Post-Craniotomy Pain Management: Beyond Opioids

Abstract

Craniotomy pain may be severe and is often undertreated. Pain management following craniotomy is a balancing act of achieving adequate analgesia but avoiding sedation, respiratory depression, hypercapnia, nausea and vomiting, and hypertension. Opioids are a first-line analgesic therapy; however, concern that opioid-related adverse effects (sedation, respiratory depression) may interfere with neurologic assessment and increase intracranial pressure has limited use of these drugs for intracranial surgery. Non-opioid analgesics avoid these effects and may be useful as part of a multimodal regimen for post-craniotomy pain. Regional scalp blocks, paracetamol, and non-steroidal anti-inflammatory drugs are beneficial in the early post-operative period. Recent studies suggest a role for novel analgesics: dexmedetomidine, gabapentinoids, and ketamine, though additional studies are necessary.

Management of Postoperative Pain after Elective Craniotomy: A Prospective Randomized Controlled Trial of a Neurosurgical Enhanced Recovery after Surgery (ERAS) Program

“…Firstly, one of the main interventions in ERAS protocol is smoking cessation [1]. Smoking has been known to be harmful to overall health, and cigarette smoking may also be associated with a worse surgical outcome and prognosis in patients undergoing craniotomy [13]. Some studies indicate that smoking cessation may reduce postoperative complications following craniotomy [38].…”

Local anesthetics for brain tumor resection: current perspectives

“…Interestingly, these theoretical adverse effects have not been observed in studies using opioids. 11 Nevertheless, post-craniotomy pain should be treated by multimodal pain management where several classes of drugs are combined with local anesthesia. 11 , 12 Since patient-related factors that can predict the occurrence of serious postoperative pain are not known, it is recommended to provide on-demand analgesics that need to be administered with minimal delay to all craniotomy patients.…”

“… 11 Nevertheless, post-craniotomy pain should be treated by multimodal pain management where several classes of drugs are combined with local anesthesia. 11 , 12 Since patient-related factors that can predict the occurrence of serious postoperative pain are not known, it is recommended to provide on-demand analgesics that need to be administered with minimal delay to all craniotomy patients. 6 If an opioid drug is necessary, intermittent intravenous morphine provided on a medium- or high-care postoperative unit or via a patient-controlled system may be an effective option with less side effects compared to codeine or tramadol.…”

Ultrasound-guided superficial cervical plexus block for analgesia in patients undergoing craniotomy via suboccipital retrosigmoid approach: study protocol of a randomised controlled trial

“…At present, PCIA with opioid is the most common analgesia modality for patients received craniotomy 21 22. However, undesirable effects of opioids, including respiratory depression, nausea, vomiting, urinary retention, etc, not only bring discomfort to patients, but also affect neurological function evaluation by neurosurgeons 23. Besides opioids, non-steroidal anti-inflammatory drugs, another common analgesia agent is not suitable for postoperative analgesia after neurosurgery due to its effect on coagulation 24.…”