Pain Quality Among Hospitalized Postcraniotomy Brain Tumor Patients

Abstract

Purpose/Aims:

To describe how persons diagnosed with a brain tumor who have had a craniotomy describe the quality of their pain after surgery.

Design:

A qualitative descriptive design was used.

Methods:

Qualitative descriptive methods as described by Sandelowski guided this study. Semi-structured interviews were conducted with patients hospitalized on a neurological step-down unit in an urban teaching hospital in the Midwestern United States. Interviews focused on the quality of participants’ pain after surgery. Narratives were analyzed using standard content analysis.

Results:

Twenty-seven participants were interviewed. Most were Caucasian and female. Most underwent a craniotomy using an anterior approach with sedation. Participants described the quality of their pain with six different types of descriptors: pain as pressure, pain as tender or sore, pain as stabbing, pain as throbbing, pain as jarring, and pain as itching.

Conclusions:

Participants’ descriptions of their pain quality after surgery provide a different understanding than do numerical pain ratings. Clinicians should use questions to explore patients’ individual pain experiences, seeking to understand the quality of patients’ pain and their perceptions.

Introduction

Brain tumors account for between 85% and 90% of central nervous system tumors diagnosed in the United States.^1–3 Approximately 23,890 new cases of brain tumor were diagnosed in 2020.^1–3 Approximately 90% of patients with brain tumors undergo craniotomies for treatment.^4–6 A craniotomy is the surgical removal of a portion of the skull, called a bone flap, to enable surgical access to the brain.⁷ The bone flap is then reattached after surgery.⁷ Common sites for craniotomies include the frontal, bifrontal, parietal, and occipital lobes of the brain.⁷

Pain following a craniotomy is caused by skin incision and retraction of scalp muscles during surgery.⁸ The scalp contains large and small diameter nerve fibers that transmit pain signals to the brain when stimulated.⁹ Post-craniotomy pain stems mainly from the superficial nerves in the scalp, muscles, and soft tissue throughout the head, although surgical manipulation of the dura mater during surgery may also result in pain.¹⁰ The nature of the pain experienced by post-craniotomy patients may be related to the surgical site as incisions in the subtemporal or suboccipital region are likely to produce more pain.^{7, 9–11}

Despite the common belief that craniotomies are less painful than other types of surgery, pain in post-craniotomy patients is likely underestimated.^4,5,12 For example, one study found that patients experienced minimal pain after a craniotomy, but the patients in this study were given intravenous opioid analgesics and were observed for only 24 hours after surgery.¹³ Conversely, other studies have shown that up to 93% of post-craniotomy patients experience moderate to severe nociceptive pain.^4,5,12 An integrative review revealed that between 60% and 96% of post-craniotomy patients experience pain within the first two days after surgery despite the use of analgesics, with multiple doses of medications frequently needed to reduce patients’ pain levels.¹⁴

Despite the fact that a significant number of patients experience pain after a craniotomy, the experience of such pain is poorly understood. One theory that provides a broad-based perspective on symptom experiences, including pain, and thus could guide inquiry into post-craniotomy pain, is the Theory of Unpleasant Symptoms (TOUS).¹⁵ According to the TOUS, symptoms can be caused by a single event (e.g., surgery) or develop over time.¹⁵ The TOUS identifies three components of the symptom experience: the symptom(s), the influencing factors that cause or affect the nature of the symptom(s), and the results or consequences of the symptom(s).¹⁵ Influencing factors include the physiologic, psychological, and situational factors that affect the experience of a symptom.¹⁵ Consequences include the effects of symptoms on functional and cognitive performance.¹⁵ The relationships among these three components are considered reciprocal rather than linear.¹⁵ The theory also outlines four symptom dimensions: intensity (i.e., severity), timing (i.e., duration and frequency), distress (i.e., amount of bother perceived), and quality (i.e., how the symptom feels).¹⁵ Each of these dimensions is distinct but interacts with the other dimensions to affect the overall symptom experience.¹⁵

Some of the TOUS dimensions have been examined in post-craniotomy pain studies. These studies, however, have typically measured only intensity and timing. For example, an integrative review of 26 studies of post-craniotomy pain in brain tumor patients revealed that most studies were randomized controlled trials of pharmacological pain management.¹⁴ These studies measured primarily pain intensity and timing with visual analogue scales, numerical rating scales, visual rating scales, or visual numeric scales^16–18 and did not address pain distress or quality.

