Topical Anesthetic EMLA for Postoperative Wound Pain in Stereotactic Gamma Knife Radiosurgery: A Perspective, Randomized, Placebo-Controlled Study

Abstract

Background: Patients who undergo stereotactic gamma knife radiosurgery (GKRS) need a rigid frame fixation for the stereotactic procedures. Many patients suffered from postoperative wound pain after frame removal. The present study investigated whether an additional application of a topical anesthetic prior to frame removal could reduce this discomfort.

Patients and Methods: 60 patients who underwent GKRS were enrolled in this study. Of these 60 patients, 30 were treated with a topical application of EMLA, a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine; the remaining 30 were treated with a placebo. The nurses explained the definition of the visual analogue scale (VAS, scored from 0 to 10), and the patients evaluated their pain at 7 time points during the GKRS procedure by using the VAS. After each of these evaluations, the patients’ vital signs (blood pressure, heart rate, and respiratory rate) were measured.

Results: There was no significant difference in the patients’ age, gender, duration of frame fixation, and types of the lesions between the EMLA and placebo groups. The EMLA group reported significantly lower pain scores 20 and 60 min after frame removal than the placebo group (p=0.001 and p<0.001, respectively). Additionally, patients in the placebo group had significantly higher blood pressure readings compared with baseline data, during and after frame removal, thus indicating that postoperative wound pain caused them more discomfort after frame removal.

Conclusion: EMLA when applied 60 min before frame removal has an anesthetic effect of reducing the postoperative wound pain in patients who undergo GKRS.

Key words

EMLA - gamma knife radiosurgery - stereotactic frame - wound pain

References

• 1 Kondziolka D, Lunsford LD, Flickinger JC. The application of stereotactic radiosurgery to disorders of the brain.  Neurosurgery. 2008;  62 (S 02) 707-719
• 2 Kondziolka D, Martin JJ, Flickinger JC. et al . Long-term survivors after gamma knife radiosurgery for brain metastases.  Cancer. 2005;  104 2784-2791
• 3 Kondziolka D, Perez B, Flickinger JC. et al . Gamma knife radiosurgery for trigeminal neuralgia: results and expectations.  Arch Neurol. 1998;  55 1524-1529
• 4 Madhok R, Kondziolka D, Flickinger JC. et al . Gamma knife radiosurgery for facial schwannomas.  Neurosurgery. 2009;  64 1102-1105
• 5 Nicolato A, Foroni R, Pellegrino M. et al . Gamma knife radiosurgery in meningiomas of the posterior fossa. Experience with 62 treated lesions.  Minim Invas Neurosurg. 2001;  44 211-217
• 6 Ohye C, Shibazaki T. Treatment of functional disorders with gamma knife thalamotomy.  Prog Neurol Surg. 2009;  22 170-181
• 7 Carter EL, Coppola CA, Barsanti FA. A randomized, double-blind comparison of two topical anesthetic formulations prior to electrodesiccation of dermatosis papulosa nigra.  Dermatol Surg. 2006;  32 1-6
• 8 Kaur G, Gupta P, Kumar A. A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns.  Arch Pediatr Adolesc Med. 2003;  157 1065-1070
• 9 Taddio A, Nulman I, Goldbach M. et al . Use of lidocaine-prilocaine cream for vaccination pain in infants.  J Pediatr. 1994;  124 643-648
• 10 Rogers TL, Ostrow CL. The use of EMLA cream to decrease venipuncture pain in children.  J Pediatr Nurs. 2004;  19 33-39
• 11 Fassoulaki A, Sarantopoulos C, Melemeni A. et al . EMLA reduces acute and chronic pain after breast surgery for cancer.  Reg Anesth Pain Med. 2000;  25 350-355
• 12 Flaherty SA. Pain measurement tools for clinical practice and research.  AANA J. 1996;  64 133-140
• 13 Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena.  Res Nurs Health. 1990;  13 227-236
• 14 Lunsford LD, Flickinger J, Lindner G. et al . Stereotactic radiosurgery of the brain using the first United States 201 cobalt-60 source gamma knife.  Neurosurgery. 1989;  24 151-159
• 15 Kondziolka D, Maitz AH, Niranjan A. et al . An evaluation of the Model C gamma knife with automatic patient positioning.  Neurosurgery. 2002;  50 429-431
• 16 Riendeau LA, Bennett D, Black-Noller G. et al . Evaluation of the analgesic efficacy of EMLA cream in volunteers with differing skin pigmentation undergoing venipuncture.  Reg Anesth Pain Med. 1999;  24 165-169
• 17 Neri I, Savoia F, Guareschi E. et al . Purpura after application of EMLA cream in two children.  Pediatr Dermatol. 2005;  22 566-568
• 18 Godwin Y, Brotherston M. Hyperpigmentation following the use of EMLA cream.  Br J Plast Surg. 2001;  54 82-83
• 19 Waton J, Boulanger A, Trechot PH. et al . Contact urticaria from Emla cream.  Contact Dermatitis. 2004;  51 284-287
• 20 Koh JL, Harrison D, Myers R. et al . A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion.  Paediatr Anaesth. 2004;  14 977-982
• 21 Serour F, Ben-Yehuda Y, Boaz M. EMLA cream prior to digital nerve block for ingrown nail surgery does not reduce pain at injection of anesthetic solution.  Acta Anaesthesiol Scand. 2002;  46 203-206
• 22 Kuvaki B, Gökmen N, Günenç F. et al . EMLA does not permit pain-free retrobulbar injection.  Acta Anaesthesiol Scand. 2003;  47 739-741
• 23 Bacsik CJ, Swift JQ, Hargreaves KM. Toxic systemic reactions of bupivacaine and stidocaine.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;  79 18-23
• 24 Foster RH, Markham A. Levobupivacaine: A review of its pharmacology and use as a local anesthetic.  Drugs. 2000;  59 551-579
• 25 McClellan KJ, Faulds D. Ropivacaine: An update of its use in regional anaesthesia.  Drugs. 2000;  60 1065-1093

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