Hostname: page-component-745bb68f8f-s22k5 Total loading time: 0 Render date: 2025-01-24T22:55:59.576Z Has data issue: false hasContentIssue false
  • English
  • Français

Pain Management in Post-Craniotomy Patients: A Survey of Canadian Neurosurgeons

Published online by Cambridge University Press:  02 December 2014

Basil Hassouneh ,
John E. Centofanti  and
Kesava Reddy
Basil Hassouneh*
Affiliation:
Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
John E. Centofanti
Affiliation:
Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
Kesava Reddy
Affiliation:
Department of Surgery - Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
*
Health Research Methodology Program, McMaster University, HSC-2C1 - 1200 Main St. W., Hamilton, Ontario, L8N 3Z5, Canada
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Introduction:

Despite the growing recognition for analgesic needs in post-craniotomy patients, this remains a poorly studied area in neurological surgery. The class and regimen of analgesia that is most suitable for these patients remains controversial. The objective of this study is to examine the current beliefs and practices of Canadian neurosurgeons when managing post-craniotomy pain.

Methods:

A survey was sent to all practicing Canadian neurosurgeons to examine the following aspects of analgesia in craniotomy patients: type of analgesics used, common side effects encountered, satisfaction with current regimen and the rationale for their practice.

Results:

Of 156 potential respondents, 103 neurosurgeons (66%) completed the survey. Codeine (59%) was the most prescribed firstline analgesic followed by morphine (38%). The use of a second-line opioid was significantly higher among codeine prescribers compared to morphine, 53% compared to 28% (p < 0.001). Nausea, constipation and neurologic depression were reported as common side effects by 76%, 66% and 27% of respondents respectively. Of the respondents, 90% reported a high level of satisfaction with their current choice of analgesia; nonetheless, they predominantly described their practice as personal preference or protocol driven rather than evidence-based.

Conclusions:

Codeine - a weak opioid - is the most common first-line analgesic prescribed to craniotomy patients. This practice is associated with substantially increased reliance on potent opioids for rescue analgesia. Whether novel regimens can provide optimal pain control while minimizing neurologic and gastrointestinal side effects remains to be addressed by future trials.

Résumé:

Résumé:Contexte:

Même si la nécessité d’administrer des analgésiques chez les patients qui ont subi une craniotomie est maintenant mieux établie, c’est un sujet qui a été peu étudié. La classe et le régime posologique d’analgésiques qui convient le mieux à ces patients demeurent controversés. ‘objectif de cette étude était d’examiner les convictions et les pratiques actuelles des neurochirurgiens canadiens concernant le soulagement de la douleur après une craniotomie.

Méthode:

Une enquête a été faite auprès de tous les neurochirurgiens canadiens actuellement en pratique pour examiner les aspects suivants concernant l’analgésie chez les patients qui ont subi une craniotomie : le type d’analgésiques utilisés, les effets secondaires fréquemment observés, le degré de satisfaction concernant les régimes posologiques actuels et la justification de leurs habitudes de prescription.

Résultats:

Des 156 répondants potentiels, 103 neurochirurgiens (66%) ont complété l’enquête. L’analgésique de première ligne le plus fréquemment prescrit était la codéine (59%), suivi de la morphine (38%). L’utilisation d’un opioïde de deuxième ligne était significativement plus élevée parmi les prescripteurs de codéine que parmi les prescripteurs de morphine, soit 53% par rapport à 28% (p < 0,001). Les effets secondaires les plus courants étaient les nausées, la constipation et la dépression neurologique, rapportés par 76%, 66% et 27% des répondants respectivement. De plus, 90% d’entre eux ont rapporté un haut degré de satisfaction concernant leur choix actuel d’analgésique. Cependant, ils ont décrit leur choix comme étant motivé par une préférence personnelle ou un protocole plutôt que fondé sur des preuves.

