Incidence of pain after craniotomy in children

Safety and Preliminary Efficacy of Cervical Paraspinal Interfascial Plane Block for Postoperative Pain after Pediatric Chiari Decompression

BACKGROUND

Surgery for lesions of the posterior fossa is associated with significant postoperative pain in pediatric patients related to extensive manipulation of the suboccipital musculature and bone. In this study, we assess the preliminary safety, effect on neuromonitoring, and analgesic efficacy of applying a cervical paraspinal interfascial plane block in pediatric patients undergoing posterior fossa surgery.

METHODS

In this prospective case series, we enrolled five patients aged 2-18 years undergoing surgery for symptomatic Chiari type I malformation. An ultrasound-guided cervical cervicis plane (CCeP) block was performed prior to the incision. A local anesthetic agent (bupivacaine) and a steroid adjuvant (dexamethasone) were injected into the fascial planes between the cervical semispinalis capitis and cervical semispinalis cervicis muscles at the level of the planned suboccipital decompression and C1 laminectomy. Motor-evoked and somatosensory-evoked potentials were monitored before and after the block. Patients were assessed for complications from the local injection in the intraoperative period and for pain in the postoperative period.

RESULTS

No adverse events were noted intraoperatively, and there were no changes in neuromonitoring signals. Pain scores were low in the immediate postoperative period, and rescue medications were minimal. No complaints of incisional pain or need for narcotics were noted at the time of the 3-month postsurgical follow-up.

CONCLUSIONS

In this study, we demonstrate the preliminary safety and analgesic efficacy of a novel application of a CCeP block to pediatric patients undergoing suboccipital surgery. Larger studies are needed to further validate the use of this block in children.

Severity and associated factors of postoperative pain in paediatric surgical patients aged 2 months-7 years at selected Addis Ababa Public Hospitals: a multicenter prospective longitudinal study

Background

Postoperative pain is a common and distressing consequence of surgery in children. It can lead to suffering, prolonged recovery, impaired physical functioning, and even chronic pain. Effective postoperative pain management is crucial for improving patient outcomes. However, several factors hinder the accurate assessment and management of pain in children, particularly in low-income countries. This study aims to evaluate the severity of postoperative pain in paediatric patients and identify its predictors.

Materials and methods

A longitudinal study was conducted on 235 paediatric surgical patients aged 2 months-7 years in Public Hospitals of Addis Ababa from January to April 2023. The primary outcome, pain severity, was assessed at three different times using a pain assessment tool. Cochran's q-test was used to compare postoperative pain incidences. The Generalized Estimating Equation was used to determine predictor variables' effects on pain severity over time. The study demonstrated the direction of association and significance using an AOR with a 95% CI at a P value of 0.05.

Result

The incidence of moderate to severe postoperative pain was 36.6% at 12 h, 20% at 24 h, and 10% at 36 h. Patients with preoperative pain and preoperative anxiety were more likely to experience moderate to severe postoperative pain [adjusted odds ratio (AOR)=3.41, CI=1.15, 10.00 and AOR=2.28, CI=1.219, 4.277, respectively). Intraoperative predictors of postoperative pain severity included longer duration of surgery (AOR=6.62, CI=1.90, 23.00) and major surgery (AOR=5.2, CI=2.11, 12.88). Postoperative pain severity was reduced in patients receiving multimodal analgesia (AOR=0.24; CI=0.091, 0.652) and in patients assessed frequently in the postoperative period (AOR=0.09; CI=0.022, 0.393).

Conclusion

A significant portion of paediatric surgical patients in this study experienced high levels of postoperative pain, particularly within the first 24 h. The most influential factors affecting pain severity were postoperative pain management strategies and assessment practices.

Ultrasound-Guided Occipital Nerve Blocks as Part of Multi-Modal Perioperative Analgesia in Pediatric Posterior Craniotomies: A Case Series

Various regional anesthetics have been used for postoperative analgesia for pediatric craniotomy. In this case series, we report retrospectively collected data on postoperative pain and analgesic use in 44 patients who received ultrasound-guided occipital nerve blocks in addition to intravenous analgesic agents for posterior craniotomy procedures. In the immediate post-anesthesia care unit, pain was rated as zero or well controlled in 77% of patients, with only 43% requiring intravenous or demand patient-controlled analgesia opioids. There were no block-related complications. Occipital nerve blocks may constitute a safe and effective component of multimodal analgesia in this population.

Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-antinociception balance in paediatric craniotomies: a prospective observational study

INTRODUCTION

Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-anti-nociception balance has not been studied in paediatric neurosurgery. The objectives were to study the correlation between ANI (Mdoloris Education system) and revised FLACC (r-FLACC) score for the prediction of acute postoperative pain in paediatric population undergoing elective craniotomies and to compare the changes in ANI values with heart rate (HR), mean arterial pressure (MAP) and surgical plethysmographic index (SPI) during various time points of intraoperative noxious stimulation and before and after opioid administration.

METHODS

This prospective observational pilot study included 14 patients between 2 and 12 years of age undergoing elective craniotomies. HR, MAP, SPI, ANI instantaneous (ANIi) and ANI mean (ANIm) values were recorded intraoperatively and before and after opioid administration. Postoperatively HR, MAP, ANIi and ANIm, and pain scores (r-FLACC scale) were recorded.

RESULTS

There was a statistically significant negative correlation between ANIi and ANIm with r-FLACC during the time course of PACU stay (r =  - 0.89, p < 0.001 and r =  - 0.88 and p < 0.001 respectively). Intraoperatively, in patients with ANIi values < 50, with additional fentanyl administration, there was an increasing trend in values beyond 50, which was statistically significant (p < 0.05) at 3, 4, 5 and 10 min. The trend in changes of SPI after opioid administration was not found to be significant for patients irrespective of the baseline SPI values.

CONCLUSION

The ANI is a reliable tool for objective assessment of acute postoperative pain as assessed by r-FLACC in children undergoing craniotomies for intracranial lesions. It may be used as a guide to nociception-antinociception balance during the peri-operative period in this population.

Special Anaesthetic Considerations for Brain Tumour Surgery in Children

Brain tumours are among the most common neoplasm in children. Therefore, paediatric anaesthesiologists face the challenge of neurosurgical interventions in all age groups. To minimize perioperative mortality and morbidity, a comprehensive understanding of age-dependent differences in anatomy and cerebrovascular physiology is a mandatory prerequisite. Advances in subspeciality training in paediatric neurosurgery and paediatric anaesthesia may improve clinical outcomes and advance communication between the teams.

Dexamethasone as a ropivacaine adjuvant to pre-emptive incision-site infiltration analgesia in pediatric craniotomy patients: A prospective, multicenter, randomized, double-blind, controlled trial

BACKGROUND

Dexamethasone added to incision-site infiltration has been routinely used to reduce pain after tonsillectomy in children. However, this has not been studied in pediatric craniotomy patients yet. We hypothesized that incision-site infiltration with a combination of ropivacaine and dexamethasone might provide superior analgesia to ropivacaine alone in pediatric craniotomy patients.

METHODS

In this multicenter, double-blind, randomized, controlled trial, children aged 2-12 years, scheduled for craniotomy, were prospectively enrolled at two study centers, from September 2, 2019, to July 5, 2020. Eighty children were randomly assigned (1:1) to either ropivacaine plus dexamethasone group who received pre-emptive incision-site infiltration with 0.2% ropivacaine plus 0.025% dexamethasone, or ropivacaine group who received 0.2% ropivacaine alone. Primary outcome was the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 24 h postoperatively. Primary analysis was performed using the modified intention-to-treat principle.

RESULTS

Pre-emptive incision-site infiltration with ropivacaine plus dexamethasone had a reduced pain score of 2.0, compared with the pain score of 2.9 in the ropivacaine group, at 24 h postoperatively (mean difference -0.9, 95% confidence interval [CI], -1.7 to -0.2; p = .019). Estimated median of the time of first rescue analgesic demand was 24 h in the ropivacaine plus dexamethasone group and 8.5 h in the ropivacaine group [hazard ratio 0.43, 95% CI 0.24 to 0.08; Log-rank p = .0025]. No adverse events related to incision-site infiltration with dexamethasone were observed in this study.

DISCUSSION

Dexamethsone reduces the local production of pro-inflammatory factors after tissue damage and as a ropivacaine adjuvant for incision-site infiltration reduced the pain scores by 31% at 24 h postoperatively. The results were similar to several prior studies on to tonsillectomy patients. However, this changes on pain scores might has limited clinical significance.

CONCLUSIONS

The addition of dexamethasone to ropivacaine for preoperative incision-site infiltration has better postoperative analgesic effect than ropivacaine alone in pediatric craniotomy patients.

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.

