Postoperative Opioid Use in Skull Base Craniotomies and Endoscopic Endonasal Surgery

Background: In 2017, the United States officially declared opioid overuse to be a public health emergency, and healthcare providers in all disciplines have been tasked with better understanding the use of opioids in their respective practices. There is a paucity of benchmark data on the quantity of opioid use in typical skull base craniotomies and endoscopic endonasal procedures. In this study, we quantified postoperative opioid use in patients undergoing skull base craniotomies and endoscopic endonasal (EE) operations and identified factors that influence postoperative opioid use.

Methods: We identified consecutive patients who underwent a skull base craniotomy or endoscopic endonasal surgery between 2014 and 2020. Demographic and surgical data, including age, sex, preoperative opioid use, history of anxiety or depression, and type and length of surgery, were collected. Patients were dichotomized by the following time periods: 2014 to 2017 (pre-awareness of the opioid epidemic) and 2018 to 2020 (post-awareness of the opioid epidemic). Patients were categorized based on surgical approach: supratentorial craniotomies, infratentorial craniotomies, or EE operations. Patients undergoing craniotomies were further classified as having significant or minimal muscle dissection. Frontotemporal, far-lateral, and suboccipital approaches were defined as significant muscle dissection, whereas supraorbital, calvarial (frontal, parietal, bifrontal, occipital) and retrosigmoid approaches were defined as minimal muscle dissection. Total inpatient opioid use in oral morphine milligram equivalents (MME) was calculated, and univariable linear regression analysis was performed to identify demographic and surgical parameters that correlated with postoperative opioid use at 24 and 48 hours. Variables with p < 0.10 were included in a multivariable linear regression analysis to identify independent predictors of opioid consumption at 24 and 48 hours.

Results: We included a total of 64 supratentorial, 62 infratentorial, and 62 endoscopic endonasal patients in this study (Table 1). Increased age predicted lower total opioid use in the first 24 (coefficient = −1.08, p = 0.001) and 48 (coefficient = −2.11, p < 0.001) hours after surgery (Table 2). Patients undergoing surgery in the post-awareness time period used an average of 32.01 and 42.31 fewer MME than those undergoing surgery in the pre-awareness period at 24 (p = 0.001) and 48 (p = 0.001) hours postoperatively, respectively. Patients with a history of anxiety or depression consumed an average of 30.72 and 39.25 more MME than patients without a mood disorder at 24 (p = 0.006) and 48 (p = 0.008) hours postoperatively, respectively (Table 3). Patients undergoing operation with significant muscle dissection used 33.64 more MME than patients undergoing operations with minimal muscle dissection at 48 hours postoperatively (p = 0.020).

Conclusion: In this study, we found that younger age, preoperative anxiety or depression, and significant muscle dissection were associated with higher postoperative opioid consumption. We also found that older age and surgeries that took place after the post-awareness period was associated with lower postoperative opioid consumption. Although our study also suggests a decrease in opioid consumption in the post-awareness period, future studies may be useful to tailor alternative analgesic approaches to patients who are likely to consume more opioids in the postoperative period.