|Year : 2013 | Volume
| Issue : 1 | Page : 7-11
Pain after craniotomy: A time for reappraisal?
Pradipta Saha1, Suman Chattopadhyay2, A Rudra3, Sourabh Roy3
1 R.M.O-Cum-Clinical Tutor, Bangur Institute of Neurology, Kolkata, West Bengal, India
2 Department of Anesthesiology, Medical College, Kolkata, West Bengal, India
3 K.P.C. Medical College, Kolkata, West Bengal, India
|Date of Web Publication||10-Jul-2013|
BC 103, Salt Lake, Kolkata - 700 064, West Bengal
Source of Support: None, Conflict of Interest: None
Until recently, perioperative pain management in neurosurgical patients has been inconsistently recognized and inadequately treated. An increased awareness of pain management in general along with advances in the understanding of pain modulation and pathophysiology, has led to improved practice and perioperative care of patients following craniotomy. Otherwise, severe postoperative pain impairs the quality of recovery and causes emotional distress with the possibility of inducing chronic pain and lasting functional deficits. The greatest challenge in managing neurosurgical patients is the need to assess the neurological function while providing superior analgesia with minimal side effects. To achieve this goal, a multimodal approach to analgesia, using various drugs and techniques, is advocated. There still remains a need, however, to conduct further randomized, controlled trials, to determine the best combination of drugs or techniques for treating perioperative pain in this patient population. Improved awareness, assessment, and treatment of pain result in better care and overall patient outcome.
Keywords: Analgesia, craniotomy, dexmedetomidine, neurosurgery, opioids, paracetamol, pain, scalp block, wound infiltration
|How to cite this article:|
Saha P, Chattopadhyay S, Rudra A, Roy S. Pain after craniotomy: A time for reappraisal?. Indian J Pain 2013;27:7-11
| Introduction|| |
Pain has been defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage or both.
Pain is a complex syndrome causing emotional and physical distress, which results in adverse physiological impact to several organ systems, ultimately aﬀecting patient recovery and general well-being.
Postoperative pain is a form of acute pain, which starts with surgical trauma and ends with tissue healing. It worsens in the first few postoperative days. It is influenced by the patients' previous experience and also by social, cultural, and psychological factors. Management of postoperative pain helps in relief from suffering and leads to earlier mobilization and shortened hospital stay. Analgesia requirement after neurosurgery is a controversial topic. It is established in the adult neurosurgical patient population that significant pain is not uncommon and strong analgesics are frequently required. ,, It is acknowledged that poorly treated pain may lead to intracranial hypertension, but the optimal form of analgesic therapy is still unclear. In children, there are very few data describing pain or analgesic needs after neurosurgery, but two studies reported that, 42 percent to 48 percent of the children had episodes of moderate to severe pain following craniotomy. , Therefore, preventing postoperative pain and improving the long-term outcome in neurosurgical patients is an enormous challenge. Only a very limited number of randomized, controlled trials on perioperative treatment of pain in neurosurgical patients are available. ,,, Pain after craniotomy seems poorly treated in the postoperative period, as the pain is inconsistently recognized.  Moreover, specific procedures and the site of surgery influence pain following craniotomy and the degree of pain varies from moderate to severe in adults.  The preoperative pain provider is faced with a serious dilemma. Aggressive postoperative analgesia management may result in an unintended risk of producing an overly sedated patient, which could mask new neurological deﬁcits. The typical side effects of opioids like miosis, nausea, and vomiting may mask the signs of increased intracranial pressure (ICP). A decreased minute ventilation may result in an increase in carbon dioxide (CO2), intracerebral blood volume, ICP, and edema. In addition, some neurosurgical patients may not be able to eﬀectively communicate their need for analgesics, because of an altered mental status or neurological deﬁcits. On the other hand, inadequate pain treatment may be associated with agitation and sympathetic stress responses, which increase the risk of hypertension, intracranial hemorrhage, rise in ICP, and other neurological threats after brain surgery. ,,,
Recovery from neurosurgical anesthesia is followed by elevation in body oxygen consumption and serum catecholamine concentration. The cerebral consequences of the recovery period can lead to cerebral hyperemia and increased intracranial pressure. Therefore, prevention or control of pain is one of the major factors limiting these adverse systemic effects. Moreover, these are also directed at improving rehabilitation and long-term outcome. ,
| Physiology of pain following neurosurgery|| |
Pain experienced by patients after craniotomy are predominantly superficial (86%) suggesting a somatic rather than visceral origin and possibly involving the scalp, pericranial muscles, and soft tissue. , Pain is also sensed due to manipulation of the dura mater. , There is a strong correlation between the site of the surgical wound and the source of pain experienced by patients, with the subtemporal and suboccipital surgical routes yielding the highest incidence of postoperative pain. 
| Nerve supply|| |
The scalp receives its innervations from branches originating at the cervical plexus and the trigeminal nerve.
