Neurocritical Care

, Volume 10, Issue 3, pp 387–402

The Perioperative Management of Pain from Intracranial Surgery

Review Article


Analgesic therapy following intracranial procedures remains a source of concern and controversy. Although opioids are the mainstay of the “balanced” general anesthetic techniques frequently used during intracranial procedures, neurosurgeons and others have been reluctant to administer opioid analgesics to patients following such procedures. This practice is supported by the concern that the sedation and miosis associated with opioid administration could mask the early signs of intracranial catastrophe, or even exacerbate it through decreased ventilatory drive, elevated arterial carbon dioxide levels, and increased cerebral blood flow. This reluctance to use opioids following intracranial surgery is enabled by decades of training and anecdote emphasizing that pain is minimal following these procedures. However, recent data suggests otherwise, and raises the question of how to provide safe and effective analgesia for these patients. Here, this data is reviewed along with the relevant pain pathways, analgesic drugs and techniques, and the available data on their use following intracranial surgery. Although pain following intracranial surgery appears to be more intense than initially believed, it is readily treated safely and effectively with techniques that have proven useful following other types of surgery, including patient-controlled administration of opioids. The use of multimodal analgesic therapy is emphasized not only for its effectiveness, but to reduce dosages and, therefore, side effects, primarily of the opioids, that could be of legitimate concern to physicians and affect the comfort of their patients.


Craniotomy Neurosurgery Analgesia Analgesics Opioids Acute pain 


  1. 1.
    Stoneham MD, Walters FJ. Post-operative analgesia for craniotomy patients: current attitudes among neuroanaesthetists. Eur J Anaesthesiol. 1995;12(6):571–5.PubMedGoogle Scholar
  2. 2.
    Cold GE, Felding M. Even small doses of morphine might provoke “luxury perfusion” in the postoperative period after craniotomy. Neurosurgery. 1993;32(2):327.PubMedGoogle Scholar
  3. 3.
    Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. Br J Anaesth. 2008;101(1):17–24.PubMedGoogle Scholar
  4. 4.
    Grossman SA, Sheidler VR, Swedeen K, Mucenski J, Piantadosi S. Correlation of patient and caregiver ratings of cancer pain. J Pain Symptom Manage. 1991;6(2):53–7.PubMedGoogle Scholar
  5. 5.
    Berkow LC, Erdek M, Gottschalk A, Thompson RE, White ED, Yaster M. Pain assessment in adult post-craniotomy patients: a preliminary prospective study. Anesth Analg. 2005;100:S-248.Google Scholar
  6. 6.
    Eich E, Reeves JL, Jaeger B, Graff-Radford SB. Memory for pain: relation between past and present pain intensity. Pain. 1985;23(4):375–80.PubMedGoogle Scholar
  7. 7.
    Hunter M, Philips C, Rachman S. Memory for pain. Pain. 1979;6(1):35–46.PubMedGoogle Scholar
  8. 8.
    Juhl IU, Christensen BV, Bulow HH, Wilbek H, Dreijer NC, Egelund B. Postoperative pain relief, from the patients’ and the nurses’ point of view. Acta Anaesthesiol Scand. 1993;37(4):404–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Svensson I, Sjostrom B, Haljamae H. Influence of expectations and actual pain experiences on satisfaction with postoperative pain management. Eur J Pain. 2001;5(2):125–33.PubMedGoogle Scholar
  10. 10.
    Dawson R, Spross JA, Jablonski ES, Hoyer DR, Sellers DE, Solomon MZ. Probing the paradox of patients’ satisfaction with inadequate pain management. J Pain Symptom Manage. 2002;23(3):211–20.PubMedGoogle Scholar
  11. 11.
    Durieux ME, Himmelseher S. Pain control after craniotomy: off balance on the tightrope? J Neurosurg. 2007;106:207–9.PubMedGoogle Scholar
  12. 12.
    De Benedittis G, Lorenzetti A, Migliore M, Spagnoli D, Tiberio F, Villani RM. Postoperative pain in neurosurgery: a pilot study in brain surgery. Neurosurgery. 1996;38(3):466–9.PubMedGoogle Scholar
  13. 13.
    Quiney N, Cooper R, Stoneham M, Walters F. Pain after craniotomy. A time for reappraisal? Br J Neurosurg. 1996;10(3):295–9.PubMedGoogle Scholar
  14. 14.
