Postoperative pain

Postoperative pain

Perioperative pain assessment and management in neurosurgical patients varies widely across the globe. There is lack of data from developing world regarding practices of pain assessment and management in neurosurgical population.

A survey aimed to capture practices and perceptions regarding perioperative pain assessment and management in neurosurgical patients among anesthesiologists who are members of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) and evaluated if hospital and pain characteristics predicted the use of structured pain assessment protocol and use of opioids for postoperative pain management.

A 26-item English language questionnaire was administered to members of ISNACC using Kwiksurveys platform after ethics committee approval. This outcome measures were adoption of structured protocol for pain assessment and opioid usage for postoperative pain management.

The response rate for this survey was 55.15% (289/524). One hundred eighteen (41%) responders informed that their hospital setup had a structured pain protocol while 43 (15%) responders reported using opioids for postoperative pain management. Predictors of the use of structured pain protocol were private setup (odds ratio [OR] 2.64; 95% confidence interval [CI] 1.52-4.59; p=0.001), higher pain intensity (OR 0.37; 95% CI 0.21-0.64; p<0.001) and use of pain scale (OR 7.94; 95% CI 3.99-15.81; p<0.001) while availability of structured pain protocol (OR 2.04; 95% CI 1.02-4.05; p=0.043) was the only significant variable for postoperative opioid use.

Less than half of the Indian neuroanesthesiologists who are members of ISNACC use structured protocol for pain assessment and very few use opioids for postoperative pain management in neurosurgical patients 1).

Studying the characteristics of postoperative pain at such an early stage allows for improved management. It helps to predict, according to the type of surgery and the anaesthesia used, those patients in which higher VAS values may be seen and to better adapt analgesic therapy 2).

Despite advances in surgical and anesthesiology techniques, many patients continue to experience postoperative pain after lumbar disc operations

The administration of tramadol with paracetamol was more effective than tramadol alone for early acute postoperative pain therapy following lumbar discectomy. Therefore while adding paracetamol in early pain management is recommended, continuing paracetamol for the late postoperative period is not advised 3).


Epidural fibrosis and epidural adhesion after laminectomy are developed from adjacent dense scar tissue, which is a natural wound healing process 4) 5) 6) 7) , and ranked as the major contributor for postoperative pain recurrence after laminectomy or discectomy.


The goal of postoperative pain management is to relieve pain while keeping side effects to a minimum. After hundreds of years of advances, the mainstay of pain therapy is still the opioids. While they are very effective analgesics, opioids also carry with them many undesirable side effects: sedation, respiratory depression, nausea and vomiting, hypotension and bradycardia, pruritus, and inhibition of bowel function. The treatment of complications such as nausea and pruritus may include the administration of antihistamines, which have an additive effect on sedation and respiratory depression.



Sriganesh K, Bidkar PU, Krishnakumar M, Singh GP, Hrishi AP, Jangra K. Perioperative Analgesia In Neurosurgery (PAIN): A national survey of pain assessment and management among neuroanesthesiologists of India. Int J Clin Pract. 2020 Sep 23:e13718. doi: 10.1111/ijcp.13718. Epub ahead of print. PMID: 32966673.

Cabedo N, Valero R, Alcón A, Gomar C. Prevalence and characterization of postoperative pain in the Postanaesthesia Care Unit. Rev Esp Anestesiol Reanim. 2017 Mar 28. pii: S0034-9356(16)30211-0. doi: 10.1016/j.redar.2016.11.006. [Epub ahead of print] English, Spanish. PubMed PMID: 28363327.

Uztüre N, Türe H, Keskin Ö, Atalay B, Köner Ö. Comparison of Tramadol versus Tramadol with Paracetamol for efficacy of postoperative pain management in lumbar discectomy: a randomized controlled study. Int J Clin Pract. 2019 Sep 11. doi: 10.1111/ijcp.13414. [Epub ahead of print] PubMed PMID: 31508863.

Alkalay RN, Kim DH, Urry DW, Xu J, Parker TM, Glazer PA. Prevention of postlaminectomy epidural fibrosis using bioelastic materials. Spine (Phila Pa 1976) 2003;28:1659–1665.

Hsu CJ, Chou WY, Teng HP, Chang WN, Chou YJ. Coralline hydroxyapatite and laminectomy-derived bone as adjuvant graft material for lumbar posterolateral fusion. J Neurosurg Spine. 2005;3:271–275.

Temel SG, Ozturk C, Temiz A, Ersozlu S, Aydinli U. A new material for prevention of epidural fibrosis after laminectomy: oxidized regenerated cellulose (interceed), an absorbable barrier. J Spinal Disord Tech. 2006;19:270–275.

