Post-Craniotomy Pain in a Paediatric Population

Abstract

There is little information about analgesia use or pain experienced in children after neurosurgery. The aims of this study were to assess the degree of pain experienced by children after neurosurgery and the analgesic regimens used, and to identify factors associated with significant pain. Data for 52 children who underwent craniotomy were collected contemporaneously over 72 hours. Data included demographics, intraoperative surgical and anaesthetic details, postoperative medications and postoperative pain scores as routinely collected by nursing staff. Pain was also assessed by an independent observer (auditor) using an age and developmentally appropriate tool, on a scale from zero to 10.For most of the time the children had little or no pain. Over the 72 hours the median pain score recorded by nursing staff was 0.7 and by the auditor was 1.3. However, in spite of the low median scores, 42% of children had at least one episode of a pain score ≥3.Postoperatively, 71% of children received parenteral morphine, 92% of children received paracetamol, 35% oxycodone, 19% oral codeine, 4% tramadol and 2% ibuprofen. Using multivariate regression, duration of procedure was the only factor associated with parenteral morphine use for >24 hours, and older age was the only factor associated with having an episode of pain scoring >3. No episodes of significant respiratory depression were noted.At our institution, children receive multimodal analgesia after neurosurgery, commonly parenteral morphine, and this is usually associated with low pain scores.

Incidence of pain after craniotomy in children

“…There are limited data describing the incidence of pain and the effects of treatment after neurosurgery in children. A single‐centre cohort study evaluating 52 children who underwent craniotomy reported that the majority of pediatric neurosurgical patients complained of little pain in the setting of substantial multimodal postoperative therapy including parenteral strong opioids . This study also found that older age and longer procedures were associated with increased pain after intracranial surgery.…”

“…One can hypothesize that an increased surgical length may produce longer central nervous system stimulation and thus wind up of pain pathways. Furthermore, it was previously reported that a long surgical procedure is associated with an increase in morphine consumption after major craniotomy .…”

“…As in our study, Teo et al . reported that children receiving multimodal analgesia including strong opioids presented low pain scores after major craniotomy. In our study, children undergoing longer surgical procedures were more prone to present moderate or severe pain.…”

Pain management following major intracranial surgery in pediatric patients: a prospective cohort study in three academic children's hospitals

“…Few studies of any size have focused specifically on the incidence and severity of postoperative pain in pediatric patients after cranial surgery or on how this pain is treated . In adult populations, some investigators have questioned the need for analgesia, believing pain was minimal, whereas others recommended PCA .…”

Good Practice in Postoperative and Procedural Pain Management, 2nd Edition

“…There have been few studies comparing standard analgesic regimens. Opioids: the use of parenteral opioids following craniotomy and major neurosurgery has been described (387)(388)(389)(390). PCA with fentanyl plus a continuous infusion of midazolam has been described (391).…”