The Perioperative Management of Pain from Intracranial Surgery

Abstract

Analgesic therapy following intracranial procedures remains a source of concern and controversy. Although opioids are the mainstay of the "balanced" general anesthetic techniques frequently used during intracranial procedures, neurosurgeons and others have been reluctant to administer opioid analgesics to patients following such procedures. This practice is supported by the concern that the sedation and miosis associated with opioid administration could mask the early signs of intracranial catastrophe, or even exacerbate it through decreased ventilatory drive, elevated arterial carbon dioxide levels, and increased cerebral blood flow. This reluctance to use opioids following intracranial surgery is enabled by decades of training and anecdote emphasizing that pain is minimal following these procedures. However, recent data suggests otherwise, and raises the question of how to provide safe and effective analgesia for these patients. Here, this data is reviewed along with the relevant pain pathways, analgesic drugs and techniques, and the available data on their use following intracranial surgery. Although pain following intracranial surgery appears to be more intense than initially believed, it is readily treated safely and effectively with techniques that have proven useful following other types of surgery, including patient-controlled administration of opioids. The use of multimodal analgesic therapy is emphasized not only for its effectiveness, but to reduce dosages and, therefore, side effects, primarily of the opioids, that could be of legitimate concern to physicians and affect the comfort of their patients.

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

“…Subsequent studies have shown that the incidence of PCH is underestimated both by physicians and nurses [5,6] , [7]. The past decade has seen publication of many studies assessing the efficacy and safety of preoperative, intraoperative, and postoperative treatments.…”

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

“…Indeed, because side effects are so common and expected, in this study, all three institutions used a multimodal approach to maximize analgesia and to minimize opioid‐related side effects . In this study, almost all patients were treated with acetaminophen in addition to opioids (BCH 80%, CHOP 91%; JHH 75% on POD1) (Figure , right panel).…”

“…In the current study, most patients had local anesthetic infiltration of the site of the incision but not specific nerve blocks, and steroid administration was not documented. Only through a multimodal analgesic strategy can the side effects of opioids be limited, while providing patients recovering from craniotomy with effective pain relief . Larger, prospective studies, powered to detect these differences will be needed in the future.…”

“…Historically, the pain associated with intracranial surgery has been under‐treated because of the fear that the use of opioids may interfere with the neurologic examination or lead to its deterioration . Much of the information concerning the quality, duration, and treatment of pain following cranial surgery is anecdotal .…”

Neuroscience Nurses' Perceptions of the Barriers to Identifying and Treating Pain in Acutely Brain-Injured Adult Patients

“…Untreated pain has physiological consequences that may alter cerebral perfusion pressure and lead to permanent brain damage (Roulin & Ramelet, 2012). In the past, it had been thought that pain from intracranial surgery was minimal, but more recent investigations have found such pain to be more intense, and the effect on the quality of recovery more profound, than previously thought (Gottschalk & Yaster, 2009). Significant pain should be assumed to be present in neurocritically ill patients and assiduous assessment of pain using validated assessment tools is the first step toward appropriate pain management (Gelinas, Klein, Naidech, & Skrobik, 2013).…”