Clinical nurse specialists, as experts in clinical practice and leaders in health systems, are well suited to guide pain management practices in post-operative settings.¹⁹ In order to provide optimal pain management for patients with post-craniotomy pain, it is important to understand how patients perceive not just the intensity and timing of the pain, but the quality as well. For example, a report by the National Association of Clinical Nurse Specialists (NACNS) Opioid Pain Management Task Force states that assessment of patients’ pain should include “onset, location, chronicity, characteristics, quality, associated factors, and severity” (p. 138).¹⁹ Patients’ perceptions of the quality of their pain are likely to influence their overall pain experience and thus have implications for pain management strategies. Because no studies have focused on this aspect of the pain experience in this population, the purpose of this study was to describe how persons diagnosed with a brain tumor who have had a craniotomy describe the quality of their pain while hospitalized.

Methods

Qualitative Description (QD) methods as outlined by Sandelowski guided the study.^20,21 QD is a research approach frequently used in the health sciences to describe the experiences of persons who share a common health challenge in straight-forward terms. Semi-structured interviews are commonly used to generate information about the participants’ experiences. Researchers use low inference analytic strategies to generate a surface description of participant experiences rather than more complex strategies to generate highly theoretical or conceptual renderings of the data. The product of QD is therefore a comprehensive summary of the main characteristics of the participants’ experiences that can be used to answer pragmatic practice questions. Because our aim was to provide a straightforward description of how patients described the quality of their post-craniotomy pain, QD methods were the most suitable for this study.

Setting

Data were collected on the neurosurgical step-down unit of a large urban teaching hospital in the Midwestern United States from February 2016 through December 2016. The hospital completes an average of 900 craniotomies for the treatment of brain tumors annually. The hospital’s neurosurgical practice provides service for patients throughout the Midwestern United States. The step-down unit has 23 beds with an average daily census of 23 patients. Patients on this unit have undergone procedures for neurological illness and injuries, including craniotomies. They are clinically stable but have acute care needs that prevent transfer to medical-surgical acute care units. Standard post-surgical order sets that include a variety of recommended analgesics are utilized by the hospital’s neurosurgical practice.

Inclusion and Exclusion Criteria

Patients who had a craniotomy for the excision and removal of a brain tumor within the prior two weeks were recruited for the study. Other eligibility criteria included being age 21 years and older and speaking English fluently. Patients who were clinically unstable, actively psychotic, and/or who had hearing, speech, or cognitive deficits that would interfere with full study participation were excluded.

Recruitment

Prior to recruitment, institutional review board approval was obtained from the investigators’ university and a waiver of authorization was obtained from the hospital for the use of protected health information for study recruitment. The medical records of consecutive patients hospitalized for the treatment of primary brain tumors were reviewed weekly by the unit’s clinical nurse specialist to determine study eligibility. The clinical nurse specialist approached eligible patients and obtained their verbal consent to be contacted by the study’s primary investigator, a doctoral candidate with experience in acute care nursing (first author). The primary investigator obtained verbal consent using a standard script to describe the study, confirm eligibility, and discuss study requirements. For those patients who agreed to participate, written informed consent for the interview and for review of medical records was obtained. Participants were informed that study participation was voluntary and that they could withdraw at any time.

Data Collection

In order to describe the sample, the following data were collected from the participants’ medical records: (1) length of hospital stay; (2) participant age, gender, body mass index, and race/ ethnic background; (3) tumor type, grade, and location; (4) surgical approach, length of time, and head positioning; (5) documented pain ratings; (6) Glasgow Coma Scale ratings; (7) analgesics prescribed, dosages, and number of doses administered; (8) steroids prescribed, dosages, and number of doses administered; (9) prior pain history; and (10) prior opioid use.

