Pain treatment after craniotomy: where is the (procedure-specific) evidence? A qualitative systematic review

Regional Anesthesia Techniques in Modern Neuroanesthesia Practice: A Narrative Review of the Clinical Evidence

Neurosurgical procedures are often associated with significant postoperative pain that is both underrecognized and undertreated. Given the potentially undesirable side effects associated with general anesthesia and with various pharmacological analgesic regimens, regional anesthetic techniques have gained in popularity as alternatives for providing both anesthesia and analgesia for the neurosurgical patient. The aim of this narrative review is to present an overview of the regional techniques that have been incorporated and continue to be incorporated into modern neuroanesthesia practice, presenting in a comprehensive way the evidence, where available, in support of such practice for the neurosurgical patient.

Systematic Review and Meta-Analysis of Randomized Controlled Trials for Scalp Block in Craniotomy

BACKGROUND

Scalp block is regional anesthetic injection along nerves innervating the cranium. Scalp blocks for craniotomy may decrease postoperative pain and opioid consumption. Benefits may extend beyond the anesthetic period.

OBJECTIVE

To analyze evidence for scalp block on postoperative pain and opioid use.

METHODS

This systematic review and meta-analysis, Prospective Register of Systematic Reviews registration (CRD42022308048), included Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials inception through February 9, 2022. Only randomized controlled trials were included. We excluded studies not reporting either main outcome. Duplicate reviewers performed study selection, risk of bias assessment, data extraction, and evidence certainty Grading of Recommendations Assessment, Development, and Evaluation appraisal. Main outcomes were postoperative pain by visual analog scale within 72 hours and opioid consumption as morphine milligram equivalent (MME) within 48 hours.

RESULTS

Screening filtered 955 studies to 23 trials containing 1532 patients. Risk of bias was overall low. Scalp block reduced postoperative pain at 2 through 72 hours, visual analog scale mean differences of 0.79 to 1.40. Opioid requirements were reduced at 24 hours by 16.52 MME and 48 hours by 15.63 MME.

CONCLUSION

Scalp block reduces postoperative pain at 2 through 48 hours and may reduce pain at 72 hours. Scalp block likely reduces opioid consumption within 24 hours and may reduce opioid consumption to 48 hours. The clinical utility of these differences should be interpreted within the context of modest absolute reductions, overall care optimization, and patient populations. This is the first level 1A evidence to evaluate scalp block efficacy in craniotomy.

Association of scalp block with intraoperative hemodynamic profiles and postoperative pain outcomes at 24-48 hours following craniotomy: An updated systematic review and meta-analysis of randomized controlled studies

BACKGROUND

Despite the demonstrated analgesic efficacy of scalp block (SB) during the immediate postoperative period, the impact of SB on pain outcomes at postoperative 24 and 48 h in adults receiving craniotomy remains unclear.

METHODS

The databases of Medline, Embase, and Cochrane Central Register were searched from inception to January 2022 for available randomized controlled trials (RCTs). The primary outcome was the severity of pain at postoperative 24 and 48 h, while the secondary outcomes included morphine consumption, hemodynamic profiles after surgical incision and in the postanesthesia care unit (PACU), and risk of postoperative nausea/vomiting (PONV).

RESULTS

Meta-analysis of 12 studies revealed a lower pain score [MD = -0.83, p = 0.03, 375 patients, certainty of evidence (COE): low] and morphine consumption (MD = -9.21 mg, p = 0.03, 246 patients, COE: low) at postoperative 24 h, while there were no differences in these pain outcomes at postoperative 48 h (COE: low). The use of SB significantly decreased intraoperative heart rate (MD = -10.9 beats/min, p < 0.0001, 189 patients, COE: moderate) and mean blood pressure (MD = -13.02 mmHg, p < 0.00001, 189 patients, COE: moderate) after surgical incision, but these hemodynamic profiles were comparable in both groups in the PACU setting. There was also no difference in the risk of PONV between the two groups (RR = 0.78, p = 0.2, 299 patients, COE: high).

CONCLUSION

This meta-analysis demonstrated that scalp block not only provided hemodynamic stability immediately after surgical incision but was also associated with a lower pain score and morphine consumption at postoperative 24 h. Further studies are needed for elucidation of its findings.

Scalp block for postoperative pain after craniotomy: A meta-analysis of randomized control trials

Background

Postoperative pain after craniotomy is an important clinical concern because it might lead to brain hyperemia and elevated intracranial pressure. Considering the side effects of opioid, several studies have been conducted to investigate the effect of local anesthetics, especially the scalp block, on postoperative pain. However, the strength of evidence supporting this practice for postoperative pain after craniotomy was unclear and the best occasion of scalp block was also not identified. Therefore, we conducted a meta-analysis to evaluate the efficacy, safety, and the best occasion of scalp block for postoperative pain after craniotomy.

Methods

PubMed, Embase, and the Cochrane Library databases from database inception to October 10, 2021 were searched for all randomized controlled trials evaluating the effect of scalp block on postoperative pain after craniotomy. Data were assessed by StataMP 16 software.

Results

A total of 12 studies were included. A random-effect model was used to analyze all data. Patients under scalp block earned fewer scores than the non-scalp block group in visual analogue scale at the very early period (MD = −1.97, 95% CI = −3.07 to −0.88), early period (MD = −1.84, 95% CI = −2.95 to −0.73) and intermediate period (MD = −1.16, 95% CI = −1.84 to −0.49). Scalp block could also significantly prolong the time of the first request of rescue analgesia and reduce the use of additional analgesics without a significant difference in the incidence of complications. Subgroup analysis showed there was no significant difference in analgesia effect between pre-incision scalp block and post-incision scalp block in all periods.

Conclusion

Scalp block could lead to lower pain intensity scores, more time of the first request of rescue analgesia, and fewer analgesic drugs applied in the first 12 h after craniotomy. There was no significant difference between pre-incision and post-incision scalp block in the occurrence and severity of postoperative pain.

The effect of scalp block or local wound infiltration versus systemic analgesia on post-craniotomy pain relief

BACKGROUND

This is a prospective, double-blind observational study in which different types of analgesia and its effect on postoperative pain reduction in patients undergoing craniotomy for brain tumor removal were compared.

METHODS

The study included 141 adult craniotomy patients that were randomly separated into three equal groups. A group with scalp nerve blockade (B) and wound infiltration (I) received 0.25% bupivacaine combined with 1% lidocaine and 1:200,000 epinephrine. One gram of paracetamol and 2 mg/kg ketoprofen were administered intravenously (IV) after skin closure in a group with systemic analgesia (S). Pain intensity was evaluated after 1, 3, 6, and 24 h postoperatively using a visual analogue scale (VAS). The amount of rescue analgesia (ketorolac, paracetamol, and pethidine) and the duration for its first requirement were recorded.