Conclusions:

La codéine, un opioïde faible, est l’analgésique de première ligne le plus fréquemment prescrit chez les patients qui ont subi une craniotomie. Cette pratique est associée à un recours à des opioïdes puissants comme analgésique de rattrapage. Il faudra effectuer des essais cliniques pour évaluer si de nouveaux régimes de traitement pourraient optimiser le contrôle de la douleur tout en minimisant les effets secondaires neurologiques et gastro-intestinaux.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 38 , Issue 3 , May 2011 , pp. 456 - 460
Copyright
Copyright © The Canadian Journal of Neurological 2011

References

1 Dunbar, PJ, Visco, E, Lam, AM. Craniotomy procedures are associated with less analgesic requirements than other surgical procedures. Anesth Analg. 1999;88(2):335–40.CrossRefGoogle ScholarPubMed
2 Gottschalk, A, Berkow, LC, Stevens, RD, et al. Prospective evaluation of pain and analgesic use following major elective intracranial surgery. J Neurosurg. 2007;106(2): 210–16.CrossRefGoogle ScholarPubMed
3 Thibault, M, Girard, F, Moumdjian, R, et al. Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study. Can J Anaesth. 2007;54(7): 544–8.CrossRefGoogle ScholarPubMed
4 Ortiz-Cardona, J, Bendo, AA. Perioperative pain management in the neurosurgical patient. Anesthesiol Clin. 2007;25(3):655–74.CrossRefGoogle ScholarPubMed
5 Talke, PO, Gelb, AW. Postcraniotomy pain remains a real headache! Eur J Anaesthesiol. 2005;22(5):325–7.CrossRefGoogle ScholarPubMed
6 Durieux, ME, Himmelseher, S, Durieux, ME, Himmelseher, S. Pain control after craniotomy: off balance on the tightrope? J Neurosurg. 2007;106(2):207–9.CrossRefGoogle ScholarPubMed
7 Kotak, D, Cheserem, B, Solth, A. A survey of post-craniotomy analgesia in British neurosurgical centres: time for perceptions and prescribing to change? Br J Neurosurg. 2009;23(5):538–42.CrossRefGoogle ScholarPubMed
8 Gottschalk, A. Craniotomy pain: trying to do better. Anesth Analg. 2009;109(5):1379–81.CrossRefGoogle Scholar
9 Jutsum, FJ. Time for perceptions and prescribing to change? Br J Neurosurg. 2010;24(1):94.CrossRefGoogle ScholarPubMed
10 Nemergut, EC, Durieux, ME, Missaghi, NB, et al. Pain management after craniotomy. Best Pract Res Clin Anaesthesiol. 2007;21(4): 557–73.CrossRefGoogle ScholarPubMed
11 Poulsen, L, Brosen, K, Arendt-Nielsen, L, Gram, LF, Elbaek, K, Sindrup, SH. Codeine and morphine in extensive and poor metabolizers of sparteine: pharmacokinetics, analgesic effect and side effects. Eur J Clin Pharmacol. 1996;51(3-4):289–95.CrossRefGoogle ScholarPubMed
12 Goldsack, C, Scuplak, SM, Smith, M. A double-blind comparison of codeine and morphine for postoperative analgesia following intracranial surgery. Anaesthesia. 1996;51(11):1029–32.CrossRefGoogle ScholarPubMed
13 Stoneham, MD, Cooper, R, Quiney, NF, Walters, FJ. Pain following craniotomy: a preliminary study comparing PCA morphine with intramuscular codeine phosphate. Anaesthesia. 1996;51(12): 1176–8.CrossRefGoogle ScholarPubMed
14 Sudheer, PS, Logan, SW, Terblanche, C, Ateleanu, B, Hall, JE. Comparison of the analgesic efficacy and respiratory effects of morphine, tramadol and codeine after craniotomy. Anaesthesia. 2007;62(6):555–60.CrossRefGoogle ScholarPubMed