Interviews were conducted in the participants’ private hospital rooms by the primary investigator (first author), who is an experienced critical care nurse and who was completing a doctoral degree in nursing. Participants were asked to describe (a) their pain since surgery, (b) how they dealt with their pain, and (c) how it was how managed by their healthcare providers. Our findings related to the ways in which the participants dealt with their pain and how healthcare providers managed it have been described elsewhere.²² To better understand how the participants experienced the quality of their pain, the interviewer used prompts such as “tell me more about what the pain felt like to you” and “how would you describe your pain.” Interviews were audio-recorded and transcribed by a professional transcriptionist. Transcriptions were verified for accuracy by the primary investigator.

Data Analysis

Descriptive statistics were used to describe the sample. Patient pain intensity ratings and Glasgow Comma Scale ratings were summarized and averaged for each inpatient day. Narrative data were analyzed in several stages by the research team using standard content analytic procedures as described by Miles, Huberman, and Saldaña.²³ The research team included the primary investigator and two investigators who are senior nurse scientists with expertise in qualitative methods and oncology (second and third authors respectively).

First, all the investigators read through the transcripts multiple times in order to fully understand the participants’ overall pain experiences. Second, the primary investigator highlighted and extracted all text units (e.g., phrases, sentences, or stories) that reflected how the participants described their pain, focusing particularly on participants’ descriptions of symptom quality as discussed in the TOUS.¹⁵ Third, the primary investigator coded each text unit with a word or phrase that captured its essence. The codes were verified by the other investigators. Fourth, the primary investigator developed a preliminary data display table to group similar codes. Fifth, the table was presented to the other investigators in a series of research meetings. Through discussion and consensus and a reexamination of the verbatim transcripts, categories that reflected unique pain descriptors were identified. The primary investigator wrote a narrative description of each descriptor and the narratives were reviewed and refined by the other investigators.

While the categories represent varied descriptors representing different types of pain quality, many participants indicated that their pain felt different at different points during the post-surgical period. The team therefore selected three specific cases that exemplified the complexity and progression of the subjective experience of post-craniotomy pain. A brief case summary was written for each of these participants with a focus on how they described the quality of their pain after surgery.

Enhancing Credibility

Several procedures were used to enhance the credibility of the findings. To promote reflectivity and reduce bias, the primary investigator frequently discussed her assumptions and personal biases with the other investigators. In addition, the primary investigator kept an audit trial that chronicled all methodological and analytic decisions. Peer debriefing was used as the findings were based on team discussion and consensus that occurred regularly throughout the research process. Moreover, member checks were conducted by presenting emerging categories to subsequent participants to determine resonance with their experiences.

Results

Demographic and Medical Data

Twenty-eight patients met study criteria and provided consent. Because one patient appeared to be confused after providing consent, she was not interviewed and her demographic and medical data were not included in the findings. Another patient was interviewed but his medical record could not be located, and thus his demographic and medical data were not available. Therefore, the findings discussed here are based on interview data from 27 patients, and demographic and medical information are reported for 26 of the 27 patients who were interviewed.

Complete demographic data for the sample have been published previously.²² In summary, participants were between the ages of 21 and 83 years. The majority of participants were women and most were Caucasian. The participants’ lengths of hospital stay were between 3 and 13 days. Most participants did not have a history of opioid use or prior pain. They had a variety of tumor types and all grades of tumors were represented. The location of tumors varied considerably although the majority were in the supratentorial region. The surgeries lasted between approximately 2 1/2 and 16 hours. An anterior approach was most frequently used, and most participants received sedation. The most frequently prescribed post-surgical analgesics were fentanyl, hydrocodone-acetaminophen, acetaminophen, oxycodone-acetaminophen, and hydromorphone. Some patients were prescribed more than one medication. Most of the participants were also prescribed dexamethasone.