Yu CH, Lee JH, Baek HR, Nam H. The effectiveness of poloxamer 407-based new anti-adhesive material in a laminectomy model in rats. Eur Spine J. 2012;21:971–979.

Update: Postoperative hemorrhage after anterior cervical discectomy and fusion

Postoperative hemorrhage after anterior cervical discectomy and fusion

Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain
Surgeons need to be alert for this complication and try their best to prevent it 1) 2) 3) 4), because it is one of the most catastrophic complications of anterior cervical discectomy and fusion(ACDF), which may result in dyspnea, respiratory arrest, and death 5) 6) 7) 8) 9) 10).


see also Anterior cervical discectomy and fusion complications.
The reported incidence of this postoperative complication has varied from 0.2% to 1.9% 11).
Fountas et al. reported that postoperative hematoma occurred in 5.6% patients who underwent ACDF, 2.4% of whom required reoperation 12).
However, Aono et al.reported an incidence of 0.21% 13).
Case reports of life-threatening circumstances and critical patients who required tracheotomy and reoperation have also been published 14) 15) 16).


Neck swelling and progressive respiratory disturbance have become important, as proposed in the guidelines by Palumbo et al 17).
The results of the study of Kogure et al. indicated that indwelling drains are not necessary in patients who undergo one-level anterior cervical fixation surgery, and that observation of the prevertebral space (PVS) on simple cervical spine radiographs is the simplest and most useful method to determine any complications 18).

Basques et al. 19) measured the amount of drainage. Only a few reports have mentioned the drainage status, even in case reports of postoperative hematomas. Furthermore, one report documented the absence of drainage 20).

Bleeding point

In the early postoperative period, when bleeding from the superior thyroid artery was excluded, the point of bleeding during the time of reoperation has been unclear in many cases 21).


Application of Floseal at the end, can significantly reduce the amount of postoperative hemorrhage 22) 23).

1) Yeom JS, Buchowski JM, Shen HX, Liu G, Bunmaprasert T, Riew KD. Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine (Phila Pa 1976) 2008;33:E543–E547.
2) Cho SK, Yi JS, Park MS, et al. Hemostatic techniques reduce hospital stay following multilevel posterior cervical spine surgery. J Bone Joint Surg Am. 2012;94:1952–1958.
3) Tsutsumimoto T, Shimogata M, Ohta H, Yui M, Yoda I, Misawa H. Tranexamic acid reduces perioperative blood loss in cervical laminoplasty: a prospective randomized study. Spine (Phila Pa 1976) 2011;36:1913–1918.
4) Schubert M, Merk S. Retrospective evaluation of efficiency and safety of an anterior percutaneous approach for cervical discectomy. Asian Spine J. 2014;8:412–420.
5) Sagi HC, Beutler W, Carroll E, Connolly PJ. Airway complications associated with surgery on the anterior cervical spine. Spine (Phila Pa 1976) 2002;27:949–953.
6) , 11) , 17) Palumbo MA, Aidlen JP, Daniels AH, Thakur NA, Caiati J. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J. 2012;6:108–113.
7) Dagli M, Er U, Simsek S, Bavbek M. Late results of anterior cervical discectomy and fusion with interbody cages. Asian Spine J. 2013;7:34–38.
8) Pallud J, Belaid H, Aldea S. Successfull management of a life threatening cerebellar haemorrhage following spine surgery: a case report. Asian Spine J. 2009;3:32–34.
9) Song KJ, Choi BY. Current concepts of anterior cervical discectomy and fusion: a review of literature. Asian Spine J. 2014;8:531–539.
10) Buerba RA, Giles E, Webb ML, Fu MC, Gvozdyev B, Grauer JN. Increased risk of complications after anterior cervical discectomy and fusion in the elderly: an analysis of 6253 patients in the American College of Surgeons National Surgical Quality Improvement Program database. Spine (Phila Pa 1976) 2014;39:2062–2069.
12) Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007 Oct 1;32(21):2310-7. Review. PubMed PMID: 17906571.
13) Aono H, Ohwada T, Hosono N, Tobimatsu H, Ariga K, Fuji T, Iwasaki M. Incidence of postoperative symptomatic epidural hematoma in spinal decompression surgery. J Neurosurg Spine. 2011 Aug;15(2):202-5. doi: 10.3171/2011.3.SPINE10716. Epub 2011 May 6. PubMed PMID: 21529204.
14) , 20) Yu NH, Jahng TA, Kim CH, Chung CK: Life-threatening late hemorrhage due to superior thyroid artery dissection after anterior cervical discectomy and fusion. Spine (Phila Pa 1976) 2010; 35: E739―E742.
15) Skovrlj B, Mascitelli JR, Camins MB, Doshi AH, Qureshi SA: Acute respiratory failure from Surgifoam expansion after anterior cervical surgery: case report. J Neurosurg Spine 2013; 19: 428―430.
16) Dedouit F, Grill S, Guilbeau-Frugier C, Savall F, Rougé D, Telmon N: Retropharyngeal hematoma secondary to cer- vical spine surgery: report of one fatal case. J Forensic Sci 2014; 59: 1427―1431.
18) , 21) Kogure K, Node Y, Tamaki T, Yamazaki M, Takumi I, Morita A. Indwelling Drains Are Not Necessary for Patients Undergoing One-level Anterior Cervical Fixation Surgery. J Nippon Med Sch. 2015;82(3):124-9. doi: 10.1272/jnms.82.124. PubMed PMID: 26156665.
19) Basques BA, Bohl DD, Golinvaux NS, Yacob A, Varthi AG, Grauer JN: Factors predictive of increased surgical drain output after anteriorcervical discectomy and fusion. Spine (Phila Pa 1976) 2014; 39: 728―735.
22) Yeom JS, Buchowski JM, Shen HX, Liu G, Bunmaprasert T, Riew KD. Effect of fibrin sealant on drain output and duration of hospitalization after multilevel anterior cervical fusion: a retrospective matched pair analysis. Spine (Phila Pa 1976). 2008 Jul 15;33(16):E543-7. doi: 10.1097/BRS.0b013e31817c6c9b. PubMed PMID: 18628695.
23) Li QY, Lee O, Han HS, Kim GU, Lee CK, Kang SS, Lee MH, Cho HG, Kim HJ, Yeom JS. Efficacy of a Topical Gelatin-Thrombin Matrix Sealant in Reducing Postoperative Drainage Following Anterior Cervical Discectomy and Fusion. Asian Spine J. 2015 Dec;9(6):909-15. doi: 10.4184/asj.2015.9.6.909. Epub 2015 Dec 8. PubMed PMID: 26713124; PubMed Central PMCID: PMC4686397.

