Deconstructing Post Craniotomy Pain

Barbara Van de Wiele MD Clinical Professor, Vice Chair & Director of Neurosurgical Anesthesiology UCLA Department of Anesthesiology and Perioperative Medicine

Post craniotomy pain

Quality

Severity

Time course

Patient factors

Procedure factors

Treatment options

Implications for perioperative management and anesthesia care

Postoperative Pain in Neurosurgery: A Pilot Study in Brain Surgery. De Benedittis G et al: Neurosurgery. 38(3):466-470,1996.

Postoperative Pain in Neurosurgery: A Pilot Study in Brain Surgery. De Benedittis G et al: Neurosurgery. 38(3):466-470,1996.

Pain Topography and Quality

Topography

Superficial

Deep

Both

Quality

Pulsing andPounding

Steady

Heavy

Stabbing

Burning

Postoperative Pain in Neurosurgery: A Pilot Study in Brain Surgery. De Benedittis G et al: Neurosurgery. 38(3):466-470,1996.

Craniotomy procedures are associated with less analgesic requirements than other surgical procedures. Dunbar P et al. Anesth Analg 1999

EXTRA INTRA LUMBAR

PTS 134 78 21

# OF PAIN SCORES 124 77 19

PACU MORPHINE .0013(.0001) .0004(.001) .0015(.0001)

PAIN SCORES 2.5 (.2) .76 (.3) 2.4 (.6)

Pain Score in PACU 0 1 2 3 4 6 7 9

# OF PTS 45 3 3 3 1 1 1 1

Most intracranial surgery patients reported no postoperative pain to postanesthesia care unit nurses. A small number did report severe to moderate pain.

Gelb A et al: Remifentanil with morphine transitional analgesia shortens neurologic recovery compared to fentanyl for supratentorial craniotomy Can J Anaesth 50:2003

Quality of Recovery and Pain:

Remifentanil Fentanyl p

Initial Pain Score: Severe 24% 11% <.011

Median time to first analgesic 0.5 hrs 1.08 hrs <.001

Level of consciousness % better 71 27 < .05

Gotschalk A et al. Prospective evaluation of pain and analgesic use following major intracranial surgery. J Neurosurg 2007

Pain experience on the first and second postoperative day

Patient and anesthesia related factors:

POD Pain Scores % of pts

One >4 69%

Two >4 48%

N=187

Factor More Pain?

Preoperative Opioids Yes

Infra vs Supratentorial Yes

Younger vs Older Yes

Women vs Men Trend

Remifentanil vs Fentanyl No

Mordhurst C et al. Prospective Assessment of Postoperative Pain after Craniotomy. J Neurosurgical Anesthesiol 22:202, 2010

Pain experience within 24 hours of tracheal extubation

Pain (NRS) Score %

None (0) 13

Mild ( 1-3) 32

Moderate (4-7) 44

Severe (8-10) 11

Patient and anesthesia related factors:

Factor More Pain?

Younger vs Older Yes

TIVA vs Sevo 1st hour Yes

Sevo vs TIVA Overall Yes

No intraoperative steroids Yes

Women vs Men No

Infra vs Supratentorial No

Hansen MS et al. Suboptimal pain treatment after craniotomy. Dan Med J 2013

Pain experience: 1,2,4,8,and 24 hrs after tracheal extubation

Pain (NRS) Score %

Moderate to Severe Pain at Hour 1

56%

Moderate to Severe at Hour 24

38%

Patient and anesthesia related factors:

Factor More Pain?

No intraoperative steroids Yes

Women vs Men No

Infra vs Supratentorial No

Craniotomy Site and Postoperative Pain

0

10

20

30

40

50

60

70

80

90

100

Frontal FTP Temporal Parietal Occipital Post Fossa

Mild

Mod/Sev

• Less pain after frontal craniotomy

Thibault et al: Postoperative Pain in Neurosurgery Can J Anesth 54: 544, 2007

Post craniotomy pain

Quality: Pulsing and Pounding

Severity: Moderate to severe in ~ 50

Time course: for the first 24 -48 hours

Patient factors: age, gender, preoperative pain

Procedure factors: anesthesia, steroids, site

PAIN

Hypertension

Hemorrhage

Mobilization

• Jian M et al: Flurbiprofen and hypertension but not HES are associated with post-craniotomy intracranial haematoma requiring surgery. British Journal of Anaesthesia, 2014

• Basali A, Mascha EJ, Kalfas I, Schubert A. Relation between perioperative hypertension and intracranial hemorrhage after craniotomy. Anesthesiology 2000; 93: 48–54.