Interviews

The interviews lasted between 7 and 50 minutes and averaged 30 minutes. Most participants were oriented and alert, although a few were lethargic but able to participate in the interview. Some participants provided elaborate, in-depth descriptions of their pain quality, while others provided shorter descriptions. A few participants did not describe the quality of their pain despite interview probes, but instead focused on its intensity, timing, or location. The participants’ demeanor varied during the interviews, which could possibly be attributed to pain. Many participants reported their pain had subsided, while a few reported some pain during the interview. Despite the fact that some interviews lasted short periods of time, and some participants provided sparse descriptions of their pain, all participants contributed some data to the findings.

Quality of Pain

The participants described the quality of their pain with six different types of descriptors. We labeled the types of descriptors as follows: pain as pressure, pain as tender or sore, pain as sharp or stabbing, pain as throbbing, pain as jarring, and pain as itching. Some participants used more than one descriptor to describe their pain. Each type of descriptor is described below. To categorize and label the types of descriptors, we used common word use definitions, which are provided for each type of descriptor. While the focus of this analysis was on the quality of the participants’ pain, we also include relevant references to the intensity, timing, or location of their pain experience.

Pain as Pressure

Eight participants described the quality of their pain as pressure. Pressure in common usage is defined as “the application of force to something by something in direct contact with it.”²⁴ Most of these participants used the word pressure. One participant said, “It feels like a lot of pressure behind my forehead. It feels like a lot of pressure and it’s pushing in there or like it’s full and it can’t get any fuller.” Others did not use the word pressure but described a sensation of being squeezed. One participant, for example, said the pain was like having her head in a vise and having a screw put in. Several of the participants indicated that the pressure was severe; they described it as “lots and lots of pressure,” “intense pressure pain,” or pressure that “really, really hurts.” The participant quoted above who compared her pain to a vise said the pressure “makes you feel like your head will explode.” Most of the participants described the pressure as constant, but one participant experienced it only when she vomited. Some described the pressure throughout their heads but others described it as localized, such as in the forehead or at the site of the incision.

Pain as Tender or Sore

Eight participants described the quality of their pain as tender or sore. Tender is defined in common usage as “sensitive to touch or palpation,”²⁵ and sore as “physically tender (as from overuse or injury).”²⁶ Many of the participants described their pain using the words tender or sore. One participant stated, “When I let my head down, it is a little tender.” Several indicated they only felt pain upon touch. Another participant said, “Right now I am sore and if I touch it, it hurts.” Others described tenderness due to bruising or swelling. The tenderness or soreness was usually experienced as mild or manageable, occurred occasionally, and was typically associated with site of the incision. One participant said,

[The pain is] very minor here right where I had pain before. And I have pain now when I touch it. There’s not much pain here, in fact, it’s less. It’s not throbbing. I have a sore spot which is somewhat like before. I’ve got pain in my brain. Now it’s sore and it’s only sore because I touch it.

Pain as Sharp or Stabbing

Five participants described the quality of their pain as sharp or stabbing. Sharp in common usage is defined as “severe or harsh” or “clear in outline or detail,” whereas stabbing is defined as “a sudden sharp feeling.”^27,28 Most of these participants used the work sharp. One participant said the pain felt like “a very sharp, stiff pain spiking in and out.” Some used the metaphor of being stabbed. One described the onset of the pain in this way:

It starts to feel like I’m getting stabbed with needles in the side of my face and my head. If it goes on, I start to [also] get a headache…. It just feels like I’m getting stabbed and then it gets a little tingle. It kind of feels like I’m getting stabbed with a pin and then it almost feels like it’s bleeding.

The timing of the sharp or stabbing pain varied. Some participants said the pain was constant and on-going, whereas others said it occurred occasionally. The location also varied as some participants said the sharp or stabbing pain was “all over,” whereas others said it was localized at the incision site.

Pain as Throbbing

Four participants described the quality of their pain as throbbing. In common usage, throbbing is defined as “pulsating or pounding rhythmically.”²⁹ All participants in this group used the word throbbing to describe their pain, and all indicated it was intense. One participant described the pain like a heartbeat. Another stated, “It [the pain] was excruciating upon waking up. The pain was a shock to me. I felt like I had taken an axe to the head. It was a throbbing pain all around the incision.” One participant said the throbbing pain occurred upon coughing, and another said it was on-going. Some of these participants said the throbbing pain was localized to the site of the incision.

