Introduction: Pain control after cranial surgery remains challenging for neurosurgeons. Despite its untoward effects, opioid analgesia is a mainstay of post-operative treatment. Additionally, no single intervention has resulted in a significant decrease in post-craniotomy narcotic requirement. We present the results of a pilot study utilizing a comprehensive, generalizable and multi-modal protocol focused on non-narcotic analgesia to reduce opioid utilization following all craniotomies.
Methods: We conducted a multi-cohort analysis comparing post-operative opioid utilization throughout hospitalization in patients undergoing elective, urgent and emergent craniotomies at a single institution by a single surgeon. Patients in the historical cohort (September 2017 – December 2018) utilized the traditional pain-control algorithm. A comprehensive, multi-modal protocol spanning the patient’s surgical continuum (including pre-operative counseling, total-Intravenous-anesthesia (TIVA), multimodal opioid-sparing analgesia, and early mobilization) was implemented from January 2019-December 2020). This cohort was also compared to the post-implementation cohort (January 2021-December 2023).
Results: We included 649 consecutive craniotomy patients (591-supratentorial, 58-infratentorial) for review. Indications for craniotomy spanned neuro-oncology, cerebrovascular and facial pain. There were significant decreases in post-operative opioid utilization in the post-implementation cohort versus both the implementation and historical cohorts (11.8 morphine milligram equivalents (MME) vs 41.68 MME vs 135.46 MME, respectively, p < 0.001). No post-craniotomy hemorrhage related to peri-operative NSAIDs was noted in either the implementation or post-implementation cohort. In the post-implementation cohort, 75.2% of patients did not require a single opioid following craniotomy, compared to 50.3% and 25.0% in the implementation and historical cohorts, respectively. Mean length of stay decreased from 12.61 days [95% CI 10.3, 14.92] in the historic cohort to 7.36 days [95% CI 6.41, 8.31] and 6.67 days [95% CI 5.79, 7.55] in the implementation and post-implementation cohorts, respectively.
Conclusion : Utilization of a comprehensive, generalizable and multi-modal pain protocol resulted in significant decreases in narcotic requirements in patients undergoing craniotomy without increasing the risk of post-craniotomy hemorrhage.
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