Chronic Pain after Craniotomy

Risk Factors for Chronic Pain

• Greater acute pain intensity

• Posterior fossa procedures

• Skull based procedures

• Gender

• Anxiety and depression

• Muscle adherence to dura

Flexman et al: Acute and chronic pain following craniotomy. Curr Opin Anaesthesiol 2010 Kaur et al: Persistent headache after supratentorial craniotomy Neurosurgery 47:633, 2000

The analgesic properties of scalp infiltrations with ropivicaine after intracranial tumor resection.

Batoz et al: Anesth Analg 2009

Postoperative persistent and neuropathic pain at 2 months

Group C N=25

Group I N=24

P

Persistent pain 56% 8% .0003

Neuropathic pain 25% 4% .04

• Scalp infiltration may be relevant for the rehabilitation of neurosurgical patients and their quality of life by limiting the development of persistent pain and particularly neuropathic pain.

Clinical examination of the awake patient is the mainstay of complication surveillance after neurosurgery

Misinformation Lack of

Information Concern about

side effects

• Level of consciousness • Respiration • Coagulation • Cognition

Multimodal Analgesia

OPIOIDS

TYLENOL

REGIONAL ANESTHESIA

PREVENTATIVE ANALGESIC THERAPIES

ADJUNCTS

NSAIDS

IV OPIOIDS

• Mainstay for early postoperative pain

• Small doses and careful titration emphasized

• Morphine & Fentanyl PCA have been used successfully

Goldsack et al. Anaesthesia 1996; Stoneham et al. Anaesthesia 1996; Scott Jellish et al: Neurosurgical Focus 2002; Morad et al: J Neurosurg 2009; Na HS et al Korean J Anesthesiol 2011

Morad A et al. Efficacy of intravenous patient-controlled analgesia after supratentorial intracranial surgery: a prospective randomized controlled trial: Clinical article. Journal of Neurosurgery 2009

ACETAMINOPHEN

• Common component of multimodal analgesia

• Insufficient alone for craniotomy pain

• Procedure specific effect not well established

• Cumulative dosing a concern

Verchère et al: Postoperative pain management after supratentorial craniotomy. J Neurosurg Anesthesiol. 2002 ; prospective RCT of three IV regimens; Acetominophen arm terminated due to insufficient pain control

Preemptive scalp infiltration with 0.5% ropivacaine and 1% lidocaine reduces postoperative pain after craniotomy Acta Nurochir 2015

Time Before incision Group A

At closure Group B

p

1h 0 2 <.001

2h 1 2 <.001

4h 1 3 <.001

6h 2 2 .005

8h 3 2 .398

12h 2 2 .961

24h 2 1 .969

• Ropivacaine 0.5% and 1% lidocaine before incision (A) vs at closure (B)

• VAS A< B first 6 h

• MS A< B first 24h

REGIONAL ANESTHESIA

1st Author N Infiltration Effect on Pain Analgesic Req

Bloomfield 1998

18/18 Incision site & pins Before and at end

VAS decreased on admission to PACU and 1h PO

NA

Saringcarinkul 2008

24/25 Incision site At end

Pain Score reduced from 0-1 h

NS

Law Koune 2005

20/19/37 Incision site At end

NS MS consumption decreased 0-2’

Batoz 2009

25/27 Incision site At end

VAS decreased 0-24h

NS

El Dewately 2008

30/30 Pin sites VAS decreased at 2,4,24 36and 48

NS

Hansen et al: Pain treatment after craniotomy where is the procedure specific evidence? A qualitative systemic review. Eur J Anaesthesiol 2011

SCALP INFILTRATION

Scalp Block

Nerve Branch Anterior Craniotomy

Posterior Craniotomy

Supraorbital Ophthalmic Branch of the TG N Yes No

Supratrochlear Ophthalmic Branch of the TG N Yes No

Auriculotemporal Mandibular Branch of the TG N Yes No

Zygomaticotemporal Maxillary branch of the TG N Yes Yes

Greater occipital Posterior ramus of C2 No Yes

Lesser occipital Ventral rami of C2 and C3 No Yes

Osborn I, Sebeo J. Scalp block during craniotomy: A classic technique revisited. J Neurosurg Anesthesiol 22:187, 2010

Study N Timing Drug

Ayoub 2006

55 Postop Lidocaine + bupivacaine

Bala 2006

40 Postop Bupivacaine + epinephrine

El Dahab 2009

80 Preop Bupivacaine + epinephrine

Gazoni 30 Preop Ropivacaine

Hernandez Palazon 2007

30 Postop Bupivacaine + epinephrine

Nguyen 2001

30 Postop Ropivacaine

Tuchinda 2010

60 Preop Bupivacaine + epinephrine

Guilfoyle M et al. Regional scalp block for postcraniotomy analgesia a systemic review and meta-analysis. Anesth Analg 116:1093, 2013

Pain Scores ( metanalysis)

• RSB Significant reduction at 1,2,4,6-8 not at 12 or 24h

• Largest effect ( -1.6) at 1h

• Subgroup analysis – Pre 1,2,4

– Post 1,4,6,12

NSAIDS: Non Selective COX1/COX 2 Inhibitors

• Preoperative use linked to ICH

• A few small trials have not shown and increased complication rate.