    Talke PO, Gelb AW. Postcraniotomy pain remains a real headache! Eur J Anaesthesiol. 2005;22:324–6.Google Scholar
  15. 15.
    de Gray LC, Matta BF. Acute and chronic pain following craniotomy: a review. Anaesthesia. 2005;60(7):693–704.PubMedGoogle Scholar
  16. 16.
    Dunbar PJ, Visco E, Lam AM. Craniotomy procedures are associated with less analgesic requirements than other surgical procedures. Anesth Analg. 1999;88(2):335–40.PubMedGoogle Scholar
  17. 17.
    Klimek M, Ubben JF, Ammann J, Borner U, Klein J, Verbrugge SJ. Pain in neurosurgically treated patients: a prospective observational study. J Neurosurg. 2006;104(3):350–9.PubMedGoogle Scholar
  18. 18.
    Gottschalk A, Berkow LC, Stevens RD, et al. A prospective evaluation of pain and analgesic use following major elective intra-cranial surgery. J Neurosurg. 2007;106:210–6.PubMedGoogle Scholar
  19. 19.
    Thibault M, Girard F, Moumdjian R, Chouinard P, Boudreault D, Ruel M. Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study. Can J Anaesth. 2007;54(7):544–8.PubMedGoogle Scholar
  20. 20.
    Irefin SA, Schubert A, Bloomfield EL, DeBoer GE, Mascha EJ, Ebrahim ZY. The effect of craniotomy location on postoperative pain and nausea. J Anesth. 2003;17(4):227–31.PubMedGoogle Scholar
  21. 21.
    Koperer H, Deinsberger W, Jodicke A, Boker DK. Postoperative headache after the lateral suboccipital approach: craniotomy versus craniectomy. Minim Invasive Neurosurg. 1999;42(4):175–8.PubMedGoogle Scholar
  22. 22.
    Schessel DA, Nedzelski JM, Rowed D, Feghali JG. Pain after surgery for acoustic neuroma. Otolaryngol Head Neck Surg. 1992;107(3):424–9.PubMedGoogle Scholar
  23. 23.
    Nguyen A, Girard F, Boudreault D, et al. Scalp nerve blocks decrease the severity of pain after craniotomy. Anesth Analg. 2001;93(5):1272–6.PubMedGoogle Scholar
  24. 24.
    Bloomfield EL, Schubert A, Secic M, Barnett G, Shutway F, Ebrahim ZY. The influence of scalp infiltration with bupivacaine on hemodynamics and postoperative pain in adult patients undergoing craniotomy. Anesth Analg. 1998;87(3):579–82.PubMedGoogle Scholar
  25. 25.
    Leslie K, Troedel S, Irwin K, et al. Quality of recovery from anesthesia in neurosurgical patients. Anesthesiology. 2003;99(5):1158–65.PubMedGoogle Scholar
  26. 26.
    Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000;93(4):1123–33.PubMedGoogle Scholar
  27. 27.
    Kaur A, Selwa L, Fromes G, Ross DA. Persistent headache after supratentorial craniotomy. Neurosurgery. 2000;47(3):633–6.PubMedGoogle Scholar
  28. 28.
    Hanson MB, Glasscock MEIII, Brandes JL, Jackson CG. Medical treatment of headache after suboccipital acoustic tumor removal. Laryngoscope. 1998;108(8 Pt 1):1111–4.PubMedGoogle Scholar
  29. 29.
    Ryzenman JM, Pensak ML, Tew JM Jr. Headache: a quality of life analysis in a cohort of 1,657 patients undergoing acoustic neuroma surgery, results from the acoustic neuroma association. Laryngoscope. 2005;115(4):703–11.PubMedGoogle Scholar
  30. 30.
    Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg. 2005;100(3):757–73.PubMedGoogle Scholar
  31. 31.
    Gray’s Anatomy. 37th ed. Edinburgh: Churchill Livingstone; 1989. p. 1129.Google Scholar
  32. 32.
    Feindel W, Penfield W, McNaughton F. The tentorial nerves and localization of intracranial pain in man. Neurology. 1960;10:555–63.PubMedGoogle Scholar
  33. 33.
    Cavallotti D, Artico M, De SS, Iannetti G, Cavallotti C. Catecholaminergic innervation of the human dura mater involved in headache. Headache. 1998;38(5):352–5.PubMedGoogle Scholar
  34. 34.
    Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618–25.PubMedGoogle Scholar
  35. 35.
    Swenson JD, Davis JJ, Johnson KB. Postoperative care of the chronic opioid-consuming patient. Anesthesiol Clin North America. 2005;23(1):37–48.PubMedGoogle Scholar
  36. 36.