- The anterior scalp region is innervated by the supraorbital and supratrochlear nerves (branches of the frontal nerve).
- The temporal scalp region is supplied by the zygomaticotemporal, temporomandibular, and auriculotemporal nerves (branches of the trigeminal nerve)
- The occiput and scalp regions receive their sensory innervations from the greater auricular and the greater and lesser occipital nerves (originating from the cervical plexus)
- The dura mater is innervated by nerves that accompany the meningeal arteries.
| Analgesic therapy after craniotomy|| |
There are some important issues that need to be taken into account before the anti-nociceptive options can be discussed:  First, there are no standardized or proactive protocols for the evaluation of post-craniotomy pain and analgesic therapy. second, physicians are confronted with the difficulties of diagnosing pain and its severity in patients with aphasia, altered mental status or cognitive impairment; and finally, there are various practices with different anesthetics and analgesics without a single regimen being established as supreme. These drug combinations have effects that last beyond the immediate intraoperative period. For example, the intraoperative use of fentanyl or sufentanil, as compared with remifentanil, has a direct impact on post-craniotomy pain. Remifentanil allows for rapid emergence from anesthesia, but causes opioid tachyphylaxis and increased postoperative pain. In the majority of patients undergoing intracranial surgery, transitional and potent early postoperative analgesia is required when remifentanil has been used intraoperatively. , As a result of these factors a uniform approach to post-craniotomy pain evaluation and treatment is subject to debate.
| Regional analgesia|| |
Analysis of the small number available, small controlled trials on pain treatment after intracranial surgery, shows that regional analgesia (either scalp block or wound infiltration) is often used as a first-line approach for post-craniotomy pain. , In particular, scalp block has been used in patients undergoing awake procedures or for provision of transitional analgesia after the use of remifentanil, similar to that of intravenous morphine, in the immediate postoperative period.  The major advantage of a scalp block is its lack of interference with the neurological examination. Furthermore, different stimuli during craniotomy cause different levels of nociception. These noxious events can result in sudden increases in blood pressure and heart rate, which may further increase the ICP, particularly in patients with impaired autoregulation, leading to a rupture of an intracranial aneurysm and postoperative intracranial hematoma. Scalp blocks act as a form of pre-emptive analgesia. They decrease the need for frequent rescue pain medication, increase the time between the end of surgery and the first request for postoperative analgesics, and lower pain score values in the early postoperative period.  The major advantage of using scalp blocks is that they provide transitional analgesia without hindering neurological examination. It does not affect the patient's mental status or the motor or sensory function, and provides ideal conditions for postoperative neurological assessment.
Preincisional local anesthetic scalp infiltration is often used in neurosurgical practice to blunt the hemodynamic responses to craniotomy and to minimize bleeding from the skin incision (by addition of epinephrine to the local anesthetic). However, if wound infiltration is used prior to the incision either none or only minor analgesic effects on postoperative pain have been observed. If used after skin closure, a temporary reduction in pain in the immediate and early postoperative period may be achieved. There appears to be a trend for a better pain score and an opioid-sparing effect following wound infiltration, compared to scalp blocks. 
Note: Recommended maximum doses for the local anesthetic agent must be strictly followed with either technique and intravascular injections with their risk for seizure induction must be avoided.
| Parenteral opioids|| |
Parenteral opioids remain the cornerstone for managing moderate-to-severe pain, especially in the postoperative period after a major surgery. However, use of parenteral opioids for postoperative analgesia in spontaneously breathing craniotomy patients has often been viewed as impossible, mainly because of the fears of excess sedation and respiratory depression. Nevertheless, opioids may become necessary when the local anesthetic and less potent analgesics fail to achieve sufficient pain relief.
