Pain after craniotomy can be intense and its management is often suboptimal.
We aimed to evaluate the available literature and develop recommendations for optimal pain management after craniotomy.
A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken.
Randomised controlled trials and systematic reviews published in English from 1 January 2010 to 30 June 2021 assessing pain after craniotomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases.
Each randomised controlled trial (RCT) and systematic review was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and NSAIDs, and current clinical relevance.
Out of 126 eligible studies identified, 53 RCTs and seven systematic review or meta-analyses met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, NSAIDs, intravenous dexmedetomidine infusion, regional analgesia techniques, including incision-site infiltration, scalp nerve block and acupuncture. Limited evidence was found for flupirtine, intra-operative magnesium sulphate infusion, intra-operative lidocaine infusion, infiltration adjuvants (hyaluronidase, dexamethasone and α-adrenergic agonist added to local anaesthetic solution). No evidence was found for metamizole, postoperative subcutaneous sumatriptan, pre-operative oral vitamin D, bilateral maxillary block or superficial cervical plexus block.
The analgesic regimen for craniotomy should include paracetamol, NSAIDs, intravenous dexmedetomidine infusion and a regional analgesic technique (either incision-site infiltration or scalp nerve block), with opioids as rescue analgesics. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.
Recommendations for patients undergoing craniotomy
- (1) Systemic analgesia should include paracetamol, NSAIDs administered pre-operatively or intra-operatively and continued postoperatively.
- (2) Intra-operative dexmedetomidine infusion is recommended, as it is associated with reduced postoperative pain. Caution with regards of cardiovascular effects is warranted.
- (3) Either incision-site infiltration or scalp nerve block is recommended as regional analgesic technique.
- (4) Opioids should be reserved as rescue analgesia in the postoperative period.