A single preoperative dose of diclofenac reduces the intensity of acute postcraniotomy headache and decreases analgesic requirements over five postoperative days in adults: A single center, randomized, blinded trial

Abstract

A single preoperative dose of diclofenac reduces the intensity of acute postcraniotomy headache and decreases analgesic requirements over five postoperative days in adults: a single center, randomized, blinded trial This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. KTIA_13_NAP-A-II/5. None of the authors has a personal financial interest in this research. A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT 2 AbstractObjective: Postcraniotomy headache causes considerable pain and can be difficult to treat. We therefore tested the hypothesis that a single 100-mg preoperative dose of diclofenac reduces the intensity of postcraniotomy headache, and reduces analgesic requirements.Methods: 200 patients having elective craniotomies were randomly assigned to diclofenac (n=100) or control (n=100). Pain severity was assessed by an independent observer using a 10-cm-long visual analogue scale the evening of surgery, and on the 1st and 5th postoperative days. Analgesics given during the first five postoperative days were converted to intramuscular morphine equivalents.Results were compared using Mann-Whitney-tests; P<0.05 was considered statistically significant.Results: Baseline and surgical characteristics were comparable in the diclofenac and control groups. Visual analogue pain scores were slightly, but significantly lower with diclofenac at all times (means and 95% confidence intervals): the evening of surgery, 2.47 (1.8-3.1) vs. 4. 37(5.0-3.7), (P<0.001); first postoperative day, 3.98 (3.4-4.6) vs.5.6 (4.9-6.2) cm (P<0.001) and 5th postoperative day: 2.8 (2.2-3.4) vs. 4.0 ± (3.3-4.7) cm (P = 0.013). Diclofenac reduced systemic analgesic requirements over the initial five postoperative days (mean and 95% CI): 3.3 (2.6 -3.9) vs. 4.3 (3.5-5.1) mg morphine equivalents (p<0.05). Conclusions: Preoperative diclofenac administration reduces postcraniotomyheadache and postoperative analgesic requirements -a benefit that persisted throughout five postoperative days.

Postoperative Pain Control Following Craniotomy: A Systematic Review of Recent Clinical Literature

“…Interestingly, in the subgroup of patients who underwent infratentorial interventions, the benefit of pain relief with the use of diclofenac was maintained up to the late postoperative period (POD5). Analgesic requirements as assessed with equivalent doses of morphine were lower in the diclofenac group, without any adverse effects …”

“…Intra‐operative administration of dexmedetomidine compared with placebo or active comparator provided better analgesic effect during PACU stay, and up to the first 12 hours in the ward . This was associated with reduced consumption of either tramadol or cumulative morphine compared with placebo or control group up to 24 hours postoperatively . Additionally, the mean time to first request for analgesia was prolonged in the dexmedetomidine group compared with placebo.…”

“…Pre‐operative administration of NSAIDs may enhance analgesia through local inflammation attenuation and consequent sensitization and pain windup during craniotomy, but their use in neurosurgery is still a contentious issue, mainly due to augmentation of the risk of intracranial bleeding . Premedication with diclofenac or its administration at regular time intervals provided satisfactory pain relief postoperatively, persisting over a 5‐day period, which far exceeds its duration of analgesic efficacy . No difference in adverse effects, including bleeding, was recorded in both studies.…”

“…The analgesic efficacy of COXIBs or NSAIDs for postcraniotomy pain control was assessed in 3 RCTs . Administration of parecoxib at dural closure demonstrated no clinical benefit regarding the primary and secondary endpoints of this systematic review .…”

“…No difference in adverse effects, including bleeding, was recorded in both studies. Diclofenac seems to be the most popular NSAID for craniotomy pain control, as 2 of 3 studies applying NSAIDs or COXIBs in this clinical setting included diclofenac sodium in their analgesic regimen . Of interest, in both studies diclofenac sodium was administered either as a single dose or at the lowest effective dose for a limited time frame, possibly with a view to provide an analgesic benefit without significant toxicity …”