Despite widespread belief, up to 80% of patients report moderate to severe pain on the first postoperative day after intracranial surgery. However, the pain is not as severe as experienced following some extra-cranial interventions.

Management of postoperative pain after intracranial surgery is often poor and may stem form concerns related to adverse effects of analgesics. Opioidsare a cause of concern in that they may interfere with recovery and neurological assessment as well as concern that opioid-induced respiratory depression may lead to hypercarbia and increased intra-cranial pressure. Concerns related to NSAIDsinclude that they may interfere with haemostasis and increase intra-cranial bleeding. There is limited procedure specific evidence from which to devise protocols for assessment and treatment.

Craniotomy may lead to significant chronic headache. Six months after supratentorial craniotomy for aneurysm repair, 40% of patients reported headache according to the classification of the International Headache Society, in 10.7% of patients it was acute and in 29.3% chronic. ANZCA, chapter 9.1.5, p 241-241.

Evidence-based recommendations specific to the condition

Preoperative

No specific evidence

Intaoperative

A long acting local anaesthetic should be infiltrated into the wound margins. German section 4.1.1.2.3. page 11.

Postoperative

Paracetamol as a single agent, provided ineffective pain relief in most patients ANZCA chapter 9.1.5, p 242.

Non-specific (ns) NSAIDs. An association was found between development of postoperative haematoma and aspirin and nsNSAIDs in a single, retrospective study of 6668 cases ANZCA, chapter 9.1.5, p 242.

Cox-2 inhibitors: there is limited evidence about their effectiveness ANZCA, chapter 9.1.5, p 242.

Opioids: Morphine is more effective than codeine and tramadol.

PCA morphine, PCA fentanyl and PCA morphine with ondansetron were superior to placebo following craniotomy and do not increase the risk of adverse effects. ANZCA, chapter 9.1.5, p 242.

Local anaesthetic scalp block: Scalp infiltration with a local anaesthetic provided analgesia in the first few postoperative hours and reduced the incidence of subsequent chronic pain. ANZCA, chapter 9.1.5, p 243.

Issues related to nursing / monitoring of patients

Patients receiving opioids should be monitored for respiratory depression, hypercarbia and increased intracranial pressure and the staff need to be aware about interference with neurological assessment.

Summary

To date, no firm recommendations about analgesic therapy following craniotomy can be given as the number of well performed RCTs is limited and study populations are very small. However, according to current evidence, craniotomy can lead to significant chronic headache. Furthermore, scalp infiltration provides analgesia during the first few postoperative hours and morphine is more effective than codeine and tramadol after craniotomy.

Supplementary reading

1. Flexman AM, Ng JL, Gelb AW. Acute and chronic pain following craniotomy. Curr Opin Anaesthesiol. 2010 Oct;23(5):551-7.
2. Nemergut EC, Durieux ME, Missaghi NB, Himmelseher S. Pain management after craniotomy. Best Pract Res Clin Anaesthesiol. 2007 Dec;21(4):557-73.