15 Morad, AH, Winters, BD, Yaster, M, et al. Efficacy of intravenous patient-controlled analgesia after supratentorial intracranial surgery: a prospective randomized controlled trial. Clinical article. J Neurosurg. 2009;111(2):343–50.CrossRefGoogle ScholarPubMed
16 Rahimi, SY, Alleyne, CH, Vernier, E, Witcher, MR, Vender, JR. Postoperative pain management with tramadol after craniotomy: evaluation and cost analysis. J Neurosurg. 2010;112(2):268–72.CrossRefGoogle ScholarPubMed
17 Stoneham, MD, Walters, FJ. Post-operative analgesia for craniotomy patients: current attitudes among neuroanaesthetists. Eur J Anaesthesiol. 1995;12(6):571–5.Google ScholarPubMed
18 Roberts, G. A review of the efficacy and safety of opioid analgesics post-craniotomy. Nurs Crit Care. 2004;9(6):277–83.CrossRefGoogle ScholarPubMed
19 Cold, GE, Felding, M. Even small doses of morphine might provoke “luxury perfusion” in the postoperative period after craniotomy. Neurosurgery. 1993;32(2):327.Google ScholarPubMed
20 Rahimi, SY, Vender, JR, Macomson, SD, et al. Postoperative pain management after craniotomy: evaluation and cost analysis. Neurosurgery. 2006;59(4):852–7; discussion 857.CrossRefGoogle ScholarPubMed
21 Jones, SJ, Cormack, J, Murphy, MA, Scott, DA. Parecoxib for analgesia after craniotomy. Br J Anaesth. 2009;102(1):76–9.CrossRefGoogle ScholarPubMed
22 Umamaheswara Rao, GS, Gelb, AW. To use or not to use: the dilemma of NSAIDs and craniotomy. Eur J Anaesthesiol. 2009; 26(8):625–6.CrossRefGoogle ScholarPubMed
23 Palmer, JD, Sparrow, OC, Iannotti, F. Postoperative hematoma: a 5-year survey and identification of avoidable risk factors. Neurosurgery. 1994;35(6):1061–4; discussion 1064-5.CrossRefGoogle ScholarPubMed
24 Roberts, GC. Post-craniotomy analgesia: current practices in British neurosurgical centres-a survey of post-craniotomy analgesic practices. Eur J Anaesthesiol. 2005;22(5):328–32.CrossRefGoogle ScholarPubMed
25 Wilkinson, GR. Drug metabolism and variability among patients in drug response. N Engl J Med. 2005;352(21):2211–21.CrossRefGoogle ScholarPubMed
26 Kirchheiner, J, Schmidt, H, Tzvetkov, M, et al. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J. 2007;7(4): 257–65.CrossRefGoogle ScholarPubMed
27 Quigley, C, Wiffen, P. A systematic review of hydromorphone in acute and chronic pain. J Pain Symptom Manage. 2003;25(2): 169–78.CrossRefGoogle ScholarPubMed
28 Murray, A, Hagen, NA. Hydromorphone. J Pain Symptom Manage. 2005;29 Suppl 5:S57–66.CrossRefGoogle ScholarPubMed
29 Riley, J, Eisenberg, E, Muller-Schwefe, G, Drewes, AM, Arendt-Nielsen, L. Oxycodone: a review of its use in the management of pain. Curr Med Res Opin. 2008;24(1):175–92.CrossRefGoogle ScholarPubMed
30 Tanskanen, P, Kytta, J, Randell, T. Patient-controlled analgesia with oxycodone in the treatment of postcraniotomy pain. Acta Anaesthesiol Scand. 1999;43(1):42–5.CrossRefGoogle ScholarPubMed
31 Lenz, H, Sandvik, L, Qvigstad, E, Bjerkelund, CE, Raeder, J. A comparison of intravenous oxycodone and intravenous morphine in patient-controlled postoperative analgesia after laparoscopic hysterectomy. Anesth Analg. 2009;109(4):1279–83.CrossRefGoogle ScholarPubMed
32 Kearney, PM, Baigent, C, Godwin, J, Halls, H, Emberson, JR, Patrono, C. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ. 2006;332(7553):1302–8.CrossRefGoogle ScholarPubMed