    Roberts GC. Post-craniotomy analgesia: current practices in British neurosurgical centres—a survey of post-craniotomy analgesic practices. Eur J Anaesthesiol. 2005;22(5):328–32.PubMedGoogle Scholar
  37. 37.
    Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104(3):570–87.PubMedGoogle Scholar
  38. 38.
    Celerier E, Rivat C, Jun Y, et al. Long-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology. 2000;92(2):465–72.PubMedGoogle Scholar
  39. 39.
    Van Elstraete AC, Sitbon P, Mazoit JX, Benhamou D. Gabapentin prevents delayed and long-lasting hyperalgesia induced by fentanyl in rats. Anesthesiology. 2008;108(3):484–94.PubMedGoogle Scholar
  40. 40.
    Gelb AW, Salevsky F, Chung F, et al. Remifentanil with morphine transitional analgesia shortens neurological recovery compared to fentanyl for supratentorial craniotomy. Can J Anaesth. 2003;50(9):946–52.PubMedGoogle Scholar
  41. 41.
    Guy J, Hindman BJ, Baker KZ, et al. Comparison of remifentanil and fentanyl in patients undergoing craniotomy for supratentorial space-occupying lesions. Anesthesiology. 1997;86(3):514–24.PubMedGoogle Scholar
  42. 42.
    Gerlach K, Uhlig T, Huppe M, et al. Remifentanil-propofol versus sufentanil-propofol anaesthesia for supratentorial craniotomy: a randomized trial. Eur J Anaesthesiol. 2003;20(10):813–20.PubMedGoogle Scholar
  43. 43.
    Hopf HW. Is it time to retire high-concentration nitrous oxide? Anesthesiology. 2007;107(2):200–1.PubMedGoogle Scholar
  44. 44.
    Mathews DM, Gaba V, Zaku B, Neuman GG. Can remifentanil replace nitrous oxide during anesthesia for ambulatory orthopedic surgery with desflurane and fentanyl? Anesth Analg. 2008;106(1):101–8.PubMedGoogle Scholar
  45. 45.
    Petersen-Felix S, Luginbuhl M, Schnider TW, Curatolo M, Rendt-Nielsen L, Zbinden AM. Comparison of the analgesic potency of xenon and nitrous oxide in humans evaluated by experimental pain. Br J Anaesth. 1998;81(5):742–7.PubMedGoogle Scholar
  46. 46.
    Georgiev SK, Kohno T, Ikoma M, Yamakura T, Baba H. Nitrous oxide inhibits glutamatergic transmission in spinal dorsal horn neurons. Pain. 2008;134(1–2):24–31.PubMedGoogle Scholar
  47. 47.
    Cormack JR, Orme RM, Costello TG. The role of alpha2-agonists in neurosurgery. J Clin Neurosci. 2005;12(4):375–8.PubMedGoogle Scholar
  48. 48.
    Gurbet A, Basagan-Mogol E, Turker G, Ugun F, Kaya FN, Ozcan B. Intraoperative infusion of dexmedetomidine reduces perioperative analgesic requirements. Can J Anaesth. 2006;53(7):646–52.PubMedGoogle Scholar
  49. 49.
    Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350(24):2441–51.PubMedGoogle Scholar
  50. 50.
    Yaksh TL, Dirig DM, Conway CM, Svensson C, Luo ZD, Isakson PC. The acute antihyperalgesic action of nonsteroidal, anti-inflammatory drugs and release of spinal prostaglandin E2 is mediated by the inhibition of constitutive spinal cyclooxygenase-2 (COX-2) but not COX-1. J Neurosci. 2001;21(16):5847–53.PubMedGoogle Scholar
  51. 51.
    Harner SG, Beatty CW, Ebersold MJ. Impact of cranioplasty on headache after acoustic neuroma removal. Neurosurgery. 1995;36(6):1097–9.PubMedGoogle Scholar
  52. 52.
    Ruckenstein MJ, Harris JP, Cueva RA, Prioleau G, Alksne J. Pain subsequent to resection of acoustic neuromas via suboccipital and translabyrinthine approaches. Am J Otol. 1996;17(4):620–4.PubMedGoogle Scholar
  53. 53.
    van Leeuwen JP, Braspenning JC, Meijer H, Cremers CW. Quality of life after acoustic neuroma surgery. Ann Otol Rhinol Laryngol. 1996;105(6):423–30.PubMedGoogle Scholar
  54. 54.