RESULTS

One hundred and forty-one patients were included in the study. The main pain scores were significantly lower in the groups with regional anesthesia compared to group S in the first hours post-surgery (p < 0.05). Significantly lower pain scores were observed in the group with a scalp nerve blockade compared to the group with systemic analgesia or wound infiltration after 24 h (p < 0.05). Regional anesthesia ensured a stable analgesic effect for all 24 h. Patients in groups B and I required significantly fewer rescue analgesics compared to patients in group S. The duration for the requirement of the first rescue analgesia was significantly longer in groups B and I compared to group S (p = 0.000).

CONCLUSIONS

The results of our study show that most patients experience pain in the early postsurgical hours. Regional analgesia could help reduce the incidence and severity of pain after a craniotomy and the amount of rescue analgesia used in this group of patients.

Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review

Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.

Multimodal analgesia in neurosurgery: a narrative review

Pain following brain surgery can compromise the result of surgery. Several pharmacological interventions have been used to prevent postoperative pain in adults undergoing brain surgery. Pain following craniotomy is considered to be moderate to severe during the first two post-operative days. Opioids have been historically the mainstay and are the current prominent strategy for pain treatment. They produce analgesia but may alter respiratory, cardiovascular, gastrointestinal, and neuroendocrine functions. All these side effects may affect the normal postoperative course of craniotomy by affecting neurological function and increasing intracranial pressure. Therefore, their use in neurosurgery is limited, and opioids are used in case of strict necessity or as rescue medication. In addition to opioids, drugs with differing mechanisms of actions target pain pathways, resulting in additive and/or synergistic effects. Some of these agents include acetaminophen/non-steroidal anti-inflammatory drugs (NSAIDs), alpha-2 agonists, NMDA receptor antagonists, gabapentinoids, and local anesthesia techniques. Multimodal analgesia should be a balance between adequate analgesia and less drug-induced sedation, respiratory depression, hypercapnia, nausea, and vomiting, which may increase intracranial pressure. Non-opioid analgesics can be an useful pharmacological alternative in multimodal regimes to manage post-craniotomy pain. This narrative review aims to outline the current clinical evidence of multimodal analgesia for post craniotomy pain control.

Preoperative Versus Postoperative Scalp Block Combined With Incision Line Infiltration for Pain Control After Supratentorial Craniotomy

OBJECTIVE

Postoperative pain after craniotomy is a significant clinical problem that is sometimes underestimated, although moderate or severe pain in early postoperative period complicates up to 60% of cases. The purpose of this prospective randomized multicenter trial was to determine the optimal timing for selective scalp block in patients undergoing general anesthesia for supratentorial craniotomy.

MATERIALS AND METHODS

After ethics committee approval and informed consent, 56 adult patients were enrolled, and randomly assigned to receive a selective scalp block combined with incision line infiltration preoperatively or postoperatively.

RESULTS

Postoperative pain at 24 hours after the procedure was recorded in all 56 enrolled patients. In patients assigned to receive a scalp block preoperatively, median VAS score at 24 hours after surgery was 0 (0 to 2), and in patients assigned to receive a scalp block postoperatively it was 0 (0 to 3) (P>0.05). There was no difference in severity of pain at 24, 12, 6, and 2 hours after surgery between the 2 study groups, but the amount of fentanyl administered intraoperatively was lower in patients assigned to the preoperative scalp block group (1.6±0.7 vs. 2.4±0.7 mkg/kg/h, P=0.01).

DISCUSSION

This study confirms and extends available clinical evidence on the safety and efficacy of selective scalp blocks for the prevention of postoperative pain. Recorded data suggest that there is no difference in terms of occurrence and severity of postoperative pain regardless of whether the scalp block is performed preoperatively (after general anesthesia induction) or postoperatively (before extubation). Patients assigned to receive a scalp block combined with incision line infiltration preoperatively needed less intraoperative opioids than those assigned to postoperative scalp block.

Prevention and treatment of postoperative pain in pediatric patients undergone craniotomy: Systematic review of clinical evidence

BACKGROUND

Prevention and treatment of postoperative pain after craniotomy in pediatric patients is an open and challenging clinical problem due to limited epidemiological data and significant concerns on safety of the most common analgesics in neurosurgical patients. We reviewed the literature to evaluate the possible available strategies in pain management in pediatric patients.

METHODS

The systematic review was performed in accordance with PRISMA statement recommendations. PUBMED, EMBASE and Scopus databases were queried. Inclusion criteria were: randomized controlled trials, prospective and retrospective observational studies published before 2020 and reported postoperative pain management after craniotomy (i.e. including studies accomplished after craniotomy, craniectomy and reconstructive surgery) in children population (neonates to 18 years old).

RESULTS

A total of 11 studies - 4 randomized controlled, 5 prospective observational and 2 retrospective met criteria for inclusion. The selected studies reported data from a total of 1077 patients, with age ranging between neonates to 18 years, 52% male and 48% female. Opioids are still the most commonly used drugs. Paracetamol and NSAIDs are frequently used as adjuvants to reduce postoperative opioid requirements. Data on potential hypocoagulation due to the antiplatelet effect of NSAIDs are lacking. Selective scalp block provides lower pain scores in early postoperative period.

CONCLUSION

Clinical evidence on prevention and treatment of postoperative pain in pediatric patients undergone craniotomy is still sparse. Available data prove that a multimodal approach, realized as the use a combination of opioids, paracetamol/NSAIDs and regional anesthesia, is effective and rarely associate with complications.

Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial

BACKGROUND

The anesthetic management of supratentorial craniotomy (CR) necessitates tight intraoperative hemodynamic control. This type of surgery may also be associated with substantial postoperative pain. We aimed at evaluating the influence of regional scalp block (SB) on hemodynamic stability during the noxious events of supratentorial craniotomies and total intravenous anesthesia, its influence on intraoperative anesthetic agents' consumption, and its effect on postoperative pain control.

METHODS

Sixty patients scheduled for elective CR were prospectively enrolled. Patient, anesthesiologist, and neurosurgeon were blind to the random performance of SB with either levobupivacaine 0.33% (intervention group [group SB], n = 30) or the same volume of saline (control group [group CO], placebo group, n = 30). General anesthesia was induced and maintained using target-controlled infusions of remifentanil and propofol that were adjusted according to hemodynamic parameters and state entropy of the electroencephalogram (SE), respectively. Mean arterial blood pressure (MAP), heart rate (HR), SE, and propofol and remifentanil effect-site concentrations (Ce) were recorded at the time of scalp block performance (Baseline), and 0, 1, 3, and 5 minutes after skull-pin fixation (SP), skin incision (SI), CR, and dura-mater incision (DM). Morphine consumption and postoperative pain intensity (0-10 visual analog scale [VAS]) were recorded 1, 3, 6, 24, and 48 hours after surgery. Propofol and remifentanil overall infusion rates were also recorded. Data were analyzed using 2-tailed Student unpaired t tests, 2-way mixed-design analysis of variance (ANOVA), and Tukey's honestly significant difference (HSD) tests for post hoc comparisons as appropriate.

