Introduction: Pain control in the post-operative period is an important component of wound healing and recovery after craniotomy. There are complex issues surrounding opioid use and misuse that influence provider prescribing practices. A multidisciplinary and multimodal approach to pain management can be effective in the care of the postoperative neurosurgical patient.
Methods: A review of the current literature surrounding populations' affected most by pain, the economic and emotional impact of pain on individuals and the healthcare system as a whole is explored. This review includes an analysis of the common neurosurgical procedures most likely to cause pain and explores various options for use of a multimodal, multidisciplinary approach to pain control.
Results: There are millions of pain sufferers in the U.S. Early identification of at-risk populations may assist providers in anticipating and providing more effective pain control. Concerns over opioid misuse and a belief that neurosurgical procedures, including craniotomy, cause minimal pain have led to more conservative prescribing practices, but studies suggest that improved multimodal approaches to post-operative pain control can potentially lead to improved patient outcomes and decreased hospital lengths of stay and health-related expenses.
Conclusions: Pain management can pose challenges in the care of the neurosurgical post operative patient. Perioperative craniotomy pain management involves a multidisciplinary approach with an emphasis on a multimodal analgesic approach.
Patient Care: It will promote the early identification of at-risk patients and may help providers develop more effective, individualized pain control plans.
Learning Objectives: By the conclusion of this session, participants should be able to 1)Identify issues surrounding pain, who is affected and understand pain as a major public health issue, 2)Identify issues surrounding opioid use and misuse, 3) Describe craniotomy specific pain management issues, 4) Understand the multimodal analgesic approach to craniotomy perioperative management
References: American Pain Society, Guidelines on the Management of Postoperative Pain 2016.
American Society of Anesthesiology Newsletter, March 2014.
Cakan, T. et al. Intravenous paracetamol improves the quality of post operative analgesia. J Neurosurg Anesthesiology 2008:20(169-173).
Centers for Disease Control CDC, 2016.
Chin, M. Multimodal analgesia: Role of non opioid analgesics, ASRA on line.
Curtis, C. Perioperative multimodal pain management. Neurosurgery Grand Rounds, Emory University, April 21, 2016.
Gottschalk, et al. Prospective evaluation of pain and analgesic use following major elective intracranial surgery. J Neurosurg. 2007; 106: 210-216.
Hansen et al. Pain treatment after craniotomy: Where is the (procedure-specific) evidence? A qualitative systematic review. European Society of Anaesth. DOI: 10.1097/EJA.0b013e32834a0255.
Hinz, B. et al. 2008 FASEB Journal 22 (2) 383-390.
Hogestatt, E. et al. 2005, J Biol Chem 280 (36) 404-12.
Institute of Medicine Report: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research
Kearney, PM. et al. BMJ 332;1302-8.
Khan. ZU. et al. Intravenous paracetamol is as effective as morphine in knee arthroscopic day surgery procedures. Anesthesiology 2005; 102:822-831
Kissin, I. Long term opioid treatment of chronic nonmalignant pain: Unproven efficacy and neglected safety. Journal of Pain Research. 2013.
Lee, LA. et al. 2015, Anesthesiology, 122:659-65.
Mao, J. Clinical diagnosis of opioid induced hyperalgesia, regional anesthesia and pain medicine. Dec 2015, (40)6.
Misra, S. et al. The effect of gabapentin premedication on postoperative nausea, vomiting, and pain in patients on preoperative dexamethasone undergoing craniotomy for intracranial tumors, J Neurosurg Anesthesiol,. 2013;25(4):386-391.
Moore, DE. Drug safety: An Instructional Journal of Medical Toxicology and Drug experience. 25 (5) 345-72.
Mordhorst, et al. Prospective assessment of postoperative pain after craniotomy. J Neurosurg Anesthesiol, 2010; 22: 202-206.
Muller, JP. Curr Opin Anesthesiology, 2016, 29, (1) 129-33.
Myhre, et al. Pregabalin has analgesic, ventilator, and cognitive effects in combination with Remifentanil. Anesthesiology 2016: 124;141-9.
Rostom, A. et al. Cochrane Database system Rev (4).
Sinatra, RS. et al. Anesthesiology 2005:102:822-831.
Sessler, D. Anesthesiology, 2015; (122). 484-485.
Summary of Health Statistics for U. S. Adults: National Heath Interview Survey 2009, Department of Health and Human Services.
Trelle, S. et al. BMJ 342 Jan 11.
Ture, et al. The analgesic effect of gabapentin as a prophylactic anticonvulsant drug on post-craniotomy pain: A prospective randomized study. Anesth. Analg, 2009; 109(5): 1625-1631.
U.S. Department of Human and Health Services, Addressing Prescription Drug Abuse in the United States. 2003.
Vadivelu, et al. Options for perioperative pain management in neurosurgery. Journal of Pain Research; 2016: 9, 37-47.
http://www.hcahpsonline.org Centers for Medicare & Medicaid Services, Baltimore, MD.