Pain as Jarring

Four participants described the quality of their pain as jarring. In common usage, jar is defined as “have a harsh or unpleasant effect on someone or something,” or “hit or shake (something) forcefully.”³⁰ One of the participants used the word jarring to describe the pain: “My head was fine until I coughed the first time and then it just jarred and would hurt so bad.” The others used terms consistent with the notion of jarring. They discussed feeling slapped, slammed, or hit on the side of the head. One participant stated, “Imagine those weird curvy bike racks and slamming your head into one of those and it being this incision.” For some participants the jarring pain occurred following sudden movements such as coughing or bending over.

Pain as Itching

Four participants described the quality of their pain as itching. In common usage, to itch is defined as “to have or produce an unpleasant feeling on your skin or inside your mouth, nose, etc. that makes you want to scratch.”³¹ These participants used the word itch or indicated the need to scratch. Although itching might not be considered pain, these participants deemed it so and described it as particularly bothersome and often unremitting. One participant said,

My forehead hurts just a little bit and I just wanna get in my head and dig. I have all this and it’s real heavy and I just wanna get in there and [scratch].

Case Examples of Descriptions of Pain Quality

While the participants described the quality of their post-craniotomy pain with the six basic types of descriptions discussed above, many portrayed their pain using several of these descriptors. Examining individual cases revealed the multi-faceted nature of the post-craniotomy pain experience. Below we present three participants whose descriptions of their pain were particularly complex or dynamic. We refer to these participants as Participant 1, 2, and 3.

Participant 1

Participant 1 had been in the hospital for five days at the time of the interview. She had surgery on the left side of her skull using an anterior approach and had general anesthesia. After surgery, she had been prescribed various narcotics for post-surgical pain, including hydromorphone, oxycodone, morphine, fentanyl, and oxycodone with acetaminophen. Some of the analgesics were ordered for as frequently as every two hours, while others were to be given once daily. She was also prescribed daily doses of hydrocortisone to control post-surgical swelling. She had several surgeries in her lifetime but described this surgery as one of the most painful.

Participant 1 described the quality of her pain in multiple ways, offering vivid descriptions of it throughout her hospital stay. She initially described her pain in a way that was consistent with what we have labeled as jarring pain. She said,

I didn’t realize that I was in pain until I bent over to grab something off the floor, just a wrapper, pick it up, throw it away. Even bending at the knees still hurt, you just squat down and bend, you know, if you got up too quickly that hurts. Obviously, if someone hits you in the head with something, it hurts. Coughing. I coughed last night and I felt like someone took a cinder block and broke it over the top of my head.

She later described the pain in the following way: “It was the same as like there’s little tiny men going in there and ripping open your head. And pounding your head with little hammers. It sounds crazy but it hurts.”

In another instance, she described her pain as throbbing. She said,

I’ve laid on the back of my head [which is close to the incision] and it’s not a very comfortable feeling. The pain is more of a throbbing. It’s like you could feel your heartbeat. And the more you feel your heartbeat, the worse the pain gets.

She described her pain when she walked in yet another way. In this instance, she described a “vibrating” pain that went up her spine and that “kind of hurt.”

One of her descriptions combined several of the types of descriptors of pain quality. She said,

They’re [types of pain] all different. They all feel like you could feel your heartbeat, but when I cough really hard, it felt like my head almost split open like the incision, that’s what it felt like. It was a hard cough and it threw me for a loop. It hurt from my head down to the middle of my neck, it hurt. So that’s pretty painful.

Participant 2

Participant 2 had been in the hospital for four days at the time of the interview. She had surgery on the left side of her skull using an anterior approach and had general anesthesia. After surgery, she had been prescribed various narcotics for post-surgical pain, including hydromorphone, fentanyl, and hydrocodone with acetaminophen. Some of the analgesics were ordered for as often as every five minutes, while others were ordered for every four hours. She was also prescribed daily doses of dexamethasone to control post-surgical swelling.