RESULTS

Demographics and length of anesthetic procedure of group CO and SB were comparable. SP, SI, and CR were associated with a significantly higher MAP in group CO than in group SB, at least at one of the time points of recording surrounding those noxious events. This was not the case at DM. Similarly, HR was significantly higher in group CO than in group SB during SP and SI, at least at 1 of the points of recording, but not during CR and DM. Propofol and remifentanil Ce and overall infusion rates were significantly higher in group CO than in group SB, except for propofol Ce during SP. Postoperative pain VAS and cumulative morphine consumption were significantly higher in group CO than in group SB.

CONCLUSIONS

In supratentorial craniotomies, SB improves hemodynamic control during noxious events and provides adequate and prolonged postoperative pain control as compared to placebo.

Role of anaesthesia in neurosurgical enhanced recovery programmes

The application of Enhanced Recovery After Surgery (ERAS) in neurosurgical practice is a relatively new concept. A limited number of studies involving ERAS protocols within neurosurgery, specifically for elective craniotomy, have been published, contrary to the ERAS spine surgery pathways that are now promoted by numerous national and international dedicated surgical societies and hospitals. In this review, we want to present the patient surgical journey from an anaesthesia perspective through the key components that can be included in the ERAS pathways for neurosurgical procedures, both craniotomies and major spine surgery.

Addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia improves analgesic efficacy after tonsillectomy and adenoidectomy: A randomized controlled trial

OBJECTIVES

The aim of this study was to determine whether the addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia was more effective than ropivacaine alone in attenuating pain after tonsillectomy and adenoidectomy.

METHODS

This was a double-blind randomized clinical trial. One hundred and twenty children scheduled for tonsillectomy and adenoidectomy using a combination of general anaesthesia and local infiltration anaesthesia were randomized into the dexmedetomidine plus ropivacaine group (DR) and ropivacaine group (R). The children were locally infiltrated with 1 μg kg^-1 dexmedetomidine and 0.25% ropivacaine in the DR group or 0.25% ropivacaine alone in the R group. In both groups, local infiltration anaesthesia was performed using 5 ml of solution. The pain scores were recorded at the 1st, 4th, 8th, 12th, 16th, 20th, and 24th hours after surgery using the Face Legs Activity Cry Consolability (FLACC) scale. When the pain score exceeded 4, paracetamol syrup (15 mg kg^-1) was administered as a rescue analgesic. Time to the first administration of analgesic was recorded.

RESULTS

8th, 16th, 20th, and 24th hours after surgery, the children in the DR group had lower pain scores than those in the R group (P<0.05). The time to the first administration of analgesic was significantly longer in the DR group (mean: 10.4 h, range: 9.4-11.4 h) than in the R group (mean: 8.1 h, range: 7.3-8.8 h) (P < 0.001).

CONCLUSION

The addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia effectively improved the efficacy of analgesia and extended the duration of analgesia after tonsillectomy and adenoidectomy.

Effect of bilateral scalp nerve blocks on postoperative pain and discharge times in patients undergoing supratentorial craniotomy and general anesthesia: a randomized-controlled trial

PURPOSE

Post-craniotomy pain is a common clinical issue and its optimal management remains incompletely studied. Utilization of a regional scalp block has the potential advantage of reducing perioperative pain and opioid consumption, thereby facilitating optimal postoperative neurologic assessment. The purpose of this study was to assess the efficacy of regional scalp block on post-craniotomy pain and opioid consumption.

METHODS

We performed a prospective randomized-controlled trial in adults scheduled to undergo elective supratentorial craniotomy under general anesthesia to assess the efficacy of postoperative bilateral scalp block with 0.5% bupivacaine with 1:200,000 epinephrine compared with placebo on postoperative pain and opioid consumption. The primary outcome was the visual analogue scale (VAS) for pain at 24 hr postoperatively.

RESULTS

Eighty-nine patients were enrolled (n = 44 in block group; n = 45 in control group). There was no difference in the mean (standard deviation) VAS score at 24 hr postoperatively between the treatment group and the control group [31.2 (21.4) mm vs 23.0 (19.2) mm, respectively; mean difference, 6.6; 95% confidence interval, -2.3, 15.5; P = 0.15]. There was also no significant difference in postoperative opioid consumption. Distribution of individual VAS score and opioid consumption revealed that postoperative pain was highly variable following craniotomy. Time to hospital discharge was not different between treatment and placebo groups. No adverse events associated with scalp block were identified.

CONCLUSION

These data show that bilateral scalp blocks using bupivacaine with epinephrine did not reduce mean postoperative VAS score or overall opioid consumption at 24 hr nor the time-to-discharge from the postanesthesia care unit or from hospital.

TRIAL REGISTRATION

www.ClinicalTrials.gov, NCT00972790; registered 9 September, 2009.

Effect of Scalp Nerve Block with Ropivacaine on Postoperative Pain in Patients Undergoing Craniotomy: A Randomized, Double Blinded Study

Scalp nerve block with ropivacaine has been shown to provide perioperative analgesia. However, the best concentration of ropivacaine is still unknown for optimal analgesic effects. We performed a prospective study to evaluate the effects of scalp nerve block with varied concentration of ropivacaine on postoperative pain and intraoperative hemodynamic variables in patients undergoing craniotomy under general anesthesia. Eighty-five patients were randomly assigned to receive scalp block with either 0.2% ropivacaine, 0.33% ropivacaine, 0.5% ropivacaine, or normal saline. Intraoperative hemodynamics and post-operative pain scores at 2, 4, 6, 24 hours postoperatively were recorded. We found that scalp blockage with 0.2% and 0.33% ropivacaine provided adequate postoperative pain relief up to 2 h, while administration of 0.5% ropivacaine had a longer duration of action (up to 4 hour after craniotomy). Scalp nerve block with varied concentration of ropivacaine blunted the increase of mean arterial pressure in response to noxious stimuli during incision, drilling, and sawing skull bone. 0.2% and 0.5% ropivacaine decreased heart rate response to incision and drilling. We concluded that scalp block using 0.5% ropivacaine obtain preferable postoperative analgesia compared to lower concentrations. And scalp block with ropivacaine also reduced hemodynamic fluctuations in craniotomy operations.

Anesthesia for meningioma surgery

Patients receiving treatment for a meningioma require anesthesia when undergoing open craniotomy and, in some cases, during preoperative tumor embolization and radiosurgery. Adequate anesthesia management is integral to patients' perioperative care, which consists of the three phases of preoperative assessment and optimization, intraoperative care, and postoperative recovery. The preoperative anesthesia evaluation focusses on the cardiorespiratory and neurologic systems, as well as the airway, but also extends to ensure the optimal treatment of significant comorbidities before surgical intervention. The goals of intraoperative care are maintenance of brain physiology, facilitating surgery, and correcting any adverse effects of surgery and underlying pathology to preserve general patient homeostasis. This requires adequate intraoperative patient monitoring, cardiorespiratory support, management of infusion therapy, and application of knowledge about the effects of anesthetic agents on brain physiology. The anesthesiologist's responsibilities for patient care extend well into the postoperative recovery period, with a focus on pain control, prevention, and treatment of postoperative nausea and vomiting (PONV), and, in some patients, intensive care therapy.

