidine in patients undergoing elective thyroid surgery.

Methods

Sixty patients undergoing thyroidectomy were randomized into 3 groups. The control group (Group C, n = 20) received BSCPB with 0.9% saline plus oral placebo. The superficial cervical group (Group SC, n = 20) received BSCPB with 0.25% bupivacaine plus oral placebo. The superficial cervical and tizanidine group (Group SC + T, n = 20) received BSCPB with 0.25% bupivacaine plus tizanidine 6 mg capsule. Surgical site pain scores, opioid consumption, rescue analgesia, posterior neck pain, headache, and opioid-related side effects were assessed for the first 24 h.

Results

Compared with Group C, rest and swallowing pain scores in Group SC and Group SC + T were statistically lower at all postoperative time points (p < 0.05). Fentanyl consumption was lower in Group SC and Group SC + T than in Group C at time periods 0–4 and 4–8 h (p < 0.05). Fentanyl consumption was lower in Group SC + T than in Group SC at 0–4 h (p = 0.006). Total fentanyl consumption was higher in Group C than in the other groups (p < 0.001). Postoperative cervical pain and occipital headache were significantly lower in Group SC + T than in the other groups (p < 0.05).

Conclusions

Ultrasound-guided BSCPB with or without preemptive oral tizanidine was effective at reducing postoperative pain and opioid consumption in patients undergoing total thyroidectomy. Addition of preemptive oral tizanidine to BSCPB reduced the early postoperative opioid consumption, posterior neck pain, and occipital headache.

Clinical trials registry

The study was registered with a clinical trials registry (ClinicalTrials.gov. identifier NCT02725359).

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1

References

  1. Yucel A, Yazici A, Muderris T, Gul F. Comparison of lornoxicam and low-dose tramadol for management of post-thyroidectomy pain. Agri. 2016;28(4):183–9.

    PubMed  Google Scholar 

  2. Long K, Ruiz J, Kee S, Kowalski A, Goravanchi F, Cerny J, French K, Hernandez M, Perrier N, Rebello E. Effect of adjunctive dexmedetomidine on postoperative intravenous opioid administration in patients undergoing thyroidectomy in an ambulatory setting. J Clin Anesth. 2016;35:361–4.

    CAS  Article  PubMed  Google Scholar 

  3. Bindu M, Kumar AA, Kesavan M, Suresh V. Effect of preoperative pregabalin on postoperative pain relief in thyroidectomy patients: a prospective observational study. Anesth Essays Res. 2015;9(2):161–6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. Miu M, Royer C, Gaillat C, Schaup B, Menegaux F, Langeron O, Riou B, Aubrun F. Lack of analgesic effect induced by ropivacaine wound infiltration in thyroid surgery: a randomized, double-blind, placebo-controlled trial. Anesth Analg. 2016;122(2):559–64.

    CAS  Article  PubMed  Google Scholar 

  5. Gurkan Y, Tas Z, Toker K, Solak M. Ultrasound guided bilateral cervical plexus block reduces postoperative opioid consumption following thyroid surgery. J Clin Monit Comput. 2015;29(5):579–84.

    Article  PubMed  Google Scholar 

  6. Motamed C, Merle JC, Yakhou L, Combes X, Dumerat M, Vodinh J, Kouyoumoudjian C, Duvaldestin P. Intraoperative i.v. morphine reduces pain scores and length of stay in the post anaesthetic care unit after thyroidectomy. Br J Anaesth. 2004;93(2):306–7.

    CAS  Article  PubMed  Google Scholar 

  7. Ahiskalioglu EO, Ahiskalioglu A, Aydin P, Yayik AM, Temiz A. Effects of single-dose preemptive intravenous ibuprofen on postoperative opioid consumption and acute pain after laparoscopic cholecystectomy. Medicine (Baltimore). 2017;96(8):e6200.

    CAS  Article  PubMed  Google Scholar 

  8. Tabari M, Alipour M, Esalati H. Evaluation of oral tizanidine effects on [intraoperative] hemodynamic responses during direct laryngoscopy under general anesthesia. Iran Red Crescent Med J. 2013;15(7):541–6.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Takenaka M, Iida H, Kasamatsu M, Katoh H, Tashiro T, Dohi S. Tizanidine for preanesthetic medication. Masui. 1996;45(8):971–5.