Participant 2 described a pain trajectory that was similar to other participants as she had severe pain immediately after surgery and pain that lessened over time throughout the post-surgical period. When she discussed her pain immediately after surgery, she did not describe the quality of her pain but instead focused on its intensity. She stated,

The first day was a killer. Oh, my, God. The first day of surgery, I was demanding pain medicine every two minutes because it hurt that bad. The pain was extremely excruciating. It was horrible.

Later in the interview, she again stressed the intensity of her pain upon waking from surgery: “On a scale of one to ten, it was a twenty. It was horrid. It would not go away. It was just bad. The first day was bad.”

When the interviewer inquired about the quality of her pain right after surgery, Participant 2 likened it to a migraine. She stated,

Migraines run in my family bad and that’s what it felt like to me, was having a severe migraine attack. It felt so bad that I felt sick to my stomach like I could throw up. I never did, but that’s how I felt, like I could have possibly thrown up. The pain was that bad.

As her recovery progressed, however, her pain began to improve with medication. When she described her pain the day following surgery, she said,

It just started stair stepping down from there. Of course, the next day they kept me on a routine schedule where I didn’t have to worry about the pain level.

When the interviewer asked her to describe the quality of this lesser pain, she initially described the intensity and stated that she never rated it more than a two or a three on a scale of ten. She then said,

The pain was just like a small headache. Just a general headache that you’d get through the day, that you might need to take a couple of Tylenols or something to get rid of. Nothing major. Just like a small headache. Just a general headache that you’d get throughout the day. And it mostly hurts on this side that he took the tumor from. I’m tender from where I’m bruised and I’m swollen but I’m not hurting from like a headache or anything.

By the time she was interviewed on the third day after surgery, her pain had decreased and she rated it as a “one on a scale of ten.” When describing this pain, she stated,

It’s tender, but it’s nothing like having the headaches. The headaches were totally different than having the little pain from where it’s bruised. So, it is different pain. The headaches were like being hit by a Mack truck.

Participant 3

Participant 3 had been in the hospital for 4 days at the time of the interview. She had surgery on the right side of her skull using a posterior approach and had general anesthesia. After surgery, she had been prescribed fentanyl and oxycodone with acetaminophen. The oxycodone with acetaminophen was ordered for as frequently as every four hours, while the fentanyl was ordered as a one-time dose. She was also prescribed dexamethasone to control post-surgical swelling.

Participant 3 also described the quality of her pain in multiple ways as it changed over the course of her hospital stay. She initially described her pain in a way that was consistent with what we have labeled as pressure. She said,

It was pretty bad. It was like having the tumor all over again. Because of the pressure and the headache, it was pretty bad.

Similar to the other participants, the quality of her pain changed during the post-surgical period. She described her pain later in a way that is consistent with what we have labeled itching. For her, this kind of pain was more troublesome than the other kinds of pain she experienced. She stated,

The itching and swelling has been the worst. It was really starting to itch and to bother me. I was itching all over from it.

By the third day after her surgery when she was interviewed, her pain had decreased and she described it in a way consistent with what we have labeled tender or sore. She said of the pain at that point,

I don’t think I’ve had much pain, so today has been pretty good except for when I get up to go to the bathroom. It still kind of hurts. I can still feel a little and I wouldn’t know if that’s because my neck has all swelled back there. It kind of gives the headache a little bit but it’s tolerable. It’s not like it was… It hasn’t been really that bad today.

