Postoperative pain management in the neurosurgical patient.

We hope to have inspired an interest in approaching the pain management issues in this challenging group of patients. Despite significant progress in understanding the pathophysiology of pain, the development of therapeutic options, and the publication and dissemination of guidelines, this progress does not seem to have been adopted into clinical practice. Bonica has stated "for many years I have studied the reasons for inadequate management of postoperative pain, and they remain the same.... Inadequate or improper application of available information and therapies is certainly the most important reason". Let us accept the challenge to re-evaluate pain management in the postoperative neurosurgical patient. Future development may provide enhanced multimodal analgesia with the development of enantioselective NSAIDs and peripherally acting opioids that do not cross the blood-brain barrier. Targeted inhibition of the central neuroplasticity that underlies sensitization, rather than attempts to use pre-emptive analgesics, may be more fruitful. Inhibition of excitatory amino acids may prove beneficial for perioperative neuroprotection and pain management. In addition, longer-acting local anesthetics show significant promise. The importance of understanding the specific benefits available and matching these characteristics to the particular patient is emphasized. Evaluation of outcomes, including morbidity and patient satisfaction, will determine if effective and rational provision of analgesia may indeed be safer than withholding analgesia. However, it is clear that re-evaluation and refinement of conventional therapy is necessary.