The scalp block for postoperative pain control in craniosynostosis surgery: a case control study

PURPOSE

Postoperative analgesia after corrective surgery of pediatric craniosynostosis is crucial in terms of short- and long-term outcomes. The objective of this observational study was to evaluate the effectiveness of an analgesic technique based on the scalp block versus traditional pharmacological approach.

METHODS

Thirteen patients, aged between 3 months and 2 years, undergoing surgical correction of craniosynostosis, received scalp nerve block before awakening (scalp block group). This group of patients was compared to a second group of 13 patients, retrieved from our database, treated with the traditional pharmacological approach (control group). Pain scores, need of rescue therapy, resumption of oral nutrition, degree of parent satisfaction at discharge, and length of stay in the Pediatric Intensive Care Unit (PICU) and in the hospital were compared between the two groups.

RESULTS

Objective Pain Score values were significantly lower in patients treated with scalp block at 30 min and at 8 h after extubation. The number of pharmacological interventions for the treatment of pain in PICU was significantly higher in Control group. Children in Scalp block group started earlier oral feeding than in Control group, both for clear fluids and milk. Length of stay in PICU was longer in Scalp block group than in Control group, though the difference between the mean data in the two groups is about 3 . This difference does not seem significant from a clinical standpoint, since it seems more related to logistic issues (e.g., availability of bed in the Pediatric Neurosurgery Unit, presence of a parent), rather than clinical problems contraindicating the discharge from PICU. Indeed, the overall hospital length of stay was similar between the two groups.

CONCLUSION

Scalp nerve block was effective for immediate postoperative pain control in patients younger than 2 years who underwent cranioplasty for craniosynostosis. The best pain control compared to conventional therapy allowed to limit the need for rescue analgesics in PICU and an earlier recovery time. ClinicalTrials.gov Identification: NCT04133467.

Intravenous Acetaminophen (Paracetamol) for Postcraniotomy Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Acute pain control after supratentorial craniotomy is considered among the most important indicators of postoperative recovery. The aim of this study was to determine the effects of intravenous acetaminophen on postcraniotomy pain.

METHODS

We searched databases including Embase, Scopus, Medline, Cochrane Library, and Web of Science until April 2019. Cochran Q test and I² statistic were used to assess the heterogeneity across included clinical trials. Standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effect sizes.

RESULTS

Out of 479 reports, 5 randomized controlled trials met the inclusion criteria and were appropriate for our meta-analysis, which included a total of 2635 patients. The pooled results of included clinical trials indicated that paracetamol intake significantly decreased rescue dose (SMD, -0.67; 95% CI, -1.15 to -0.19; P < 0.01; I² = 90.0%), total dosage of rescue (SMD, -0.78; 95% CI, -1.18 to -0.37; P < 0.01; I² = 86.0%), intensive care unit length of stay (SMD, -0.24; 95% CI, -0.44 to -0.04; P = 0.01; I² = 0.0%), and visual analog scale score (SMD, -0.16; 95% CI, -0.31 to -0.00; P = 0.04; I² = 71.7%) and increased patient satisfaction (SMD, 0.28; 95% CI, 0.14-0.43; P < 0.01; I² = 10.2%) among patients with craniotomy. Time to rescue (SMD, 0.21; 95% CI, -0.42 to 0.85; P = 0.51; I² = 94.3%) and hospital length of stay (SMD, -0.04; 95% CI, -0.24 to 0.16; P = 0.69; I² = 0.0%) did not significantly change after paracetamol intake.

CONCLUSIONS

The results of this systematic review and meta-analysis indicate that preoperative intravenous administration of acetaminophen is associated with decreased postoperative pain, need for rescue analgesics, and dosages of analgesics after craniotomy 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.

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.

The postoperative management of pain from intracranial surgery in pediatric neurosurgical patients

Pain following intracranial surgery has historically been undertreated because of the concern that opioids, the analgesics most commonly used to treat moderate-to-severe pain, will interfere with the neurologic examination and adversely affect postoperative outcome. Over the past decade, accumulating evidence, primarily in adult patients, has revealed that moderate-to-severe pain is common in neurosurgical patients following surgery. Using the neurophysiology of pain as a blueprint, we have highlighted some of the drugs and drug families used in multimodal pain management. This analgesic method minimizes opioid-induced adverse side effects by maximizing pain control with smaller doses of opioids supplemented with neural blockade and nonopioid analgesics, such nonsteroidal antiinflammatory drugs, local anesthetics, corticosteroids, N-methyl-D-aspartate (NMDA) antagonists, α2 -adrenergic agonists, and/or anticonvulsants (gabapentin and pregabalin).