Narrative review of acute post-craniotomy pain. Concept and strategies for prevention and treatment of pain

The aim of this narrative review is to confirm that acute pain after craniotomy is frequent and presents with moderate to severe intensity. We also highlight the importance of not only treating post-craniotomy pain, but also of preventing it in order to reduce the incidence of chronic pain. Physicians should be aware that conventional postoperative analgesics (non-steroidal anti-inflammatory, paracetamol, cyclooxygenase inhibitors 2, opioids) are not the only options available. Performing a scalp block prior to surgical incision or after surgery, the use of intraoperative dexmedetomidine, and the perioperative administration of pregabalin are just some alternatives that are gaining ground. The management of post-craniotomy pain should be based on perioperative multimodal analgesia in the framework of an "enhaced recovery after surgery" (ERAS) approach.

Pharmacological interventions for the prevention of acute postoperative pain in adults following brain surgery

BACKGROUND

Pain following brain surgery can compromise recovery. Several pharmacological interventions have been used to prevent pain after craniotomy; however, there is currently a lack of evidence regarding which interventions are most effective.

OBJECTIVES

The objectives are to assess the effectiveness of pharmacological interventions for prevention of acute postoperative pain in adults undergoing brain surgery; compare them in terms of additional analgesic requirements, incidence of chronic headache, sedative effects, length of hospital stay and adverse events; and determine whether these characteristics are different for certain subgroups.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science and two trial registries together with reference checking and citation searching on 28th of November 2018.

SELECTION CRITERIA

We included blinded and non-blinded, randomized controlled trials evaluating pharmacological interventions for the prevention of acute postoperative pain in adults undergoing neurosurgery, which had at least one validated pain score outcome measure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We calculated mean differences for the primary outcome of pain intensity; any pain scores reported on a 0 to 100 scale were converted to a 0 to 10 scale.

MAIN RESULTS

We included 42 completed studies (3548 participants) and identified one ongoing study. Nonsteroidal anti-inflammatories (NSAIDs) Nonsteroidal anti-inflammatories (NSAIDs) reduce pain up to 24 hours (0 to 6 hours, MD -1.16, 95% CI -1.57 to -0.76; 12 hours, MD -0.62, 95% CI -1.11 to -0.14; 24 hours, MD -0.66, 95% CI -1.18 to -0.13; 6 studies, 742 participants; all high-quality evidence). Results for other outcomes were imprecise (additional analgesic requirements: MD 1.29 mg, 95% CI -5.0 to 2.46, 4 studies, 265 participants; nausea and vomiting RR 1.34, 95% CI 0.30 to 5.94, 2 studies, 345 participants; both low-quality evidence). Dexmedetomidine reduces pain up to 12 hours (0 to 6 hours, MD -0.89, 95% CI -1.27 to -0.51, moderate-quality evidence; 12 hours, MD -0.81, 95% CI -1.21 to -0.42, low-quality evidence). It did not show efficacy at 24 hours (MD -0.08, 95% CI -0.32 to 0.16; 2 studies, 128 participants; low-quality evidence). Dexmedetomidine may decrease additional analgesic requirements (MD -21.36 mg, 95% CI -34.63 to -8.1 mg, 2 studies, 128 participants, low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting RR -0.43, 95% CI 0.06 to 3.08, 3 studies, 261 participants; hypotension RR 0.5, 95% CI 0.05 to 5.28, 3 studies, 184 participants; both low-quality evidence). Scalp blocks may reduce pain up to 48 hours (0 to 6 hours, MD -0.98, 95% CI -1.66 to -0.3, 10 studies, 414 participants; 12 hours, MD -0.95, 95% CI -1.53 to -0.37, 8 studies, 294 participants; 24 hours, MD -0.78, 95% CI -1.52 to -0.05, 9 studies, 433 participants, all low-quality evidence; 48 hours, MD -1.34, 95% CI -2.57 to -0.11, 4 studies, 135 participants, very low-quality evidence. When studies with high risk of bias were excluded, significance remained at 12 hours only. Scalp blocks may decrease additional analgesia requirements (SMD -1.11, 95% CI -1.97 to -0.25, 7 studies, 314 participants). Results for other outcomes were imprecise (nausea and vomiting RR 0.66, 95% CI 0.33 to 1.32, 4 studies, 165 participants, very low-quality evidence). Scalp Infiltration may reduce pain postoperatively but efficacy was inconsistent, with a significant effect at 12 and 48 hours only (12 hours, MD -0.71, 95% CI -1.34 to -0.08, 7 studies, 309 participants, low-quality evidence; 48 hours, MD - 1.09, 95% CI -2.13 to - 0.06, 3 studies, 128 participants, moderate-quality evidence). No benefit was observed at other times (0 to 6 hours, MD -0.64, 95% CI -1.28 to -0.00, 9 studies, 475 participants, moderate-quality evidence; 24 hours, MD -0.39, 95% CI -1.06 to 0.27,6 studies, 260 participants, low-quality evidence. Scalp infiltration may reduce additional analgesia requirements MD -9.56 mg, 95% CI -15.64 to -3.49, 6 studies, 345 participants, very low-quality evidence). When studies with high risk of bias were excluded, scalp infiltration lost the pain benefit at 12 hours and effects on additional analgesia requirements, but retained the pain-reducing benefit at 48 hours (MD -0.56, 95% CI -1.20 to -0.32, 2 studies, 100 participants, very low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting, RR 0.74, 95% CI 0.48 to 1.41, 4 studies, 318 participants, low-quality evidence). Pregabalin or gabapentin may reduce pain up to 6 hours (2 studies, 202 participants), MD -1.15,95% CI -1.66 to -0.6, 2 studies, 202 participants, low-quality evidence). One study examined analgesic efficacy at 12 hours showing significant benefit. No analgesia efficacy was shown at later times (24 hours, MD -0.29, 95% CI -0.78 to -0.19; 48 hours, MD - 0.06, 95% CI -0.86 to 0.77, 2 studies, 202 participants, low-quality evidence). Additional analgesia requirements were not significantly less (MD -0.37 (95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Risk of nausea and vomiting was significantly reduced (RR 0.51, 95% CI 0.29 to 0.89, 3 studies, 273 participants, low-quality evidence). Results for other outcomes were imprecise (additional analgesia requirements: MD -0.37, 95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Acetaminophen did not show analgesic benefit (0 to 6 hours, MD -0.35, 95% CI -1.00 to 0.30; 12 hours, MD -0.51, 95% CI -1.04 to 0.03, 3 studies, 332 participants, moderate-quality evidence; 24 hours, MD -0.34, 95% CI -1.20 to 0.52, 4 studies, 439 participants, high-quality evidence). Results for other outcomes remained imprecise (additional analgesia requirements, MD 0.07, 95% CI -0.86 to 0.99, 4 studies, 459 participants, high-quality evidence; length of hospitalizations, MD -3.71, 95% CI -14.12 to 6.7, 2 studies, 335 participants, moderate-quality evidence).