Intermittent systemic administration of opioids is still a standard method for postoperative pain relief. However, this strategy may result in alternate periods of oversedation and inadequate analgesia. Other methods, like patient-controlled analgesia (PCA) with morphine or oxycodone, have also been used effectively in patients after craniotomy. , However, the occurrence of postoperative sedation is especially troubling because of the need for frequent postoperative neurological examinations. Hence, concern about postoperative sedation may lead to the clinician providing high-risk patients with inadequate analgesia. With careful patient monitoring and prudent titration to individual patient needs, opioids may be used after brain surgery. Dangerous hypertension during emergence from anesthesia and in the early period after intracranial surgery is prevented as it may be detrimental for the brain, associated with an increased risk of intracranial hemorrhage. ,,,
Studies on post-craniotomy pain management show that potent opioids (codeine, morphine, and oxycodone) provide better pain relief than the weaker analgesics, such as, tramadol, paracetamol or ketoprofen. Morphine and codeine appear to have similar efficacies if appropriately dosed.
Use of morphine to treat post-craniotomy pain is limited, because of its potential to produce miosis, sedation, nausea, and respiratory depression. However, in the published studies none of these effects have been reported to be of clinical significance in post-craniotomy patients, suggesting that in the current care settings, its use is relatively safe. On the other hand, there are no good clinical studies that have evaluated the safety of i.v. morphine when used in quantities that provide adequate post-craniotomy pain control. In addition to studying morphine and codeine, multimodal approaches using combinations of opioids, local anesthetics, nonsteroidal anti-inflammatory agents, and alpha-2 adrenoceptor agonists must be used. Pain is usually assessed for a minimum of 12 hours after surgery and preferably for 48 hours. The methods of assessing the severity of pain need to be detailed enough to include pain intensity at the time of assessment as well as the worst pain experienced since the last assessment. Pain assessment techniques should be developed and validated for patients with altered neurological status. The adverse effects of postoperative pain and stress have been demonstrated, while clinically significant and substantiated opioid-induced side effects have not been reported.
| Non-steroidal anti-inflammatory drugs|| |
Paracetamol is used in neurosurgical patients, but may cause increased bleeding time due to dysfunction of the platelet. Therefore, paracetamol should be used carefully in the early post-craniotomy period, to avoid devastating bleeding after neurosurgery. Furthermore, paracetamol should especially be avoided in high-risk situations, such as, after aneurysm repair, resection of arteriovenous malformations, or hematoma evacuation.
In contrast to children, repeated use of paracetamol may not be sufficient for adequate pain relief in adult post-craniotomy patients.  Moreover, paracetamol's opioid-sparing effect has not proved to be significant. 
| Alpha-2 Adrenergic agonists|| |
Dexmedetomidine, a potent highly selective alpha-2 adrenergic agonist, provides analgesia and sedation without respiratory depression.  Dexmedetomidine may be used as an opioid-sparing agent, especially when it is used before completion in major in-patient surgical procedures. One of the major advantages of this agent is to bring a patient from sedation to arousal immediately, for neurological examinations, in the Post-Anesthetic Care Unit. Dexmedetomidine may be helpful in providing transitional analgesia from the surgical plane of anesthesia to the Post-Anesthesia Care Unit. However, further research on this interesting class of drugs is needed to assess the adequacy of pain control versus side-effects following craniotomy.
| N-methyl-D-aspartate receptor antagonists|| |
This class of drugs are administered as adjuvant pain-management drugs. These agents carry out their anti-nociceptive effects by inhibiting central sensitization in painful stimuli.
For skull-pin placement, sub-anesthetic dose intravenous ketamine combined with local anesthetic scalp infiltration may be used, to attenuate hemodynamic responses. , However, the use of ketamine in patients after craniotomy may be precluded by an undesirable increase in ICP that can be seen after administration of this drug.
Note: There is little data on other drugs or methods with established analgesic efficacy and less undesirable effects after intra-cranial surgery.
| Conclusion|| |
Until recently, perioperative pain management in neurosurgical patients has been inconsistently recognized and inadequately treated. An increased awareness of pain management in general, along with advances in understanding of pain modulation and pathophysiology, has led to improved practice and perioperative care of patients following craniotomy. Otherwise, severe postoperative pain impairs the quality of recovery and causes emotional distress, with the possibility of inducing chronic pain and lasting functional deficits. The greatest challenge in managing neurosurgical patients is the need to assess the neurological function, while providing superior analgesia with minimal side effects. To achieve this goal, a multimodal approach to analgesia using various drugs and techniques is advocated. There still remains a need, however, to conduct further randomized, controlled trials, to determine the best combination of drugs or techniques for treating perioperative pain in this patient population. Improved awareness, assessment, and treatment of pain result in better care and overall patient outcome. 
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