    CAS  PubMed  Google Scholar 

  10. Wajima Z, Yoshikawa T, Ogura A, Imanaga K, Shiga T, Inoue T, Ogawa R. Oral tizanidine, an alpha2-adrenoceptor agonist, reduces the minimum alveolar concentration of sevoflurane in human adults. Anesth Analg. 2002;95(2):393–6.

    CAS  Article  PubMed  Google Scholar 

  11. Yazicioglu D, Caparlar C, Akkaya T, Mercan U, Kulacoglu H. Tizanidine for the management of acute postoperative pain after inguinal hernia repair: a placebo-controlled double-blind trial. Eur J Anaesthesiol. 2016;33(3):215–22.

    CAS  Article  PubMed  Google Scholar 

  12. Talakoub R, Abbasi S, Maghami E, Zavareh SM. The effect of oral tizanidine on postoperative pain relief after elective laparoscopic cholecystectomy. Adv Biomed Res. 2016;5:19.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Bharti N, Dontukurthy S, Bala I, Singh G. Postoperative analgesic effect of intravenous (i.v.) clonidine compared with clonidine administration in wound infiltration for open cholecystectomy. Br J Anaesth. 2013;111(4):656–61.

    CAS  Article  PubMed  Google Scholar 

  14. Blaudszun G, Lysakowski C, Elia N, Tramer MR. Effect of perioperative systemic alpha2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2012;116(6):1312–22.

    CAS  Article  PubMed  Google Scholar 

  15. Techanivate A, Dusitkasem S, Anuwattanavit C. Dexmedetomidine compare with fentanyl for postoperative analgesia in outpatient gynecologic laparoscopy: a randomized controlled trial. J Med Assoc Thail. 2012;95(3):383–90.

    Google Scholar 

  16. Smith C, Birnbaum G, Carter JL, Greenstein J, Lublin FD. Tizanidine treatment of spasticity caused by multiple sclerosis: results of a double-blind, placebo-controlled trial. US Tizanidine Study Group. Neurology. 1994;44(11 Suppl 9):S34–42 (discussion S-3).

    CAS  PubMed  Google Scholar 

  17. Malanga GA, Gwynn MW, Smith R, Miller D. Tizanidine is effective in the treatment of myofascial pain syndrome. Pain Physician. 2002;5(4):422–32.

    PubMed  Google Scholar 

  18. Semenchuk MR, Sherman S. Effectiveness of tizanidine in neuropathic pain: an open-label study. J Pain. 2000;1(4):285–92.

    CAS  Article  PubMed  Google Scholar 

  19. Saper JR, Lake AE III, Cantrell DT, Winner PK, White JR. Chronic daily headache prophylaxis with tizanidine: a double-blind, placebo-controlled, multicenter outcome study. Headache. 2002;42(6):470–82.

    Article  PubMed  Google Scholar 

  20. Park C, Choi JB, Lee YS, Chang HS, Shin CS, Kim S, Han DW. The effect of intra-operative transcutaneous electrical nerve stimulation on posterior neck pain following thyroidectomy. Anaesthesia. 2015;70(4):434–9.

    CAS  Article  PubMed  Google Scholar 

  21. Han DW, Koo BN, Chung WY, Park CS, Kim SY, Palmer PP, Kim KJ. Preoperative greater occipital nerve block in total thyroidectomy patients can reduce postoperative occipital headache and posterior neck pain. Thyroid. 2006;16(6):599–603.

    Article  PubMed  Google Scholar 

  22. Ayhan H, Tastan S, Iyigun E, Ozturk E, Yildiz R, Gorgulu S. The effectiveness of neck stretching exercises following total thyroidectomy on reducing neck pain and disability: a randomized controlled trial. Worldviews Evid Based Nurs. 2016;13(3):224–31.

    Article  PubMed  Google Scholar 

  23. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Myofascial trigger points in the suboccipital muscles in episodic tension-type headache. Man Ther. 2006;11(3):225–30.