AUTHORS' CONCLUSIONS

There is high-quality evidence that NSAIDs reduce pain up to 24 hours postoperatively. The evidence for reductions in pain with dexmedetomidine, pregabalin or gabapentin, scalp blocks, and scalp infiltration is less certain and of very low to moderate quality. There is low-quality evidence that scalp blocks and dexmedetomidine may reduce additional analgesics requirements. There is low-quality evidence that gabapentin or pregabalin may decrease nausea and vomiting, with the caveat that the total number of events for this comparison was low.

Identifying Components Necessary for an Enhanced Recovery After Surgery Pathway for Elective Intracranial Surgery: An Improvement Project Using the Quality of Recovery-15 Score

OBJECTIVE

To identify the domains of recovery, as determined by the Quality of Recovery-15 (QoR-15) score, that needed improvement to develop initial interventions for an enhanced recovery after surgery protocol for patients undergoing elective intracranial surgery under general anesthesia.

METHODS

A paired-availability design was used to assess 2 groups of 41 patients undergoing elective intracranial surgery. The baseline QoR-15 score and scores 0, 6, 12, and 24 hours after arrival in the intensive care unit characterized the postoperative recovery trajectory. The lowest scoring domains of the QoR-15 score were identified in the preimplementation group, and pharmacologic interventions were initiated in the postimplementation group.

RESULTS

Postoperative analgesia and postoperative nausea and vomiting were identified as the lowest scoring domains. The pharmacologic interventions implemented were chosen because they produced minimal sedation and were easy to administer-1 40-mg oral preoperative dose of aprepitant to target postoperative nausea and vomiting and 2 perioperative 1-g doses of intravenous acetaminophen to improve analgesia. We observed a clinically significant as well as statistically significant improvement in analgesia on arrival in the intensive care unit and at the 6-hour postoperative time point. The total QoR-15 score was improved through the 12-hour time point.

CONCLUSIONS

In this quality improvement project, the QoR-15 score allowed us to identify domains that slowed the recovery course in this patient population. Two 1-g doses of intravenous acetaminophen improved patients' well-being and analgesia after elective intracranial surgery.

Pre-emptive scalp infiltration with ropivacaine plus methylprednisolone versus ropivacaine alone for relief of postoperative pain after craniotomy in children (RP/MP vs RP): a study protocol for a randomised controlled trial

INTRODUCTION

Pre-emptive scalp infiltration with local anaesthetics is the simplest and most effective method to prevent postoperative incisional pain. However, local infiltration of an anaesthetic only provides relatively short-term pain relief. Methylprednisolone (MP) treatment, administered as an adjuvant at the wound site, has been shown to provide satisfactory pain management after lumbar laminectomy. However, there is no evidence regarding the efficacy of MP infiltration for the relief of postoperative pain after craniotomy. Currently, postoperative pain after craniotomy in children is undertreated. Therefore, we aim to investigate whether pre-emptive scalp infiltration with ropivacaine (RP) plus MP is superior to RP alone to improve postoperative pain after craniotomy in children.

METHODS AND ANALYSIS

The RP/MP versus RP trial is a prospective, single-centre, randomised, parallel-group study of 100 children aged 8-18 years undergoing intracranial surgery. Participants will be randomly allocated to receive pre-emptive scalp infiltration with either RP plus MP or RP alone. The primary outcome will be the cumulative fentanyl dose administered by patient-controlled intravenous analgesia within 24 hours postoperatively. The secondary outcomes will include postoperative Numerical Rating Scale scores, pain control satisfaction scores, length of stay and adverse events. Data will be analysed by the intention-to-treat principle.

ETHICAL APPROVAL AND DISSEMINATION

The study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (Approval Number: KY 2018-066-02). The results will be disseminated in international academic meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03636165; Pre-results.

Pain management in neurocritical care; an update

PURPOSE OF REVIEW

Pain management in neurocritical care is a subject often avoided because of concerns over the side-effects of analgesics and the potential to cause additional neurological injury with treatment. The sedation and hypercapnia caused by opioids have been feared to mask the neurological examination and contribute to elevations in intracranial pressure. Nevertheless, increasing attention to patient satisfaction has sparked a resurgence in pain management. As opioids have remained at the core of analgesic therapy, the increasing attention to pain has contributed to a growing epidemic of opioid dependence. In this review, we summarize the most recent literature regarding opioids and their alternatives in the treatment of acute pain in patients receiving neurocritical care.

RECENT FINDINGS

Studies on pain management in neurocritical care continue to explore nonopioid analgesics as part of a multimodal strategy aimed at decreasing overall opioid consumption. Agents including local anesthetics, acetaminophen, ketamine, gabapentinoids, and dexmedetomidine continue to demonstrate efficacy. In addition, the prolonged longitudinal course of many recent trials has also revealed more about the transition from acute to chronic pain following hospitalization.

SUMMARY

In an era of increasing attention to patient satisfaction mitigated by growing concerns over the harms imposed by opioids, alternative analgesic therapies are being investigated with promising results.

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

Background: Approximately 55–87% of the patients undergoing craniotomy experience moderate to severe pain during the first 48 hrs after surgery, which negatively influences patients’ postoperative rehabilitation. Recently, local infiltration of analgesia (LIA) has been widely performed clinically as a promising analgesic method that could avoid the side effects of analgesics but only has a short pain-free duration; researchers have clarified that the addition of dexamethasone to LIA could provide significant analgesic effects and significantly prolong the duration of analgesic effects without obvious complications for various types of surgeries. To date, no studies have evaluated the addition of dexamethasone to LIA for patients receiving craniotomy. The aim of the study was to test the hypothesis that pre-emptive scalp infiltration with a steroid (dexamethasone) plus a local anesthetic (ropivacaine) could achieve superior postoperative analgesic effects to a local anesthetic (ropivacaine) alone in adult patients undergoing a craniotomy.

Study design and methods: This study is a randomized controlled trial that will include one intervention and one control group involving a total of 140 adults scheduled for elective craniotomy for resection of supratentorial tumors under general anesthesia and with an anticipated full recovery within 2 hrs postoperatively. The intervention will involve pre-emptive scalp infiltration with ropivacaine plus dexamethasone (the dexamethasone group) or ropivacaine alone (the control group), and the participants in both groups will complete a 6-month follow-up. The primary outcome will be the cumulative sufentanil consumption within 48 hrs postoperatively.

