Page 290 Acute Pain Management

The management of postoperative pain after intracranial surgery is often poor. The problems
of postcraniotomy analgesia were analysed in a survey of United Kingdom neurosurgical
centres (Roberts, 2005 Level IV); the principal analgesic was IM codeine, only three of twenty‐
three centres used morphine and only one used PCA. Pain was only assessed in 57% of cases
(Roberts, 2005 Level IV). This practice had not changed since 1995 when IM codeine was the
primary analgesic used by 97% of centres (Stoneham & Walters, 1995 Level IV).
A number of reasons are likely to contribute to this, such as concerns about the adverse
effects of opioids and their ability to interfere with recovery and neurological assessment, as
well as the concern that opioid‐induced respiratory depression will lead to hypercarbia and
increased intracranial pressure (Nemergut et al, 2007). Similarly, there is a concern that non‐
steroidal anti‐inflammatory drugs (NSAIDs) could interfere with haemostasis and increase
intracranial bleeding. Furthermore, there is poor evidence on which to base protocols for the
assessment and treatment of pain after cranial surgery (Nemergut et al, 2007); the limited
number of available heterogeneous trials have many weaknesses in study design and
methodology. The question remains as to whether all craniotomies are the same with regard
to analgesic requirements (Nemergut et al, 2007).
Treatment of acute postoperative pain after cranial neurosurgery

Paracetamol
A trial comparing paracetamol (acetaminophen) alone with paracetamol plus tramadol or
paracetamol plus nalbufin was stopped early as paracetamol alone gave ineffective pain relief
in most patients (Verchere et al, 2002 Level II).
Non‐selective non‐steroidal anti‐inflammatory drugs
Ketoprofen was more effective than paracetamol in reducing PCA opioid requirements after
craniotomy but with minimal benefits in regard to pain scores and no change in adverse
effects (Tanskanen et al, 1999 Level II). However, a single‐centre, retrospective cohort study of
6668 cases over 5 years identified an association between the development of postoperative
haematoma and the use of aspirin or non‐selective NSAIDs (nsNSAIDs) (Palmer et al, 1994
Level IV).
CHAPTER 9 There was some limited benefit with the use of parecoxib over placebo at 6 hours, but not
Coxibs

at other time points in the first 24 hours postoperatively, with regard to pain scores and
morphine use in one study (Jones et al, 2009 Level II). Another study identified better pain
control and an opioid‐sparing effect of rofecoxib compared with placebo (Rahimi et al, 2006
Level II).

Opioids
Not surprisingly, PCA morphine or PCA morphine with ondansetron was superior to placebo
after infratentorial craniotomy (Jellish et al, 2006 Level II). Morphine was also more effective
than codeine following craniotomy; this was found for IM prn administration of both
compounds (Goldsack et al, 1996 Level II) but also in a comparison of PCA morphine with IM
codeine (Sudheer et al, 2007 Level II). PCA fentanyl was more effective than prn IV fentanyl and
did not increase the risk of adverse effects after craniotomy (Morad et al, 2009 Level II).
Codeine 60 mg IM was more effective than tramadol 50 mg or 75 mg IM (Jeffrey et al, 1999
Level II) and morphine PCA was better than tramadol PCA (Sudheer et al, 2007 Level II).
The intraoperative use of remifentanil may result in increased pain and/or increased analgesia
requirements postoperatively (see Section 4.1.3). This was found when compared with both
fentanyl (Gelb et al, 2003 Level II) and sufentanil (Gerlach et al, 2003 Level II).

242 Acute Pain Management: Scientific Evidence