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Non-pharmacological techniques
Non‐pharmacological techniques such as transcutaneous electrical nerve stimulation (TENS),
acupuncture, hypnosis, ultrasound, laser and cryoanalgesia have also been used in the
treatment of acute pain management after ambulatory surgery. Pressure on acupoints
decreased pain following knee arthroscopy (Felhendler & Lisander, 1996 Level II). Continuous‐flow
cold therapy has been shown to be effective following outpatient anterior cruciate ligament
reconstruction, also reducing analgesic requirements (Barber et al, 1998 Level II).

Key messages
1. Infiltration of the wound with local anaesthetic agents provides good and long‐lasting
analgesia after ambulatory surgery (U) (Level II).
2. Peripheral nerve blocks with long‐acting local anaesthetic agents provide long‐lasting
postoperative analgesia after ambulatory surgery (U) (Level II).
3. Single shot infraclavicular blocks provide effective analgesia and less nausea following hand
and wrist surgery and earlier ambulation and hospital discharge compared with general
anaesthesia (N) (Level II).
4. Continuous peripheral nerve blocks provide extended analgesia after ambulatory surgery
(U) (Level II), leading to reduced opioid requirements, less sleep disturbance, earlier
achievement of discharge criteria and improved rehabilitation (N) (Level II).
5. Continuous peripheral nerve blocks have been shown to be safe at home, if adequate
resources and patient education are provided (U) (Level IV).
6. Pain relief after ambulatory surgery remains poor (N) (Level IV) and is a common cause of
unplanned readmissions (N) (Level III‐3).

9.1.5 Cranial neurosurgery

There is a widespread belief that intracranial surgery does not result in much patient
discomfort and pain. However, recent surveys have shown that patients may have significant
pain in the early phase after intracranial surgery. In one survey, 69% of patients reported
moderate to severe pain on the first postoperative day (Gottschalk et al, 2007 Level IV). These
findings are in line with another study that found incidences of 56% moderate and 25% severe
pain (Thibault et al, 2007 Level IV). Similar numbers of up to 80% are confirmed in a review of the CHAPTER 9
literature on this topic (Nemergut et al, 2007).
However, the pain is not as severe as, for example, after spinal surgery (Klimek et al, 2006
Level III‐2) or other surgical procedures such as extracranial maxillary/mandibular surgery or
lumbar surgery (Dunbar et al, 1999 Level III‐2). The pain is said to be more severe after an
infratentorial rather than a supratentorial approach (Gottschalk et al, 2007 Level IV; Thibault et al,
2007 Level IV). These differences are disputed only by one small study (Irefin et al, 2003
Level III‐2). Non‐craniotomy neurosurgery, for example trans‐sphenoidal surgery, seems to be
associated with very limited pain and minimal morphine requirements (Flynn & Nemergut, 2006
Level IV).
It is noteworthy that craniotomy can lead to significant chronic headache. Six months after
supratentorial craniotomy for aneurysm repair, 40% of patients reported headache according
to the International Headache Society classification, of whom 10.7% had acute and 29.3%
chronic headache (Rocha‐Filho et al, 2008 Level IV). There were no differences between patients
with or without subarachnoid haemorrhage.

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