Update: Delayed postoperative spinal epidural hematoma

Delayed postoperative spinal epidural hematoma

J. Sales-Llopis
Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain
Uribe et al. defined delayed postoperative spinal epidural hematoma as an occurrence more than three days after operation 1).
Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves 2).


Awad et al. 3) divided potential risk factors into two categories, preoperative and intraoperative factors. Significant preoperative risk factors included nonsteroidal antiinflammatory drug use and patient age more than 60 years; significant intraoperative risk factors included multiple-level operation, anemia, and large blood loss. Sokolowski et al. 4) reported that age greater than 60 years, multilevel procedures, and preoperative international normalized ratio (INR) correlated with postoperative hematoma volumes.
Parthibian and Majeed described a case which developed following an episode of violent twisting movement 5).

Clinical features

Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 6).
Only one rare case of delayed onset of epidural hematoma after lumbar spine surgery whose only presenting symptom was vesicorectal disturbance is reported by Kamoda et al. 7).


Surgical evacuation if symptomatic.
The administration of prothrombin complex concentrate (PCC) facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation 8).

Case series


Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 9).


Uribe et al. report a series of delayed epidural hematomas in a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after their index procedure.
They reviewed the database of six spine surgeons over a 4-year period, looking for presence of epidural hematomas as a cause of clinical deterioration after an asymptomatic postoperative period of at least 3 days, and identified a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after spinal surgery.
Of 4,018 patients, they identified seven with spinal epidural hematoma who presented more than 3 days after their index procedure. The initial presenting symptom, which heralded the subsequent onset of neurological deterioration, consisted of severe sharp pain with radiation to the extremities. The average time to neurological deterioration was 5.3 days. Fifty-seven percent of the patients had multiple previous spinal surgeries at the site of the epidural hematoma. Surgical evacuation of the epidural hematomas resulted in neurological improvement in five patients. Persistent neurological deficits were observed in two patients.
Delayed spinal epidural hematomas are an uncommon cause of delayed deterioration after spinal surgery. Previous surgery with attendant scarring that results in impairment of clot resorption may be a contributing factor in the development of the condition 10).

Case reports


A 64-year-old woman underwent an uneventful total knee arthroplasty operation under a spinal anesthetic. A lumbar puncture was performed in the L2-L3 interspace, that was atraumatic and successful on the first attempt. The operation was uneventful. On the third postoperative day, the patient developed a SEH that expanded from C2 to T3 levels. She was presented with bilateral shoulder pain, muscle weakness of the upper extremities with normal sensation, followed by paraparesis. The magnetic resonance imaging (MRI) revealed a large vascular malformation, partially ruptured forming a hematoma compressing the spinal cord toward the vertebral bodies The patient was treated conservatively and full recovery was achieved 11).

