Evolving Trends in Perioperative Pain Management for Pediatric Patients Undergoing Cranial Vault Remodeling and Strip Craniectomy

Background: Perioperative analgesic utilization among children undergoing craniosynostosis surgery remains incompletely characterized. This study evaluated opioid exposure differences between surgical techniques and assessed temporal trends in analgesic utilization. Methods: A retrospective cohort study using the Pediatric Health Information System (PHIS) database from 2015 to 2025 identified pediatric craniosynostosis patients stratified into cranial vault remodeling (CVR) and strip craniectomy (SC) cohorts. Opioid exposure was quantified as total and daily morphine milligram equivalents (MME). Between-group differences were assessed using the Welch t tests. Temporal trends in opioid use were modeled using linear regression. Analgesic class utilization was expressed as proportions of total administrations annually. Results: Among 14,195 patients (12,159 CVR and 2036 SC), total opioid exposure was significantly greater in CVR (11.24 versus 4.42 MME, P <0.001), as was daily exposure (3.98 versus 3.52 MME/d; P <0.001). Opioid utilization declined significantly over the study period for both CVR (β=−0.33 MME/y, P <0.001) and SC (β=−0.09 MME/y, P =0.009). Acetaminophen administration increased from 33.3% to 44.0% of analgesic administrations in CVR and from 36.9% to 52.5% in SC. Opioid administration concurrently declined from 60.8% to 43.5% in CVR and 62.6% to 45.7% in SC. Conclusions: Opioid utilization in pediatric craniosynostosis surgery has declined nationally over the past decade alongside a marked increase in acetaminophen use. These findings demonstrate a national shift toward multimodal opioid-sparing perioperative pain management.