    Gottschalk A, Ochroch EA. Is preemptive analgesia clinically effective? In: Fleisher L, editor. Evidence-based practice of anesthesia. Philadelphia: Saunders; 2008.Google Scholar
  55. 55.
    Kelly DJ, Ahmad M, Brull SJ. Preemptive analgesia II: recent advances and current trends [L’analgesie preventive II : progres recents et nouvelle orientation]. Can J Anaesth. 2001;48(11):1091–101.PubMedGoogle Scholar
  56. 56.
    Kelly DJ, Ahmad M, Brull SJ. Preemptive analgesia I: physiological pathways and pharmacological modalities. Can J Anaesth. 2001;48(10):1000–10.PubMedCrossRefGoogle Scholar
  57. 57.
    Abram SE, Yaksh TL. Morphine, but not inhalation anesthesia, blocks post-injury facilitation. The role of preemptive suppression of afferent transmission. Anesthesiology. 1993;78(4):713–21.PubMedGoogle Scholar
  58. 58.
    Yaster M. Non-steroidal antiinflammatory drugs. In: Yaster M, Krane EJ, Kaplan RF, Cote CJ, Lappe DG, editors. Pediatric pain management and sedation handbook. St. Louis: Mosby Year Book, Inc; 1997. p. 19–28.Google Scholar
  59. 59.
    Murat I, Baujard C, Foussat C, et al. Tolerance and analgesic efficacy of a new i.v. paracetamol solution in children after inguinal hernia repair. Paediatr Anaesth. 2005;15(8):663–70.PubMedGoogle Scholar
  60. 60.
    Cashman JN. The mechanisms of action of NSAIDs in analgesia. Drugs. 1996;52 Suppl 5:13–23.PubMedCrossRefGoogle Scholar
  61. 61.
    Vane JR, Botting RM. Mechanism of action of aspirin-like drugs. Semin Arthritis Rheum. 1997;26(6 Suppl 1):2–10.PubMedGoogle Scholar
  62. 62.
    Vane JR, Botting RM. Mechanism of action of nonsteroidal anti-inflammatory drugs. Am J Med. 1998;104(3A):2S–8S. discussion 21S–2.PubMedGoogle Scholar
  63. 63.
    Jouzeau JY, Terlain B, Abid A, Nedelec E, Netter P. Cyclo-oxygenase isoenzymes. How recent findings affect thinking about nonsteroidal anti-inflammatory drugs. Drugs. 1997;53(4):563–82.PubMedGoogle Scholar
  64. 64.
    Vane JR, Bakhle YS, Botting RM. Cyclooxygenases 1 and 2. Annu Rev Pharmacol Toxicol. 1998;38:97–120.PubMedGoogle Scholar
  65. 65.
    Levesque LE, Brophy JM, Zhang B. The risk for myocardial infarction with cyclooxygenase-2 inhibitors: a population study of elderly adults. Ann Intern Med. 2005;142(7):481–9.PubMedGoogle Scholar
  66. 66.
    Johnsen SP, Larsson H, Tarone RE, et al. Risk of hospitalization for myocardial infarction among users of rofecoxib, celecoxib, and other NSAIDs: a population-based case-control study. Arch Intern Med. 2005;165(9):978–84.PubMedGoogle Scholar
  67. 67.
    Snyder SH, Pasternak GW. Historical review: opioid receptors. Trends Pharmacol Sci. 2003;24(4):198–205.PubMedGoogle Scholar
  68. 68.
    Standifer KM, Pasternak GW. G proteins and opioid receptor-mediated signalling. Cell Signal. 1997;9(3–4):237–48.PubMedGoogle Scholar
  69. 69.
    Radnay PA, Duncalf D, Novakovic M, Lesser ML. Common bile duct pressure changes after fentanyl, morphine, meperidine, butorphanol, and naloxone. Anesth Analg. 1984;63(4):441–4.PubMedGoogle Scholar
  70. 70.
    Krane EJ, Yaster M, Yaster M. Transition to less invasive therapy. In: Yaster M, Krane EJ, Kaplan RF, Cote CJ, Lappe DG, editors. Pediatric pain management and sedation handbook. St. Louis: Mosby Year Book, Inc; 1997. p. 147–62.Google Scholar
  71. 71.
    Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic misadventures with acetaminophen: hepatoxicity after multiple doses in children [see comments]. J Pediatr. 1998;132(1):22–7.PubMedGoogle Scholar
  72. 72.
