Pain management after elective craniotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations.

BACKGROUND Pain after craniotomy can be intense and its management is often suboptimal. OBJECTIVES We aimed to evaluate the available literature and develop recommendations for optimal pain management after craniotomy. DESIGN A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. DATA SOURCES 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. ELIGIBILITY CRITERIA 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. RESULTS 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. CONCLUSIONS 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

Alternative drugs to spinally administered opiates in animal models of neuropathic pain

Many progress in the understanding and the management of pain has been made since Melzach and Wall (1965) published the “Gate Control Theory”, 35 years ago. This theory emphasized that sensory input is subject to modulation at multiple levels in the central nervous system (CNS) and the modulation can be either excitatory or inhibitory. The dorsal horn of the spinal cord represents the first “gate” and is one of the levels on which research has focused to produce spinal analgesic drugs. The discovery of action of spinal level by Besson et al, 1973 was the first step, and that of spinal opiate receptors (Yaksh and Rudy, 1976) has opened the way to discovering multiple other receptors (adrenergic, cholinergic, purinergic …) as potential targets for pain modulatory substances (Coggeshall and Carlton, 1997). By the same way, our thinking about pain perception and maintenance – like in chronic pain states – has been in constant evolution and became even more complex. The concept that sex differences may exist both in pain perception and is response to analgesics, not only related to a pharmacokinetic difference, is also slowly emerging. Recent articles in the medical literature highlight the importance to include female subjects in experimental drug research (in animal modes, in clinical practice for volunteers and patients studies) and to analyze their data separately (Berkeley KJ, 1997; Riley et al, 1999). Today, most of us agree that persistence if chronic pain, in contrast to acute pain which is a normal response to tissue damage, offers no biological advantage and therefore, cause unnecessary suffering and distress. Evenmore, clinical and fundamental studies have stressed the important fact that chronic pain differs from acute pain and involves pathological mechanisms development at both peripheral and central levels of the nervous system. Among the common chronic pain syndromes, neuropathic pain remains one the more complex, frequently mistreated or undertreated (Ashburn and Staats, 1998). Indeed, we are currently confronted to problems in pain relief: on one hand, for acute pain (postoperative, burns, intensive care …) we have potent and effective drugs such as opioids or local anesthetics, which are nonetheless not devoid of harmful side effects; on the other hand, in chronic pain management (of malignant or non malignant origin), we are still facing patients suffering from intractable pain, especially in neuropathic pain conditions, poorly responsive to the conventional analgesic drugs we can offer. Our work will focus on the later problem. Using an animal model of neuropathic pain, we will explore which drugs could be proposed as spinal analgesics as alternative to opioids.Doctorat en sciences médicales (anesthésiologie) -- UCL, 199

The weed of epidural neostigmine combined with ropivacaine and sufentanil on neuraxial analgesia during labor

Spinal neostigmine produces analgesia without respiratory depression or hypotension but provokes major gastrointestinal side effects. Epidural injection of this drug, however, appears to induce analgesia devoid of such side effects. In this study, we evaluated the effect of a bolus of epidural neostigmine on the duration and magnitude of analgesia in early labor and assessed its eventual sparing effect on subsequent local anesthetic requirements. Epidural neostigmine methylsulfate (maximal dose 4 mug/kg) was added to 10 mL of ropivacaine 0.1%, with and without sufentanil 10 mug, to initiate analgesia. Twenty minutes after injection, pain score, sensory level, and motor block were assessed. Time until request for supplemental epidural medication was also recorded. Patient-controlled epidural analgesia with ropivacaine 0.1% was used for epidural supplementation. Maternal and fetal side effects were closely recorded. Neostigmine (4 mug/kg), when added to ropivacaine 10 mg, provided equivalent analgesia to ropivacaine 20 mg but was less effective than sufentanil 10 mug for the initiation of labor epidural analgesia. Further, neostigmine did not modify the subsequent patient-controlled epidural analgesia local anesthetic requirements during labor. No hemodynamic instability, additional motor block, or bothersome side effects were recorded

Epidural clonidine or bapivacaine as the sole analgesic agent during and after abdominal surgery : A comparative study

Epidural clonidine or bapivacaine as the sole analgesic agent during and after abdominal surgery : A comparative stud

Identification du risque de douleur chronique après hépatectomie pour don de foie par les trajectoires de douleur

