Comparative analysis of analgesic mechanisms in craniotomy pediatric patients: a scoping review

Due to the invasive nature of craniotomy, effective postoperative pain management is essential in pediatric neurosurgical patients, yet standardized guidelines remain limited. This scoping review evaluated postoperative analgesic strategies in children undergoing craniotomy to identify effective approaches and assess opioid-sparing techniques. Twenty-four studies met inclusion criteria, including five case reports/series and nineteen retrospective or prospective investigations, comprising 1,567 patients with a mean reported age of 6.3 years. Opioids were the most frequently used analgesics (70.7%), most commonly morphine and codeine, while non-opioid regimens including NSAIDs/acetaminophen, sedatives, local anesthetic infiltration, and regional nerve blocks were used. Overall clinical improvement was reported in 61.7% of patients, with similar outcomes between single-agent and multimodal regimens. Randomized trials showed scheduled non-opioid therapy, nerve blocks, and local anesthetic techniques reduced pain scores and opioid requirements without increased complications. Current evidence supports multimodal, opioid-minimizing strategies with opioids reserved for breakthrough pain, although further studies are needed.