    Gilron I. Gabapentin and pregabalin for chronic neuropathic and early postsurgical pain: current evidence and future directions. Curr Opin Anaesthesiol. 2007;20(5):456–72.PubMedGoogle Scholar
  73. 73.
    Pertovaara A. Antinociception induced by alpha-2-adrenoceptor agonists, with special emphasis on medetomidine studies. Prog Neurobiol. 1993;40(6):691–709.PubMedGoogle Scholar
  74. 74.
    Boyd RE. Alpha2-adrenergic receptor agonists as analgesics. Curr Top Med Chem. 2001;1(3):193–7.PubMedGoogle Scholar
  75. 75.
    Himmelseher S, Durieux ME. Ketamine for perioperative pain management. Anesthesiology. 2005;102(1):211–20.PubMedGoogle Scholar
  76. 76.
    Siu A, Drachtman R. Dextromethorphan: a review of N-methyl-d-aspartate receptor antagonist in the management of pain. CNS Drug Rev. 2007;13(1):96–106.PubMedGoogle Scholar
  77. 77.
    Minto CF, Power I. New opioid analgesics: an update. Int Anesthesiol Clin. 1997;35(2):49–65.PubMedGoogle Scholar
  78. 78.
    Raffa RB. A novel approach to the pharmacology of analgesics. Am J Med. 1996;101(1A):40S–46S.Google Scholar
  79. 79.
    Raffa RB, Friderichs E, Reimann W, et al. Complementary and synergistic antinociceptive interaction between the enantiomers of tramadol. J Pharmacol Exp Ther. 1993;267(1):331–40.PubMedGoogle Scholar
  80. 80.
    Desmeules JA, Piguet V, Collart L, Dayer P. Contribution of monoaminergic modulation to the analgesic effect of tramadol. Br J Clin Pharmacol. 1996;41(1):7–12.PubMedGoogle Scholar
  81. 81.
    Naguib M, Seraj M, Attia M, Samarkandi AH, Seet M, Jaroudi R. Perioperative antinociceptive effects of tramadol. A prospective, randomized, double-blind comparison with morphine. Can J Anaesth. 1998;45(12):1168–75.PubMedGoogle Scholar
  82. 82.
    Bozkurt P. Use of tramadol in children. Paediatr Anaesth. 2005;15(12):1041–7.PubMedGoogle Scholar
  83. 83.
    Gunes Y, Gunduz M, Unlugenc H, Ozalevli M, Ozcengiz D. Comparison of caudal vs intravenous tramadol administered either preoperatively or postoperatively for pain relief in boys. Paediatr Anaesth. 2004;14(4):324–8.PubMedGoogle Scholar
  84. 84.
    Yaster M, Kost-Byerly S, Maxwell LG. Opiod agonists and antagonists. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Philadelphia: Lippincott Williams and Wilkins; 2003. p. 181–224.Google Scholar
  85. 85.
    Fallon MT, Hanks GW. Morphine, constipation and performance status in advanced cancer patients. Palliat Med. 1999;13(2):159–60.PubMedGoogle Scholar
  86. 86.
    Glare P, Lickiss JN. Unrecognized constipation in patients with advanced cancer: a recipe for therapeutic disaster. J Pain Symptom Manage. 1992;7(6):369–71.PubMedGoogle Scholar
  87. 87.
    Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology treatment, and prevention. Anesthesiology. 1992;77(1):162–84.PubMedGoogle Scholar
  88. 88.
    Gan TJ, Ginsberg B, Glass PS, Fortney J, Jhaveri R, Perno R. Opioid-sparing effects of a low-dose infusion of naloxone in patient-administered morphine sulfate. Anesthesiology. 1997;87(5):1075–81.PubMedGoogle Scholar
  89. 89.
    Maxwell LG, Kaufmann SC, Bitzer S, et al. The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia: a double-blind, prospective, randomized, controlled study. Anesth Analg. 2005;100(4):953–8.PubMedGoogle Scholar
  90. 90.
    Maxwell LG, Yaster M. Perioperative management issues in pediatric patients. Anesthesiol Clin North America. 2000;18(3):601–32.PubMedGoogle Scholar
  91. 91.
    American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793–7.Google Scholar
  92. 92.
    McGrath PA. An assessment of children’s pain: a review of behavioral, physiological and direct scaling techniques. Pain. 1987;31(2):147–76.PubMedGoogle Scholar
  93. 93.
    Monitto CL, Greenberg RS, Kost-Byerly S, et al. The safety and efficacy of parent-/nurse-controlled analgesia in patients less than six years of age. Anesth Analg. 2000;91(3):573–9.PubMedGoogle Scholar
  94. 94.