• Some centers introduce NSAIDs postoperatively in a selective fashion.

• Use in craniotomy patients is controversial

Magni G et al: Intracranial Hemorrhage requiring surgery in neurosurgical patients given ketorolac: a case control study within a cohort (2001-2010). Anesthesia and Analgesia 2013 • Retrospective • N= 4086 patients • ICH requiring surgery

– # 8/1571 (0.5%) of patient who received ketorolac

– # 35/2515 (1.3%) did not receive ketorolac

• Statistical analysis – does not provide conclusive

evidence of the safety of ketorolac after neurosurgery

Jian M et al: Flurbiprofen and hypertension but not HES are associated with post-craniotomy intracranial haematoma requiring surgery. British Journal of Anaesthesia 2014

• Retrospective

• n= 42,350 patients

• ICH # 202

• Risk factors for ICH were:

– Hypertension: during and after surgery

– Flurbiprofen: during but not after surgery

NSAIDS: Selective COX 2 Inhibitors

• Very limited studies are currently available • Benefit not established. • Use for craniotomy pain is controversial

Williams D. L et al: Effect of intravenous parecoxib on post-craniotomy pain. Brit J Anaesthes. 2011

.

“No clinical benefit to adding parecoxib to local anesthesia infiltration, iv Paracetemol and PCA IV MS”

Ke Peng , Xiao-hong Jin , Si-lan Liu , Fu-hai Ji Effect of Intraoperative Dexmedetomidine on Post-Craniotomy Pain Clinical Therapeutics, 2015

• Prospective Randomized n=80

• Dexmedetomidine 0.5 mcg per kg per hr vs placebo during sevoflurane fentanyl anesthesia

Alpha 2 adrenergic agonists

Rahimi, S et al. Postoperative pain management with tramadol after craniotomy: evaluation and cost analysis: Clinical article. Journal of Neurosurgery 112: 268-272, 2010.

• RCT N=50

• Narcotics+ Tylenol

• Narcotics+Tylenol + Ultram 100 mg BID

TRAMADOL

Gabapentinoids

Türe H et al. The analgesic effect of gabapentin as a prophylactic anticonvulsant drug on postcraniotomy pain: a prospective randomized study. Anesth Analg 2009

Ketamine ?

GABAPENTIN 1200 mg qd

PAIN LESS

PONV LESS

MORPHINE LESS

POSTOPERATIVE SEDATION MORE

EXTUBATION TIME LONGER

-1

0

1

2

3

4

5

6

7

8

9

10

-10 0 10 20 30 40 50 60

Pai

n s

core

Hours since surgery end

Patient Pain Scores by Post-Op Hour (Bubble area represents the number of patients reaching that pain score in that hour)

Counts of patient pain scores by hour Mean of all patients with pain scores in this hour Mean of patients with non-zero pain in this hour

N=316 patients

Evaluated our pain outcomes

Evaluated our pain practices Used Consensus to increase utilization

Acetominophen Yes --

Regional Infiltration at incision Yes --

Regional infiltration at craniotomy closure

Sometimes Not too much resistance

Nerve block awake craniotomy Yes --

Nerve block after GA Rarely No

PCA Rarely No

NSAIDS Rarely No

Gabapentin No No

Dexmedetomidine Selected cases No

COX2 No No

Tramadol No No

Ketamine No No

A recipe for change • Standardized preoperative patient education

• Standardized assessment of pain risk factors

• Incorporated pain management into our extended time out and debrief

• Standardized infiltration of incision site

• Standardized postoperative order set

• Standardized pain consult criteria

• Train providers to assess and rx pain uniformly

• Establish daily goals for pain management

• Early use of non pharmacologic strategies

• Review of some pain process outcomes biweekly

IN SUMMARY

• Post craniotomy pain is often moderate to severe

• Post craniotomy pain is often undertreated

• Multimodal analgesia protocols are indicated

• Multidisciplinary approach to process and understanding of local outcomes is likely to drive change

THANK YOU