Pain after surgery for acoustic neuroma DAVID A. SCHESSEl, MD, PhD, JULIAN M. NEDZElSKI, MD, FRCS, DAVID ROWED, JOSEPH G. FEGHAlI, MD, Toronto, Ontario, Canada, and Bronx, New York
MD, FRCS, and
Postoperative pain after surgery in the cerebellopontine angle (CPA) is acknowledged to occur, but is rarely taken into account as a factor in the analysis of morbidity of such surgery. It is widely acknowledged that some patients, having undergone such surgery, particularly by means of the suboccipital approach, report significant postoperative pain and headache. This study was undertaken to determine the incidence and severity of pain after excision of acoustic neuromas and to establish whether this differed between the suboccipital and translabyrinthine routes. Ninety-one percent of all patients (n = 58), who had the suboccipital approach used for removal of their tumor, were surveyed. A smaller group (n = 40), matched for tumor size, age, and sex, but in whom the translabyrinthine approach was used, was similarly studied. A standard questionnaire, designed to detect and quantify postoperative pain, was administered to each patient. Of patients who underwent tumor excision by means of the subocclpital approach, 63.7% experienced significant local discomfort and headache, whereas this was notably absent in all those who had undergone translabyrinthine excision. In view of the significant morbidity noted to follow the sUboccipital approach, several modifications of the surgical technique used were devised. (OTOlARYNGOL HEAD NECK SURG 1992;107:424.)
A
number of surgical approaches have been used to access the cerebellopontine angle for the purpose of tumor removal-i.e., translabyrinthine, suboccipital, and middle fossa. Advantages and disadvantages of each have been discussed in the literature."? The traditional suboccipital approach was first successfully used in 1907 by Ballance, reviewed by Cushing," and later refined by Dandy? and others." Complications reported after acoustic tumor excision by means of the suboccipital approach are similar to those of the translabyrinthine approach. These include facial nerve palsy / paralysis, CSF leak, meningitis, death, hydrocephalus, and others. With the exception of one case of pain, as a result of occipital nerve neuroma, incisional pain and postsurgical headache as a specific complication of suboccipital surgery, are conspicuously lacking from the published list of complications.":"
The suboccipital approach has been used at Sunnybrook Health Science Centre, Toronto, for excision of acoustic tumors with the intent of hearing preservation. Despite the fact that the same surgical approach, as described by other authors, had been used, it was our impression that individuals in this patient group experienced pain and headache more frequently than those having undergone translabyrinthine excision of their tumors. A retrospective study was performed to assess the prevalence and severity of pain/headache after suboccipital surgery. A comparable patient group, having undergone translabyrinthine tumor excision, was also studied. The results of the study have prompted reevaluation and further modification of our approach. Several explanations as to the possible cause for pain, as well as histologic evidence to support the likelihood of one such etiology, are discussed. METHODS
Study Overview From the University of Toronto, Sunnybrook Health Science Centre, Toronto (Drs. Schessel, Nedzelski, and Rowed), and Montefiore Medical Center, Bronx (Dr. Feghali). Received for publication Dec. 12, 1991; accepted March 18, 1992. Reprint requests: Julian Nedzelski, MD, FRCS, Sunnybrook Health Science Centre, 2075 Bayview Ave., Suite A-21O, Toronto, Ontario, Canada M4N-3M5. 23/1/37906
424
All patients having undergone suboccipital excision of acoustic tumors for the purpose of hearing preservation were included in the suboccipital group. On the basis of the early recognition of pain associated with the procedure, the skin incision was altered 2.5 years ago. These subgroups will be described and compared later. Patients having undergone translabyrinthine ex-
Downloaded from oto.sagepub.com at Bobst Library, New York University on January 17, 2016
Volume 107 Number 3 September 1992
Pain after surgery for acoustic neuroma
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MD, FRCS, and
Postoperative pain after surgery in the cerebellopontine angle (CPA) is acknowledged to occur, but is rarely taken into account as a factor in the analysis of morbidity of such surgery. It is widely acknowledged that some patients, having undergone such surgery, particularly by means of the suboccipital approach, report significant postoperative pain and headache. This study was undertaken to determine the incidence and severity of pain after excision of acoustic neuromas and to establish whether this differed between the suboccipital and translabyrinthine routes. Ninety-one percent of all patients (n = 58), who had the suboccipital approach used for removal of their tumor, were surveyed. A smaller group (n = 40), matched for tumor size, age, and sex, but in whom the translabyrinthine approach was used, was similarly studied. A standard questionnaire, designed to detect and quantify postoperative pain, was administered to each patient. Of patients who underwent tumor excision by means of the subocclpital approach, 63.7% experienced significant local discomfort and headache, whereas this was notably absent in all those who had undergone translabyrinthine excision. In view of the significant morbidity noted to follow the sUboccipital approach, several modifications of the surgical technique used were devised. (OTOlARYNGOL HEAD NECK SURG 1992;107:424.)
A
number of surgical approaches have been used to access the cerebellopontine angle for the purpose of tumor removal-i.e., translabyrinthine, suboccipital, and middle fossa. Advantages and disadvantages of each have been discussed in the literature."? The traditional suboccipital approach was first successfully used in 1907 by Ballance, reviewed by Cushing," and later refined by Dandy? and others." Complications reported after acoustic tumor excision by means of the suboccipital approach are similar to those of the translabyrinthine approach. These include facial nerve palsy / paralysis, CSF leak, meningitis, death, hydrocephalus, and others. With the exception of one case of pain, as a result of occipital nerve neuroma, incisional pain and postsurgical headache as a specific complication of suboccipital surgery, are conspicuously lacking from the published list of complications.":"
The suboccipital approach has been used at Sunnybrook Health Science Centre, Toronto, for excision of acoustic tumors with the intent of hearing preservation. Despite the fact that the same surgical approach, as described by other authors, had been used, it was our impression that individuals in this patient group experienced pain and headache more frequently than those having undergone translabyrinthine excision of their tumors. A retrospective study was performed to assess the prevalence and severity of pain/headache after suboccipital surgery. A comparable patient group, having undergone translabyrinthine tumor excision, was also studied. The results of the study have prompted reevaluation and further modification of our approach. Several explanations as to the possible cause for pain, as well as histologic evidence to support the likelihood of one such etiology, are discussed. METHODS
Study Overview From the University of Toronto, Sunnybrook Health Science Centre, Toronto (Drs. Schessel, Nedzelski, and Rowed), and Montefiore Medical Center, Bronx (Dr. Feghali). Received for publication Dec. 12, 1991; accepted March 18, 1992. Reprint requests: Julian Nedzelski, MD, FRCS, Sunnybrook Health Science Centre, 2075 Bayview Ave., Suite A-21O, Toronto, Ontario, Canada M4N-3M5. 23/1/37906
424
All patients having undergone suboccipital excision of acoustic tumors for the purpose of hearing preservation were included in the suboccipital group. On the basis of the early recognition of pain associated with the procedure, the skin incision was altered 2.5 years ago. These subgroups will be described and compared later. Patients having undergone translabyrinthine ex-
Downloaded from oto.sagepub.com at Bobst Library, New York University on January 17, 2016
Volume 107 Number 3 September 1992
Pain after surgery for acoustic neuroma
! / ./
/, ,,
/'
"'-.
---
/ . ,"
' /
-,
.,
/
-,
./