Discussion: The intervention, if effective, this study will provide clinically important information on the role of dexamethasone in scalp infiltration for post-craniotomy pain management.

Postoperative analgesia for pediatric craniotomy patients: a randomized controlled trial

Background

Pain is often observed in pediatric patients after craniotomy procedures, which could lead to some serious postoperative complications. However, the optimal formula for postoperative analgesia for pediatric neurosurgery has not been well established. This study aimed to explore the optimal options and formulas for postoperative analgesia in pediatric neurosurgery.

Methods

Three hundred and twenty patients aged 1 to 12-years old who underwent craniotomy were randomly assigned to receive 4 different regimens of patient-controlled analgesia. The formulas used were as follows: Control group included normal saline 100 ml, with a background infusion of 2 ml/h, bolus 0.5 ml; Fentanyl group was used with a background infusion of 0.1–0.2 μg/k·h, bolus 0.1–0.2 μg/kg; Morphine group was used with a background infusion of 10–20 μg/kg·h, bolus 10–20 μg/kg; while Tramadol group was used with a background infusion of 100–400 μg/kg·h, bolus 100–200 μg/kg. Postoperative pain scores and analgesia-related complication were recorded respectively. Comparative analysis was performed between the four groups.

Results

In comparison of all groups with each other, lower pain scores were shown at 1 h and 8 h after surgery in Morphine group versus Tramadol, Fentanyl and Control groups (P < 0.05). Both Tramadol and Fentanyl groups showed lower pain scores in comparison to Control group (P < 0.05). Nausea and vomiting were observed more in Tramadol group in comparison to all other groups during the 48 h of PCIA usage after operation (P = 0.020). Much more rescue medicines including ibuprofen and morphine were used in Control group (CI = 0.000–0.019). Changes in consciousness and respiratory depression were not observed in study groups. Moderate-to-severe pain was observed in a total of 56 (17.5%) of the study population. Multiple regression analysis for identifying risk factors for moderate-to-severe pain revealed that, younger children (OR = 1.161, 1.027–1.312, P = 0.017), occipital craniotomy (OR = 0.374, 0.155–0.905, P = 0.029), and morphine treatment (OR = 0.077, 0.021–0.281, P < 0.001) are the relevant factors.

Conclusions

Compared with other analgesic projects, PCIA or NCIA analgesia with morphine appears to be the safest and most effective postoperative analgesia program for pediatric patients who underwent neurosurgical operations.

Trial registration

Chinese Clinical Trial Registry. No: ChiCTR-IOC-15007676. Prospective registration. http://www.chictr.org.cn/index.aspx.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0722-x) contains supplementary material, which is available to authorized users.

[Current trends in the development of neuroanesthesiology]

The paper presents the author's analysis of the main trends in the development of modern neuroanesthesiology over the past five to ten years. These, in the author\s opinion, include the introduction and elaboration of blood-sparing techniques, monitoring the depth of anesthesia, fast track concept, applying regional (conduction) anesthesia techniques, xenon anesthesia, development of effective and safe protocols for DVT and PTE prophylaxis for neurosurgical patients, study of the hemostatic system using bedside methods for assessing hemostasis (thromboelastogram) and correcting hypocoagulation by activated recombinant VII factor.

Scheduled Intravenous Acetaminophen Improves Patient Satisfaction With Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study

BACKGROUND

Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy.

MATERIALS AND METHODS

In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared.

RESULTS

There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1±0.4 vs. 6.9±0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects.

CONCLUSIONS

IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control.

Local anesthetics for brain tumor resection: current perspectives

This review summarizes the added value of local anesthetics in patients undergoing craniotomy for brain tumor resection, which is a procedure that is carried out frequently in neurosurgical practice. The procedure can be carried out under general anesthesia, sedation with local anesthesia or under local anesthesia only. Literature shows a large variation in the postoperative pain intensity ranging from no postoperative analgesia requirement in two-thirds of the patients up to a rate of 96% of the patients suffering from severe postoperative pain. The only identified causative factor predicting higher postoperative pain scores is infratentorial surgery. Postoperative analgesia can be achieved with multimodal pain management where local anesthesia is associated with lower postoperative pain intensity, reduction in opioid requirement and prevention of development of chronic pain. In awake craniotomy patients, sufficient local anesthesia is a cornerstone of the procedure. An awake craniotomy and brain tumor resection can be carried out completely under local anesthesia only. However, the use of sedative drugs is common to improve patient comfort during craniotomy and closure. Local anesthesia for craniotomy can be performed by directly blocking the six different nerves that provide the sensory innervation of the scalp, or by local infiltration of the surgical site and the placement of the pins of the Mayfield clamp. Direct nerve block has potential complications and pitfalls and is technically more challenging, but mostly requires lower total doses of the local anesthetics than the doses required in surgical-site infiltration. Due to a lack of comparative studies, there is no evidence showing superiority of one technique versus the other. Besides the use of other local anesthetics for analgesia, intravenous lidocaine administration has proven to be a safe and effective method in the prevention of coughing during emergence from general anesthesia and extubation, which is especially appreciated after brain tumor resection.

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

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.

Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration

OBJECTIVES

The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h.

METHODS

This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared.

RESULTS

The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period.

CONCLUSION

The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration.

Update on anesthesia for craniotomy

PURPOSE OF REVIEW

In this review, we present an update on the relationship between anesthesia and intraoperative hemodynamic complications, early postanesthesia recovery, postoperative pain and postoperative nausea and vomiting after craniotomy. We also review latest advances in education and research in neuroanesthesia for brain surgery.

RECENT FINDINGS

Insights from clinical reports published from January 2012 to April 2013 on anesthesia for craniotomy will be summarized. Recent findings address the need for a tight intraoperative hemodynamic monitoring - that should include aggressive prevention of arterial hypotension and cardiac arrhythmias - and a careful management of fluids and electrolytes balance. Data on the relationship between anesthesia (selection of anesthetics used intraoperatively) and early recovery demonstrate a limited benefit when ultra-short acting drugs (as remifentanil vs fentanyl) are used. Evidence on postoperative pain and postoperative nausea and vomiting contribute to define how to better prevent and treat these complications. Latest guidelines on training and research in neuroanesthesia define unique end points in this subspecialty.

SUMMARY

Neuroanesthesia for craniotomy should be aimed to ensure intraoperative loss of consciousness (unless awake craniotomy is the selected anesthesiological approach), pain control and an uneventful postoperative recovery, but should also be addressed to manipulate physiological variables including cerebral blood flow and to obtain optimal surgical exposure.

