Summary Recommendations - ESRA
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New: Craniotomy

Summary Recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Craniotomy can lead to intense postoperative pain, especially in the first two days (Santos 2021; Chowdhury 2017; Vacas 2017; Vadivelu 2016). Such poorly controlled pain may aggravate neurosurgical comorbidities and increase the length of hospital stay (Galvin 2019).

The aim of this guideline (Mestdagh 2023) is to provide clinicians with an evidence-based approach to pain management after craniotomy that should improve postoperative pain relief.

The unique PROSPECT methodology is available at ­The recommendations are based on a procedure-specific systematic review of randomised controlled trials, systematic reviews and meta-analyses, in which the evidence is critically assessed for current clinical relevance, and efficacy and adverse effects of analgesic techniques. The approach balances the invasiveness of the analgesic interventions with the degree of pain after surgery and considers the use of simple, nonopioid analgesics, such as paracetamol and NSAIDs, as baseline analgesics.

The literature search period was 1 January 2010 to 30 June 2021.

Summary of recommendations and key evidence for pain management in patients undergoing craniotomy

Pharmacological treatment

Systemic analgesia should include paracetamol and NSAIDs, administered pre-operatively or intra-operatively and continued postoperatively

Intra-operative dexmedetomidine infusion is recommended, as it is associated with reduced postoperative pain

Opioids should be reserved as rescue analgesia in the postoperative period

  • Opioid-induced side effects such as nausea, vomiting and sedation are unwanted, and because opioids can interfere with early neurologic examination, they should be used as rescue analgesia in case of severe pain and not as routine analgesia (Vacas 2017)

Regional analgesic strategies

Either incision-site infiltration (ISI) or scalp nerve block (SNB) is recommended as regional analgesic technique

  • Ten RCTs demonstrated the analgesic efficacy of SNB, administered either pre-operatively or postoperatively (Yang 2019; Yang 2020; Tuchinda 2010; Raksakietisak 2018; Can 2017; Akcil 2017; Carella 2020; Hussien 2020; Rigamonti 2020; Hwang 2015). These findings are supported by previous systematic reviews and meta-analysis, with an analgesic effect in the first 6 postoperative hours and a moderate opioid-sparing effect (Galvin 2019; Hansen 2011; Wardhana 2019; Akhigbe 2017; Guilfoyle 2013)
  • The risks associated with SNB include local anaesthetic toxicity, transient facial nerve palsy and inadvertent subarachnoid injection (Vacas 2017)
  • ISI is widely used for craniotomies. Three RCTs showed positive effects on both pain scores and opioid consumption, but only one RCT used baseline analgesia (Yang 2019; Akcil 2017; Song 2015)
  • Either SNB or ISI with long-acting local anaesthetic is recommended, but ISI may have a more limited duration of analgesia than SNB, although there are not enough studies comparing the two techniques to recommend one over the other
  • Considering the lack of data on the combination of techniques and high vascularisation of the scalp, combining the two techniques is not recommended due to the risk of local anaesthetic toxicity

COX, cyclooxygenase; ISI, incision-site infiltration; NSAIDs, non-steroidal anti-inflammatory drugs; SNB, scalp nerve block.

Analgesic interventions that are not recommended for pain management in patients undergoing craniotomy.


Reason for not recommending

Flupirtine Limited procedure-specific evidence
Metamizole Lack of procedure-specific evidence
Gabapentinoids Additional benefit is questionable and concerns about side effects
Intra-operative use of magnesium sulphate Limited procedure-specific evidence
Intra-operative use of lidocaine Limited procedure-specific evidence
Postoperative subcutaneous sumatriptan Lack of procedure-specific evidence
Pre-operative vitamin D Lack of procedure-specific evidence
Bilateral maxillary block Lack of procedure-specific evidence
Superficial cervical plexus block Lack of procedure-specific evidence
Hyaluronidase as adjuvant Limited procedure-specific evidence
Dexamethasone as adjuvant Limited procedure-specific evidence
Clonidine as adjuvant Limited procedure-specific evidence
Dexmedetomidine as adjuvant Limited procedure-specific evidence

NSAIDs, non-steroidal anti-inflammatory drugs.