Summary

The case examples provide an illustration of how persons describe the quality of post-craniotomy pain in a variety of ways. All three participants revealed a trajectory of pain that went from intense right after surgery to negligible at the time of the interview. Participant 1 used a broad range of descriptors to describe her pain and often did so in expressive and metaphoric language (e.g., “someone took a cinder block and broke it over my head,” “three little men in there ripping open your head,” “pounding your head with little hammers”). Participant 2 tended to discuss the intensity of her pain, despite being asked about the quality of the pain, stating her pain was “a killer, “excruciating,” and “horrible.” She used a numerical rating to stress how bad her pain was waking up from surgery (i.e., “on a scale of one to ten it was a twenty”) and how it subsided over time (no more than “a two or three on a scale of ten’). She also described her post-craniotomy pain by comparing it to a type of common headache (i.e., “a migraine,” “a small headache like you would get throughout the day”). In contrast, Participant 3 described her pain in straightforward language (i.e., “itching,” “swelling,” “pressure”) and, unlike the other participants, revealed that the itching was the most troublesome. Therefore, although the participants all used the basic type of descriptors we identified in the findings, they did so in varied and unique ways.

Discussion

The majority of the participants reported some pain following their craniotomies. Based on the participants’ descriptions, we identified and labeled six types of pain quality: pain as pressure, pain as tender or sore, pain as sharp or stabbing, pain as throbbing, pain as jarring, and pain as itching. Many participants gave vivid and complex descriptions of their pain quality, whereas a few gave simple or minimal descriptions and instead focused on the intensity and timing of their pain. Several participants described their pain in ways that varied significantly across the post-surgical period.

While no other studies to our knowledge have provided in-depth descriptions of pain quality in patients who had craniotomies, a few studies did measure the quality of pain following other types of surgery, primarily using the McGill Pain Questionnaire (MPQ).^32–34 In addition to measuring intensity and timing of pain, the MPQ provides sensory, affective, and evaluative word descriptors to capture respondents’ subjective pain experiences.^35–37 Seventy-eight adjectives are divided into 20 groups and respondents are asked to pick the single adjective in each group that best applies to their current pain in response to the question “What does your pain feel like?” For example, from the group labeled “temporal,” respondents would pick from among the following adjectives: flickering, quivering, pulsing, throbbing, beating, or pounding.^35–37 From the group labeled “spatial,” respondents would pick from among the following adjectives: jumping, flashing, or shooting. Each adjective is assigned an intensity point that can be summed for each dimension and for a total cumulative score.^35–37 For example, in a study of pain after surgery for an inguinal hernia, the researchers reported that participants most frequently selected the MPQ pain descriptors of aching, hot or burning, or heavy.³³ In a study of patients following percutaneous transluminal coronary angioplasty, patients with nonspecific pain selected fewer and qualitatively weaker pain descriptors compared to patients with ischemic pain.³² In a study of patients following breast reconstruction, participants who described sensory pain selected qualitatively stronger descriptors than those that described affective pain.³⁴

The pain quality descriptors provided by our participants resonated with several of the adjectives that comprise the MPQ.^35–37 Pain as pressure, for example, is analogous to the MPQ descriptors of pressing and crushing; pain as tender or sore to the MPQ descriptors of dull, sore, and tender; pain as sharp or stabbing to the MPQ descriptors of boring, drilling, stabbing, and lancinating; pain as throbbing to the MPQ descriptors of pulsing, throbbing, beating, and pounding; pain as jarring to the MPQ descriptors of jumping or flashing; and pain as itching to the MPQ descriptor of itchy. Several of the groups of adjectives on the MPQ, however, were not mentioned by our participants. For example, our participants did not provide descriptions of pain that were considered sensory pain (e.g., cool, cold, freezing) or tension pain (e.g. tiring, exhausting) on the MPQ.

Although the MPQ,^35–37 which includes a wide variety of pain quality descriptions and allows for quantification of pain quality, has been used to describe post-surgical acute pain in several studies, our study adds to the literature by providing an in-depth description of pain quality in post-craniotomy patients. Using a narrative approach, we were able to capitalize on the unique and vivid descriptions the participants used to describe their pain experience in their own words to provide a rich depiction of the participants’ subjective experiences of pain. Such descriptions can add to measures of pain intensity and timing to capture the multi-dimensional nature of post-surgical pain in this population.