Options for perioperative pain management in neurosurgery

Moderate-to-severe pain following neurosurgery is common but often does not get attention and is therefore underdiagnosed and undertreated. Compounding this problem is the traditional belief that neurosurgical pain is inconsequential and even dangerous to treat. Concerns about problematic effects associated with opioid analgesics such as nausea, vomiting, oversedation, and increased intracranial pressure secondary to elevated carbon dioxide tension from respiratory depression have often led to suboptimal postoperative analgesic strategies in caring for neurosurgical patients. Neurosurgical patients may have difficulty or be incapable of communicating their need for analgesics due to neurologic deficits, which poses an additional challenge. Postoperative pain control should be a priority, because pain adversely affects recovery and patient outcomes. Inconsistent practices and the quality of current analgesic strategies for neurosurgical patients still leave room for improvement. Given the complexity of postoperative pain management for these patients, multimodal strategies are often required to optimize pain control and at the same time limit undesired side effects.

Integrative review: postcraniotomy pain in the brain tumour patient

AIM

To conduct an integrative review to examine evidence of pain and associated symptoms in adult (≥21 years of age), postcraniotomy, brain tumour patients hospitalized on intensive care units.

BACKGROUND

Healthcare providers believe craniotomies are less painful than other surgical procedures. Understanding how postcraniotomy pain unfolds over time will help inform patient care and aid in future research and policy development.

DESIGN

Systematic literature search to identify relevant literature. Information abstracted using the Theory of Unpleasant Symptoms' concepts of influencing factors, symptom clusters and patient performance. Inclusion criteria were indexed, peer-reviewed, full-length, English-language articles. Keywords were 'traumatic brain injury', 'pain, post-operative', 'brain injuries', 'postoperative pain', 'craniotomy', 'decompressive craniectomy' and 'trephining'.

DATA SOURCES

Medline, OVID, PubMed and CINAHL databases from 2000-2014.

REVIEW METHOD

Cooper's five-stage integrative review method was used to assess and synthesize literature.

RESULTS

The search yielded 115 manuscripts, with 26 meeting inclusion criteria. Most studies were randomized, controlled trials conducted outside of the United States. All tested pharmacological pain interventions. Postcraniotomy brain tumour pain was well-documented and associated with nausea, vomiting and changes in blood pressure, and it impacted the patient's length of hospital stay, but there was no consensus for how best to treat such pain.

CONCLUSION

The Theory of Unpleasant Symptoms provided structure to the search. Postcraniotomy pain is experienced by patients, but associated symptoms and impact on patient performance remain poorly understood. Further research is needed to improve understanding and management of postcraniotomy pain in this population.

Effects of Anesthetic Management on Early Postoperative Recovery, Hemodynamics and Pain After Supratentorial Craniotomy

Various clinical trials have assessed how intraoperative anesthetics can affect early recovery, hemodynamics and nociception after supratentorial craniotomy. Whether or not the difference in recovery pattern differs in a meaningful way with anesthetic choice is controversial. This review examines and compares different anesthetics with respect to wake-up time, hemodynamics, respiration, cognitive recovery, pain, nausea and vomiting, and shivering. When comparing inhalational anesthetics to intravenous anesthetics, either regimen produces similar recovery results. Newer shorter acting agents accelerate the process of emergence and extubation. A balanced inhalational/intravenous anesthetic could be desirable for patients with normal intracranial pressure, while total intravenous anesthesia could be beneficial for patients with elevated intracranial pressure. Comparison of inhalational anesthetics shows all appropriate for rapid emergence, decreasing time to extubation, and cognitive recovery. Comparison of opioids demonstrates similar awakening and extubation time if the infusion of longer acting opioids was ended at the appropriate time. Administration of local anesthetics into the skin, and addition of corticosteroids, NSAIDs, COX-2 inhibitors, and PCA therapy postoperatively provided superior analgesia. It is also important to emphasize the possibility of long-term effects of anesthetics on cognitive function. More research is warranted to develop best practices strategies for the future that are evidence-based.

Preemptive scalp infiltration with 0.5% ropivacaine and 1% lidocaine reduces postoperative pain after craniotomy

BACKGROUND

In order to reduce the consequences of narcotic-related side effects and provide effective analgesia after craniotomy, we conducted a randomized trial to compare the analgesic efficacy of preemptive scalp infiltrations with 1% lidocaine and 0.5% ropivacaine on the postoperative pain.

METHODS

Sixty adult patients scheduled for craniotomy were enrolled. A solution contained 0.5% ropivacaine and 1% lidocaine (40 ml) was prepared. In group A, local anesthetic was injected throughout the entire thickness of the scalp before skin incision. In group B, it was injected before skin closure. Additional intravenous injection and patient-controlled analgesia with morphine was used to control postoperative pain if the verbal numerical rating scale > 4. Cumulative morphine consumption; numerical rating scale of pain at 1, 2, 4, 6, 8, 12, and 24 h; postoperative nausea, vomiting, and respiratory depression, were recorded for 24 h after the operation.

RESULTS

Postoperative pain scores were lower in group A than in group B within the first 6 h after surgery. Mean time to demand for postoperative analgesic was statistically (p < 0.001) delayed in group A 300 (240, 360) min compared to group B 150 (105, 200) min. Ten patients in group A received morphine analgesia was half less than 21 patients in group B (p < 0.006). The median morphine consumption in 24 h after operation in group A 10.5 (8, 15) mg was less than that in group B 28 (22.5, 30.5) mg (p < 0.001).

CONCLUSIONS

Preemptive scalp infiltration with 0.5% ropivacaine and 1% lidocaine provides effective postoperative analgesia after craniotomy.

Systematic review of decreased intracranial pressure with optimal head elevation in postcraniotomy patients: a meta-analysis

AIM

To determine an optimal head elevation degree to decrease intracranial pressure in postcraniotomy patients by meta-analysis.

BACKGROUND

A change in head position can lead to a change in intracranial pressure; however, there are conflicting data regarding the optimal degree of elevation that decreases intracranial pressure in postcraniotomy patients.

DESIGN

Quantitative systematic review with meta-analysis following Cochrane methods.

DATA SOURCES

The data were collected during 2014; three databases (PubMed, Embase and China National Knowledge Internet) were searched for published and unpublished studies in English. The bibliographies of the articles were also reviewed. The inclusion criteria referred to different elevation degrees and effects on intracranial pressure in postcraniotomy patients.

REVIEW METHODS

According to pre-determined inclusion criteria and exclusion criteria, two reviewers extracted the eligible studies using a standard data form.

RESULTS

These included a total of 237 participants who were included in the meta-analysis. (1) Compared with 0 degree: 10, 15, 30 and 45 degrees of head elevation resulted in lower intracranial pressure. (2) Intracranial pressure at 30 degrees was not significantly different in comparison to 45 degrees and was lower than that at 10 and 15 degrees.

CONCLUSION

Patients with increased intracranial pressure significantly benefitted from a head elevation of 10, 15, 30 and 45 degrees compared with 0 degrees. A head elevation of 30 or 45 degrees is optimal for decreasing intracranial pressure. Research about the relationship of position changes and the outcomes of patient primary diseases is absent.

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

OBJECTIVE

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 analog 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 analog 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 postcraniotomy headache and postoperative analgesic requirements - a benefit that persisted throughout five postoperative days.

