Postoperative Pain Management in Neurosurgery

Postoperative pain after neurosurgical procedures presents a unique clinical challenge, owing to the need for early neurological assessment, the risk of intracranial haemorrhage and cerebral oedema, and the complexity of central and peripheral pain pathways. Acute pain following craniotomy is more prevalent and intense than was long assumed, often peaking within the first 48 hours and, in a subset of patients, progressing to chronic post-craniotomy headache. Management strategies encompass systemic opioids, non-steroidal anti-inflammatory drugs, acetaminophen and adjuncts such as gabapentinoids, balanced against concerns over sedation, respiratory depression and interference with neurological monitoring. Regional techniques, notably scalp nerve blocks, provide targeted analgesia and attenuate haemodynamic surges during noxious stimuli without compromising consciousness. A shift towards multimodal analgesia—integrating pharmacological and regional approaches—has been driven by enhanced recovery after surgery principles, aiming to reduce opioid consumption, shorten hospital stays and improve patient satisfaction. Individual risk factors, including younger age, female sex and baseline anxiety, are increasingly recognised, underscoring the need for tailored protocols and early identification of patients at risk of persistent pain.

Research from Nature Portfolio

Recent clinical work has refined the application of scalp nerve block with ropivacaine for adult craniotomy. A randomised study compared concentrations of 0.2%, 0.33% and 0.5% ropivacaine, demonstrating that the highest concentration prolonged postoperative analgesia up to four hours and more effectively blunted intraoperative blood-pressure and heart-rate responses to incision, drilling and sawing of the skull. Lower concentrations provided adequate relief for shorter intervals. These findings support the optimisation of local anaesthetic concentration in regional scalp blocks to balance duration of action, safety and haemodynamic stability, and reinforce the role of targeted regional techniques within multimodal pain regimens for neurosurgical patients.

Postoperative Pain Management in Neurosurgery publication trend

The graph below shows the total number of articles in postoperative pain management in neurosurgery across all publications each year (not limited to Nature Index journals).

Technical terms

Craniotomy: A surgical procedure involving removal of a bone flap from the skull to access the brain.

Scalp nerve block: A regional analgesic technique in which local anaesthetic is injected around sensory nerves of the scalp to provide pain relief during and after craniotomy.

Multimodal analgesia: The combination of different classes of analgesic agents and techniques to target multiple pain pathways and minimise opioid use.

Patient-controlled intravenous analgesia (PCIA): A system allowing patients to self-administer preset doses of intravenous opioids within safety limits to manage postoperative pain.

Numerical Rating Scale (NRS): A unidimensional pain assessment tool where patients rate pain intensity on a scale typically from 0 (no pain) to 10 (worst imaginable pain).

References

1. Influence of Age and Sex on Post-Craniotomy Headache. Biomedicines (2024).
2. Effect of Scalp Nerve Block with Ropivacaine on Postoperative Pain in Patients Undergoing Craniotomy: A Randomized, Double Blinded Study. Scientific Reports (2020).
3. Effect of Preoperative Anxiety on Postoperative Pain after Craniotomy. Journal of Clinical Medicine (2022).
4. Effect of scalp nerve block with ropivacaine on postoperative pain in pediatric patients undergoing craniotomy: A randomized controlled trial. Frontiers in Medicine (2022).