    Article  PubMed  Google Scholar 

  24. Andrieu G, Amrouni H, Robin E, Carnaille B, Wattier JM, Pattou F, Vallet B, Lebuffe G. Analgesic efficacy of bilateral superficial cervical plexus block administered before thyroid surgery under general anaesthesia. Br J Anaesth. 2007;99(4):561–6.

    CAS  Article  PubMed  Google Scholar 

  25. Dieudonne N, Gomola A, Bonnichon P, Ozier YM. Prevention of postoperative pain after thyroid surgery: a double-blind randomized study of bilateral superficial cervical plexus blocks. Anesth Analg. 2001;92(6):1538–42.

    CAS  Article  PubMed  Google Scholar 

  26. Shih ML, Duh QY, Hsieh CB, Liu YC, Lu CH, Wong CS, Yu JC, Yeh CC. Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations. World J Surg. 2010;34(10):2338–43.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Eti Z, Irmak P, Gulluoglu BM, Manukyan MN, Gogus FY. Does bilateral superficial cervical plexus block decrease analgesic requirement after thyroid surgery? Anesth Analg. 2006;102(4):1174–6.

    Article  PubMed  Google Scholar 

  28. Steffen T, Warschkow R, Brandle M, Tarantino I, Clerici T. Randomized controlled trial of bilateral superficial cervical plexus block versus placebo in thyroid surgery. Br J Surg. 2010;97(7):1000–6.

    CAS  Article  PubMed  Google Scholar 

  29. Pandit JJ, Bree S, Dillon P, Elcock D, McLaren ID, Crider B. A comparison of superficial versus combined (superficial and deep) cervical plexus block for carotid endarterectomy: a prospective, randomized study. Anesth Analg. 2000;91(4):781–6.

    CAS  Article  PubMed  Google Scholar 

  30. Pandit JJ, Satya-Krishna R, Gration P. Superficial or deep cervical plexus block for carotid endarterectomy: a systematic review of complications. Br J Anaesth. 2007;99(2):159–69.

    CAS  Article  PubMed  Google Scholar 

  31. Stoneham MD, Doyle AR, Knighton JD, Dorje P, Stanley JC. Prospective, randomized comparison of deep or superficial cervical plexus block for carotid endarterectomy surgery. Anesthesiology. 1998;89(4):907–12.

    CAS  Article  PubMed  Google Scholar 

  32. Wagstaff AJ, Bryson HM. Tizanidine. A review of its pharmacology, clinical efficacy and tolerability in the management of spasticity associated with cerebral and spinal disorders. Drugs. 1997;53(3):435–52.

    CAS  Article  PubMed  Google Scholar 

Download references

Funding

None declared.

Author information

Affiliations

  1. Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Palandöken, 25070, Erzurum, Turkey

    Ali Ahiskalioglu, Ahmet Murat Yayik, Aysenur Dostbil, Omer Doymus, Muhammet Ali Ari & Haci Ahmet Alici

  2. Department of Anaesthesiology, Regional Training and Research Hospital, Erzurum, Turkey

    Elif Oral Ahiskalioglu & Erkan Cem Celik

  3. Department of General Surgery, Ataturk University School of Medicine, Erzurum, Turkey

    Erdem Karadeniz

  4. Department of Otolaryngology, Ataturk University School of Medicine, Erzurum, Turkey

    Furkan Sengoz

Authors
  1. Ali Ahiskalioglu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmet Murat Yayik
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Elif Oral Ahiskalioglu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Aysenur Dostbil
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Omer Doymus
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Erdem Karadeniz
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Muhammet Ali Ari
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Furkan Sengoz
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Haci Ahmet Alici
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Erkan Cem Celik
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ali Ahiskalioglu.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ahiskalioglu, A., Yayik, A.M., Oral Ahiskalioglu, E. et al. Ultrasound-guided bilateral superficial cervical block and preemptive single-dose oral tizanidine for post-thyroidectomy pain: a randomized-controlled double-blind study. J Anesth 32, 219–226 (2018). https://doi.org/10.1007/s00540-018-2468-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00540-018-2468-x

Keywords

  • Tizanidine
  • Thyroidectomy
  • Superficial cervical plexus block
  • Ultrasound