An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered 12).


A rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered 13).


Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesia 14).


A patient 9 days after he underwent laminoplasty. The authors draw attention to the possibility of delayed PSEH and its triggering mechanism. In this case, a 59-year-old man with no history of bleeding disorder underwent cervical laminoplasty for mild myelopathy. On the 7th postoperative day computed tomography demonstrated no abnormal findings in the operative field. On the 9th postoperative day, while straining to defecate, the patient suddenly felt neck and shoulder pain, and tetraplegia rapidly developed. Magnetic resonance imaging demonstrated a huge epidural hematoma. The clot was evacuated during emergency revision surgery, during which the arterial bleeding from a split muscle wall was confirmed. The postoperative course after the revision surgery was uneventful and the patient had none of the previous symptoms 1 year later. A PSEH causing paralysis can occur even more than a week after surgery. The possibility of a delayed-onset PSEH should be kept in mind, and prompt diagnosis should be made when a patient presents with paresis or paralysis after an operation. The authors recommend advising patients that for a while after surgery they avoid strenuous activity 15)


Treatment of thromboembolic disease in the postoperative lumbar spine patient is controversial. This case report describes an epidural hematoma with neurologic sequelae in an elderly patient who received intravenous heparin therapy over 2 weeks after lumbar decompression 16)
1) , 10) Uribe J, Moza K, Jimenez O, Green B, Levi AD. Delayed postoperative spinal epidural hematomas. Spine J. 2003 Mar-Apr;3(2):125-9. PubMed PMID: 14589226.
2) , 7) , 13) Kamoda H, Ishikawa T, Miyagi M, Eguchi Y, Orita S, Suzuki M, Sakuma Y, Oikawa Y, Yamauchi K, Inoue G, Takahashi K, Ohtori S. Delayed postoperative epidural hematoma presenting only with vesicorectal disturbance. Case Rep Orthop. 2013;2013:861961. doi: 10.1155/2013/861961. Epub 2013 Sep 1. PubMed PMID: 24073350; PubMed Central PMCID: PMC3773434.
3) Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. Journal of Bone and Joint Surgery B. 2005;87(9):1248–1252.
4) Sokolowski MJ, Garvey TA, Perl J, et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine. 2008;33(1):108–113.
5) Parthiban CJ, Majeed SA. Delayed spinal extradural hematoma following thoracic spine surgery and resulting in paraplegia: a case report. Journal of Medical Case Reports. 2008;2, article 141
6) , 9) Sokolowski MJ, Dolan M, Aminian A, Haak MH, Schafer MF. Delayed epidural hematoma after spinal surgery: a report of 4 cases. Journal of Spinal Disorders and Techniques. 2006;19(8):603–606.
8) Beynon C, Potzy A, Unterberg AW, Sakowitz OW. Prothrombin complex concentrate facilitates emergency spinal surgery in anticoagulated patients. Acta Neurochir (Wien). 2014 Apr;156(4):741-7. doi: 10.1007/s00701-014-2032-x. Epub 2014 Feb 26. PubMed PMID: 24570188.
11) Makris A, Gkliatis E, Diakomi M, Karmaniolou I, Mela A. Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site. Spinal Cord. 2014 Jun;52 Suppl 1:S14-6. doi: 10.1038/sc.2013.174. Epub 2014 Jan 21. PubMed PMID: 24445973.
12) Kin H, Mukaida M, Koizumi J, Kamada T, Mitsunaga Y, Iwase T, Ikai A, Okabayashi H. Spontaneous spinal epidural hematoma presenting as paraplegia after cardiac surgery. Gen Thorac Cardiovasc Surg. 2014 Apr 11. [Epub ahead of print] PubMed PMID: 24722959.
14) Yao W, Wang X, Xu H, Luo A, Zhang C. Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesia. J Anesth. 2012 Dec;26(6):949-50. doi: 10.1007/s00540-012-1444-0. Epub 2012 Jul 13. PubMed PMID: 22790515.
15) Neo M, Sakamoto T, Fujibayashi S, Nakamura T. Delayed postoperative spinal epidural hematoma causing tetraplegia. Case report. J Neurosurg Spine. 2006 Sep;5(3):251-3. PubMed PMID: 16961087.
16) Spanier DE, Stambough JL. Delayed postoperative epidural hematoma formation after heparinization in lumbar spinal surgery. J Spinal Disord. 2000 Feb;13(1):46-9. PubMed PMID: 10710150.
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