Objectif : Évaluer les trajectoires de douleur pour l’identification des patients à risque de douleur chronique après hépatectomie pour don vivant de foie. Type d’étude : Étude rétrospective des donneurs vivants (DoVi) de foie sur une durée de trois ans. Patients et méthodes : Recueil des données chirurgicales et anesthésiques périopératoires des DoVi de foie. Une trajectoire standard de douleur postopératoire (DPO) a été construite avec les données des patients ne présentant pas de douleur chronique post-chirurgicale (DCPC), à laquelle a été comparée l’évolution postopératoire des patients avec DCPC. Résultats : Soixante-cinq patients ont été évalués (hommes/femmes : 35/30, âge médian 34 ans). La chirurgie était une bisegmentectomie hépatique pour 89 % des patients. Une analgésie péridurale a été utilisée chez 66 %, les autres bénéficiant d’une pompe de morphine. Le premier jour, 11 % et 37 % des patients ont rapporté une DPO sévère (score > 6/10) au repos et au mouvement respectivement. Six patients (9 %) (trois hommes, trois femmes) présentaient des DCPC à trois mois et plus, sans corrélation avec la technique d’analgésie. L’analyse des trajectoires de DPO a montré que les patients avec DCPC avaient présenté des DPO plus intenses durant les premières 24 heures ou une résolution anormale de leur DPO aiguë. Conclusion : La DPO aiguë chez les DoVi de foie est un facteur de risque de DCPC. L’identification des patients à risque par les trajectoires de DPO pourrait permettre une prise en charge plus précoce

Resolution of pain after childbirth.

BACKGROUND: Chronic pain after surgery occurs in 10-40% of individuals, including 5-20% of women after cesarean delivery in previous reports. Pain and depression 2 months after childbirth are independently associated with more severe acute post-delivery pain. Here we examine other predictors of pain at 2 months and determine the incidence of pain at 6 and 12 months after childbirth. METHODS: Following Institutional Review Board approval, 1228 women were interviewed within 36 h of delivery. Of these, 937 (76%) were successfully contacted by telephone at 2 months, and, if they had pain, at 6 and 12 months after delivery. The primary outcome measure was presence of pain which began at the time of delivery. We also generated a model of severity of acute post-delivery pain and 2 month pain and depression. RESULTS: Pain which began at the time of delivery was remarkably rare 6 and 12 months later (1.8% and 0.3% [upper 95% confidence limit, 1.2%], respectively). Past history of pain and degree of tissue damage at delivery accounted for 7.0% and 16.7%, respectively, of one aspect in the variability in acute post-delivery pain. Neither of these factors was associated with incidence of pain 2 months later. CONCLUSIONS: Using a definition of new onset pain from delivery, we show a remarkably low incidence of pain 1 yr after childbirth, including those with surgical delivery. Additionally, degree of tissue trauma and history of chronic pain, risk factors for pain 2 months after other surgery, were unimportant to pain 2 months after cesarean or vaginal delivery

Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a "poor man's epidural"

The epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units. Since the end of the 90 ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don't want, can't have or don't need epidural analgesia

Effect of postoperative analgesia on acute and persistent postherniotomy pain: a randomized study.

STUDY OBJECTIVE: The study objective is to identify differences in postoperative pain management according to different analgesic treatments, targeting 2 main pathways involved in pain perception. DESIGN: The design is a randomized, parallel groups, open-label study. SETTING: The setting is in an operating room, postoperative recovery area, and surgical ward. PATIENTS: There are 200 patients undergoing open inguinal hernia repair (IHR) with tension-free technique (mesh repair). INTERVENTIONS: The intervention is a randomization to receive ketorolac (group K) or tramadol (group T) for 3 days after surgery. MEASUREMENTS: The measurements are differences in analgesic efficacy (numeric rating scale [NRS]) in the postoperative (up to 5 days) period, chronic pain incidence (1 and 3 months), side effects, and complications. MAIN RESULTS: We found no differences in analgesic efficacy (NRS value ≥4 in the first 96 hours: 26% in group K vs 32% in group T, P = .43); the proportion of patients with NRS ≥4 was similar in both groups, and the time trajectories were not significantly different (P for interaction = .24). Side effects were higher (12% vs 6%) in the tramadol group, although not significantly (P = .14), with a case of bleeding in the ketorolac group and higher incidence of constipation in tramadol group. One patient in each group developed chronic pain. CONCLUSIONS: Ketorolac or weak opioids are equally effective on acute pain and on persistent postsurgical pain development after IHR, and drug choice should be based on their potential side effects and patient's comorbidities. Further studies are needed to standardize the most rational approach to prevent persistent postsurgical pain after IHR. TRIAL REGISTRATION: ClinicalTrials.gov NCT01345162