Designing a pain management protocol for craniotomy: A narrative review and consideration of promising practices

Abstract

Background:Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain. Development of standardized pain management and enhanced recovery after surgery (ERAS) protocols are necessary and crucial to optimize outcomes and patient satisfaction and reduce health care costs.Methods:This work is based upon a literature search of published manuscripts (between 1996 and 2017) from Pubmed, Cochrane Central Register, and Google Scholar. It seeks to both synthesize and review our current scientific understanding of postcraniotomy pain and its part in neurosurgical ERAS protocols.Results:Strategies to ameliorate craniotomy pain demand interventions during all phases of patient care: preoperative, intraoperative, and postoperative interventions. Pain management should begin in the perioperative period with risk assessment, patient education, and premedication. In the intraoperative period, modifications in anesthesia technique, choice of opioids, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), regional techniques, dexmedetomidine, ketamine, lidocaine, corticosteroids, and interdisciplinary communication are all strategies to consider and possibly deploy. Opioids remain the mainstay for pain relief, but patient-controlled analgesia, NSAIDs, standardization of pain management, bio/behavioral interventions, modification of head dressings as well as patient-centric management are useful opportunities that potentially improve patient care.Conclusions:Future research on mechanisms, predictors, treatments, and pain management pathways will help define the combinations of interventions that optimize pain outcomes.

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

“…Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain 10 , 23 . Development of standardized pain management and ERAS protocols may help optimize patient-reported outcomes and reduce health care costs 1 , 23 .…”

“…Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain 10 , 23 . Development of standardized pain management and ERAS protocols may help optimize patient-reported outcomes and reduce health care costs 1 , 23 . The majority of reported ERAS programs for pain management dependent multidisciplinary cooperation, which include the efforts of neurosurgeons, anesthetists, residents, operating room nurses, neurophysiologist, dieticians and the support from family members of the patient 1 , 24 - 26 .…”

Treatment of post-craniotomy acute severe supraorbital neuralgia using ultrasound-guided pulsed radiofrequency: a case report

“… 12 Some forehead surgical procedures, such as flap and postoperative pressure dressings, may damage the supraorbital nerve, which could cause supraorbital neuralgia. 13 It is important to promptly and correctly identify the cause of this disease, which is crucial for the provision of targeted therapy as early as possible. During craniotomies, neurosurgeons should employ strategies to protect the supraorbital nerve and prevent supraorbital neuralgia.…”

<p>Pre-emptive scalp infiltration with dexamethasone plus ropivacaine for postoperative pain after craniotomy: a protocol for a prospective, randomized controlled trial</p>

“…Nonsteroidal anti-inflammatory drugs (NSAIDs) are cyclooxygenase (COX)-1/COX-2 inhibitors that appear to be effective for patients undergoing craniotomy, and NSAIDS are superior to other analgesics because they are devoid of negative side effects, including sedation, respiratory depression and so on 15. Although the utilization of NSAIDs could reduce postoperative opioid consumption,19,20 the use of NSAIDs has been restricted for its potential to cause platelet dysfunction and even regarding intracerebral hemorrhaging 20,21. COX-2 inhibitors such as parecoxib may relieve postoperative pain following craniotomies without the properties of antiplatelet but it has been clinically restricted because this drug is likely to cause cardiovascular disease secondary to thrombotic events 22.…”

“…Ketamine is a common N-methyl-D-aspartate receptor antagonist that could produce comparable analgesic effects to opioids 27. Nonetheless, its use in neurosurgery patients is questioned on account of the adverse effects on intracranial pressure, seizure threshold, and mentation 19…”