Abstract

The importance of peri-operative pain control cannot be overstated. The overwhelming majority (87%) of patients experience pain after craniotomy – 44% of patients report moderate pain and 10% report severe pain in the first 24 hours post-procedure. Adequate analgesia in the post-operative period is associated with improved patient satisfaction, increased mobility, early ambulation, shorter hospital stays, and reduced cost. There has been a tendency in neurosurgery to underestimate the severity of, and therefore under-treat, post-operative pain following craniotomy and spinal surgery. An increasing body of evidence suggests that aggressive pain control in the acute post-operative period may reduce the risk of chronic pain and chronic opioid dependence. Analgesic options are limited by bleeding risk, the need for a reliable neurologic examination, and the risk for pseudoarthrosis following spinal fusion. Prevention of acute severe pain is likely to improve visual analog scale (VAS) scores in the hospital, reduce opioid consumption, reduce opioid related side effects, and decrease the likelihood of going on to develop chronic pain. We would recommend a multi-modal strategy including the liberal use of opioids coupled with acetaminophen, gabapentin/pregabalin, and non-narcotic analgesics such as tramadol and COX-2 inhibitors. While the liberal use of opioids in encouraged in the early post-operative period, patients must be discharged with a clear and concise weaning schedule. The use of local anesthetic is recommended also. Pre-treatment protocols and the use of epidural catheters represent therapeutic options that warrant further study. More study is required both in the laboratory and in the clinic to enhance our understanding of the pain phenomenon and to formulate better treatment.

Keywords: Craniotomy; Spine surgery; Neurosurgery; Postoperative pain; Peri-operative pain; Opioid; Multimodal pain management