Incidence of pain after craniotomy in children

BACKGROUND

There is very few information regarding pain after craniotomy in children.

OBJECTIVES

This multicentre observational study assessed the incidence of pain after major craniotomy in children.

METHODS

After IRB approval, 213 infants and children who were <10 years old and undergoing major craniotomy were consecutively enrolled in nine Italian hospitals. Pain intensity, analgesic therapy, and adverse effects were evaluated on the first 2 days after surgery. Moderate to severe pain was defined as a median FLACC or NRS score ≥ 4 points. Severe pain was defined as a median FLACC or NRS score ≥ 7 points.

RESULTS

Data of 206 children were included in the analysis. The overall postoperative median FLACC/NRS scores were 1 (IQR 0 to 2). Twenty-one children (16%) presented moderate to severe pain in the recovery room and 14 (6%) during the first and second day after surgery. Twenty-six children (19%) had severe pain in the recovery room and 4 (2%) during the first and second day after surgery. Rectal codeine was the most common weak opiod used. Remifentanil and morphine were the strong opioids widely used in PICU and in general wards, respectively. Longer procedures were associated with moderate to severe pain (OR 1.30; CI 1.07-1.57) or severe pain (OR 1.41; 1.09-1.84; P < 0.05). There were no significant associations between complications, pain intensity, and analgesic therapy.

CONCLUSION

Children receiving multimodal analgesia experience little or no pain after major craniotomy. Longer surgical procedures correlate with an increased risk of having postoperative pain.

Fluctuations in vital signs and behavioural responses of brain surgery patients in the Intensive Care Unit: are they valid indicators of pain?

AIM

To examine the validity of behaviours and fluctuations in vital signs for pain assessment of postbrain surgery adults in the neurosurgical intensive care unit.

BACKGROUND

Many patients in an intensive care unit may be unable to self-report their pain. In such cases, the use of observable indicators is recommended. Very little research has explored the validity of the use of behaviours and vital signs for pain assessment of neurocritically ill patients.

DESIGN

Prospective repeated-measure within-subject observational design.

METHODS

A total of 43 postbrain surgery patients were video recorded before, during and 15 minutes after a non-nociceptive (non-invasive blood pressure cuff inflation) and a nociceptive (turning) procedures. Their behaviours and vital signs were collected with a pre-tested behavioural checklist and a data collection computer connected to the bedside monitor. The patients' self-report of pain was obtained whenever possible. Data were collected between June-December in 2011.

RESULTS

A larger number of pain-related behaviours were exhibited by participants during the nociceptive procedure compared with the non-nociceptive procedure supporting discriminant validation. Among vital signs, only respiratory rate differed significantly between the two procedures. Regarding criterion validation, only behaviours were positively correlated with self-reports of pain.

CONCLUSION

Behaviours were found valid indicators of pain in neurocritically ill patients after elective brain surgery. Fluctuations in vital signs may suggest the presence of pain, but their validity for such use is not supported. They should only be used in combination with other validated pain assessment methods.

Knowledge of doctors and nurses on pain in patients undergoing craniotomy

The study objectives were to characterize the profile of the doctors and nurses caring for patients in the craniotomy postoperative period, checking pain assessment methods and to identify the existence of analgesia protocols. Cross-sectional and analytical study. The casuistry is constituted of 30 doctors and 30 nurses. The results revealed that 83.3 % of the nurses were female, 63.3% knew pain scales, and 16.6% said that analgesia protocols exist. Regarding doctors 60% were male, 70% knew the pain scales, 3.3% had specialization in pain treatment, 13.3% they stated that there are analgesia protocols. The ignorance on the part of doctors and nurses about the assessment scales and pain assessment methods reveals the need for the creation of institutional policies on controlling pain, the use of instruments for the measurement of the pain phenomenon and analgesia protocols in the institution.

[Awake craniotomy. Considerations in special situations]

Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. In the past it was used for the surgical management of intractable epilepsy, but nowadays, its indications are increasing, and it is a widely recognized technique for the resection of mass lesions involving the eloquent cortex, and for deep brain stimulation. The procedure is safe, provides excellent results, and saves money and resources. The anesthesiologist should know the principles underlying neuroanesthesia, the technique of scalp blockade, and the sedation protocols, as well as feeling comfortable with advanced airway management. The main anesthetic aim is to keep patients cooperating when required (analgesia-based anesthesia). This review attempts to summarize the most recent evidence from the clinical literature, a long as the number of patients undergoing craniotomies in the awake state are increasing, specifically in the pediatric population.

Pain assessment in brain tumor patients after elective craniotomy

Objective

This study was performed to assess the postoperative pain of brain tumor patients who underwent elective craniotomy and to evaluate the factors associated with pain intensity.

Methods

From January 2010 to December 2011, 47 patients with newly diagnosed brain tumors who underwent craniotomy were enrolled. The postoperative pain status was assessed daily until discharge using the visual analogue scale (VAS).

Results

The study participants comprised of 22 males and 25 females with ages ranging from 18-76 years (median age, 50 years). Patients were divided into two groups: the painful group included patients who had a VAS score of more than 3 during their hospital stay after the craniotomy, and the tolerable group included patients who had a VAS score of 1 to 3 during their hospital stay. There were no differences between the two groups in terms of age, sex, location of surgery, history of diabetes, hypertension and smoking, body mass index, and hospital stay. Univariate analysis revealed that operating time, length of wound, head fixation, and perioperative administration of opioid were not associated with the intensity of postoperative pain. Daily assessment of VAS revealed the two peaks of pain on the operation day and the 4th postoperative day. The intensity of pain during the ambulation period was higher than that during intensive care unit (ICU) stay.

Conclusion

Pain following elective craniotomy for brain tumor removal is insufficiently managed, especially after discharge from the ICU. More attention needs to be paid to patients' pain throughout the hospital stay.

Immediate post-craniotomy headache

Introduction

Headache is the most common adverse event immediately following craniotomy and is due to the surgical procedure and meningeal irritation.

Objectives

The aim of this study was to investigate the prevalence of headache during the first week after a craniotomy, as well as headache intensity, whether pain was registered in the patient's medical records, the use of analgesics and predictors of headache.

Methods

Ninety-one patients who underwent craniotomy were evaluated from the first to the seventh post-operative day. The variables analysed were gender, age, medical history, indication for craniotomy, surgery, occurrence of headache, pain registration in the medical records, length of hospital stay and analgesics consumption.

Results

On the second post-operative day, 29.2% of patients had a headache and there was under-reporting of this pain in the patients’ records. The analgesics used were non-steroidal anti-inflammatory in 75% of cases. An age of <45 years (odds ratio = 3.0, p = 0.041) and surgery duration lasting >4 hours (odds ratio = 3.7, p = 0.019) were associated with the occurrence of immediate post-craniotomy headache.

Conclusion

Further training should be provided to professionals caring for patients undergoing craniotomy to better manage post-operative headache.