    Murdoch J, Larsen D. Assessing pain in cognitively impaired older adults. Nurs Stand. 2004;18(38):33–9.PubMedGoogle Scholar
  95. 95.
    Li SF, Greenwald PW, Gennis P, Bijur PE, Gallagher EJ. Effect of age on acute pain perception of a standardized stimulus in the emergency department. Ann Emerg Med. 2001;38(6):644–7.PubMedGoogle Scholar
  96. 96.
    Gagliese L, Katz J. Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain. 2003;103(1–2):11–20.PubMedGoogle Scholar
  97. 97.
    Bryson GL, Wyand A. Evidence-based clinical update: general anesthesia and the risk of delirium and postoperative cognitive dysfunction. Can J Anaesth. 2006;53(7):669–77.PubMedGoogle Scholar
  98. 98.
    Gaudreau JD, Gagnon P. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3):471–5.PubMedGoogle Scholar
  99. 99.
    Brown TM. Drug-induced delirium. Semin Clin Neuropsychiatry. 2000;5(2):113–24.PubMedGoogle Scholar
  100. 100.
    ElDesoky ES. Pharmacokinetic-pharmacodynamic crisis in the elderly. Am J Ther. 2007;14(5):488–98.PubMedGoogle Scholar
  101. 101.
    Dimsdale JE, Norman D, DeJardin D, Wallace MS. The effect of opioids on sleep architecture. J Clin Sleep Med. 2007;3(1):33–6.PubMedGoogle Scholar
  102. 102.
    Shaw IR, Lavigne G, Mayer P, Choiniere M. Acute intravenous administration of morphine perturbs sleep architecture in healthy pain-free young adults: a preliminary study. Sleep. 2005;28(6):677–82.PubMedGoogle Scholar
  103. 103.
    Knill RL, Moote CA, Skinner MI, Rose EA. Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week. Anesthesiology. 1990;73(1):52–61.PubMedCrossRefGoogle Scholar
  104. 104.
    Friese RS, Az-Arrastia R, McBride D, Frankel H, Gentilello LM. Quantity and quality of sleep in the surgical intensive care unit: are our patients sleeping? J Trauma. 2007;63(6):1210–4.PubMedGoogle Scholar
  105. 105.
    Onen SH, Onen F, Courpron P, Dubray C. How pain and analgesics disturb sleep. Clin J Pain. 2005;21(5):422–31.PubMedGoogle Scholar
  106. 106.
    Verchere E, Grenier B, Mesli A, Siao D, Sesay M, Maurette P. Postoperative pain management after supratentorial craniotomy. J Neurosurg Anesthesiol. 2002;14(2):96–101.PubMedGoogle Scholar
  107. 107.
    Goldsack C, Scuplak SM, Smith M. A double-blind comparison of codeine and morphine for postoperative analgesia following intracranial surgery. Anaesthesia. 1996;51(11):1029–32.PubMedGoogle Scholar
  108. 108.
    Stoneham MD, Cooper R, Quiney NF, Walters FJ. Pain following craniotomy: a preliminary study comparing PCA morphine with intramuscular codeine phosphate. Anaesthesia. 1996;51(12):1176–8.PubMedGoogle Scholar
  109. 109.
    Jeffrey HM, Charlton P, Mellor DJ, Moss E, Vucevic M. Analgesia after intracranial surgery: a double-blind, prospective comparison of codeine and tramadol. Br J Anaesth. 1999;83(2):245–9.PubMedGoogle Scholar
  110. 110.
    Tanskanen P, Kytta J, Randell T. Patient-controlled analgesia with oxycodone in the treatment of postcraniotomy pain. Acta Anaesthesiol Scand. 1999;43(1):42–5.PubMedGoogle Scholar
  111. 111.
    Morad A, Winters BD, Yaster M, et al. Intravenous patient controlled analgesia safely and effectively treats pain after supratentorial intracranial surgery: a prospective randomized controlled trial. J Neurosurg. 2008; Accepted for publication.Google Scholar
  112. 112.
    Mathiesen O, Moiniche S, Dahl JB. Gabapentin and postoperative pain: a qualitative and quantitative systematic review, with focus on procedure. BMC Anesthesiol. 2007;7:6.PubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2008

Authors and Affiliations

  1. 1.Department of Anesthesiology and Critical Care Medicine, Johns Hopkins HospitalThe Johns Hopkins Medical InstitutionsBaltimoreUSA

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