Limitations

These findings are best understood in the context of several limitations. Interviews for our study were conducted at a single time point. In many cases, this generated robust descriptions of pain quality, including how it changed over time, but in some cases, participants had difficulty articulating the nature of the quality of their pain or identifying how it changed from day to day. We recognize that we likely would have obtained more detailed descriptions of the quality of the participants’ pain had we queried them regularly over the post-surgical period. This would have also allowed us to triangulate numerical measures of pain intensity with narrative descriptions of pain quality. Moreover, because our participants were post-surgical patients, all of whom had had anesthesia and most of whom were often taking pain medications, it is possible that their memories of their pain experiences may have been impaired and we may not have fully captured the breadth of possible pain quality descriptions in our interviews. Also, because the primary investigator as a critical care nurse had concerns about effective pain management in this population, it is possible that she may have been predisposed to focus on descriptions of problematic pain experiences. However, as described above, peer debriefing was used throughout the research process to reduce the influence of researcher bias.

Because our study was conducted on a single unit at a large urban teaching hospital, it is possible that participants did not experience a full range of pain quality because their pain was managed with a standard protocol. Also, although brain tumors occur more frequently in non-Hispanic whites than in other minorities,¹ minorities were nonetheless under-represented in our sample. This is problematic because research suggests that different ethnic groups respond to pain differently. Some studies indicate, for example, that Hispanics and African-Americans are more likely to report severe pain than Caucasians,^38,39 Asian Americans are more likely to report less pain or to hide their pain than other groups,³⁸ and Native Americans have a higher prevalence of pain symptoms compared to the general US population.^38,39

Future Research

In order to advance our understanding of how pain quality changes over time in this population, we suggest conducting studies at multiple time points after surgery as has been done in studies of pain intensity.^40,41 In addition, conducting interviews at multiple study sites could help generate a broader range of pain quality descriptions that may have been precluded by the routine pain management practices on our single study unit. Moreover, due to differences in how ethnic minorities experience pain quality,^38,39 using a more diverse sample would enable comparison of pain quality descriptors among groups. A larger sample would allow for exploration of the impact that other factors, such as age and type of surgery, might have on the quality of pain. Mixed methods research that explores associations between pain quality descriptors, numerical pain ratings, and medication doses and frequencies would provide a more comprehensive description of the pain experiences in this population.

Clinical Implications

Despite the limitations of this study, our findings do suggest some clinical implications. Consistent with recommendations of the NACNS that a comprehensive pain assessment is essential for optimal pain management planning,¹⁹ our findings indicate that such an assessment should include a discussion with patients about what the pain “feels like” not just its location or severity. Because the descriptions of pain quality in patients’ own words provide a different understanding of their experiences after surgery than do numerical pain ratings, clinicians should engage patients in discussions about their unique pain experiences. Clinical nurse specialists could initiate these discussions with the following questions: (1) How would you describe your pain?, (2) What does your pain feel like?, or (3) What would you compare you pain to? Asking such questions can result in a more comprehensive assessment of patients’ pain that incorporates most fully their subjective experiences. For example, providing patients an opportunity to describe the quality of their pain might reveal experiences that are quite bothersome, although not necessarily severe, such as itching pain. Clinical nurse specialists who mentor other nurses or who teach in schools of nursing should encourage novice nurses to consider pain as a multi-dimensional phenomenon that requires a comprehensive assessment and tailored treatments.

A better understanding of the quality of pain might also suggest some ways to tailor non-pharmaceutical pain management strategies. Pain as jarring, for example, may indicate a need to limit exertion during post-surgical activities such as physical therapy, pain as pressure may suggest the need to reduce swelling, and pain as itching may call for topical solutions. Incorporating assessment of pain quality into routine pain management could thus improve pain outcomes and patient satisfaction.

Conclusion

Pain quality is a critical dimension of the pain experience that is not frequently studied. This is especially true among patients who have had a craniotomy, perhaps due to the misperception that these patients do not experience significant pain. Our findings suggest that the quality of pain experienced by this population varies considerably, changes over time, and can be well captured by patients’ own words. The six pain quality descriptors identified in this study, if further developed and validated, could advance assessment of pain in post-craniotomy patients and provide a foundation for the development of strategies to improve pain management for patients who have a craniotomy for tumor removal.