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Einhorn LM, Krishnan P, Poirier C, Ingelmo P. Chronic Postsurgical Pain in Children and Adolescents: A Call for Action. J Pain Res 2024; 17:1967-1978. [PMID: 38828088 PMCID: PMC11144433 DOI: 10.2147/jpr.s464009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
Chronic postsurgical pain (CPSP) affects a significant proportion of children and adolescents after major surgery and is a detriment to both short- and long-term recovery outcomes. While clinical characteristics and psychosocial risk factors for developing CPSP in children and adults are well established in the literature, there has been little progress on the prevention and management of CPSP after pediatric surgery. Limited evidence to support current pharmacologic approaches suggests a fundamentally new paradigm must be considered by clinicians to both conceptualize and address this adverse complication. This narrative review provides a comprehensive evaluation of both the known and emerging mechanisms that support our current understanding of CPSP. Additionally, we discuss the importance of optimizing perioperative analgesic strategies to mitigate CPSP based on individual patient risks. We highlight the importance of postoperative pain trajectories to identify those most at risk for developing CPSP, the early referral to multi-disciplinary pain clinics for comprehensive evaluation and treatment of CPSP, and additional work needed to differentiate CPSP characteristics from other chronic pain syndromes in children. Finally, we recognize ongoing challenges associated with the universal implementation of available knowledge about pediatric CPSP into practically useful care plans for clinicians.
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Affiliation(s)
- Lisa M Einhorn
- Department of Anesthesiology, Division of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Padmaja Krishnan
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Cassandra Poirier
- Department of Anesthesiology, University of British Columbia, Kelowna, BC, Canada
| | - Pablo Ingelmo
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, McGill University Health Center, Montreal, QC, Canada
- Research Institute, McGill University Health Center, Montreal, QC, Canada
- Department of Anesthesia, McGill University, Montreal, QC, Canada
- Alan Edwards Center for Research in Pain, Montreal, QC, Canada
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Chidambaran V, Duan Q, Pilipenko V, Glynn SM, Sproles A, Martin LJ, Lacagnina MJ, King CD, Ding L. The Role of Cytokines in Acute and Chronic Postsurgical Pain in Pediatric Patients after Major Musculoskeletal Surgeries. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.27.24304974. [PMID: 38585987 PMCID: PMC10996732 DOI: 10.1101/2024.03.27.24304974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Study Objective To determine if baseline cytokines and their changes over postoperative days 0-2 (POD0-2) predict acute and chronic postsurgical pain (CPSP) after major surgery. Design Prospective, observational, longitudinal nested study. Setting University-affiliated quaternary children's hospital. Patients Subjects (≥8 years old) with idiopathic scoliosis undergoing spine fusion or pectus excavatum undergoing Nuss procedure. Measurements Demographics, surgical, psychosocial measures, pain scores, and opioid use over POD0-2 were collected. Cytokine concentrations were analyzed in serial blood samples collected before and after (up to two weeks) surgery, using Luminex bead arrays. After data preparation, relationships between pre- and post-surgical cytokine concentrations with acute (% time in moderate-severe pain over POD0-2) and chronic (pain score>3/10 beyond 3 months post-surgery) pain were analyzed. After adjusting for covariates, univariate/multivariate regression analyses were conducted to associate baseline cytokine concentrations with postoperative pain, and mixed effects models were used to associate longitudinal cytokine concentrations with pain outcomes. Main Results Analyses included 3,164 measures of 16 cytokines from 112 subjects (median age 15.3, IQR 13.5-17.0, 54.5% female, 59.8% pectus). Acute postsurgical pain was associated with higher baseline concentrations of GM-CSF (β=0.95, SE 0.31; p=.003), IL-1β (β=0.84, SE 0.36; p=.02), IL-2 (β=0.78, SE 0.34; p=.03), and IL-12 p70 (β=0.88, SE 0.40; p=.03) and longitudinal postoperative elevations in GM-CSF (β=1.38, SE 0.57; p=.03), IFNγ (β=1.36, SE 0.6; p=.03), IL-1β (β=1.25, SE 0.59; p=.03), IL-7 (β=1.65, SE 0.7, p=.02), and IL-12 p70 (β=1.17, SE 0.58; p=.04). In contrast, CPSP was associated with lower baseline concentration of IL-8 (β= -0.39, SE 0.17; p=.02), and the risk of developing CPSP was elevated in patients with lower longitudinal postoperative concentrations of IL-6 (β= -0.57, SE 0.26; p=.03), IL-8 (β= -0.68, SE 0.24; p=.006), and IL-13 (β= -0.48, SE 0.22; p=.03). Furthermore, higher odds for CPSP were found for females (vs. males) for IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, and TNFα, and for pectus (vs. spine) surgery for IL-8 and IL-10. Conclusion We identified pro-inflammatory cytokines associated with increased acute postoperative pain and anti-inflammatory cytokines associated with lower CPSP risk, with potential to serve as predictive and prognostic biomarkers.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Qing Duan
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Valentina Pilipenko
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Susan M. Glynn
- Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Alyssa Sproles
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lisa J. Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Michael J. Lacagnina
- Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher D. King
- Division of Behavioral Medicine and Clinical Psychology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Hochreuter J, Dreher T, Hasler CC, Canonica S, Locher C, Held U, Rabbitts J, Koechlin H. Longitudinal Resilience and Risk Factors in Pediatric Postoperative Pain (LORRIS): Protocol for a Prospective Longitudinal Swiss University Children's Hospitals-Based Study. BMJ Open 2024; 14:e080174. [PMID: 38548365 PMCID: PMC10982766 DOI: 10.1136/bmjopen-2023-080174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 03/13/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Chronic postsurgical pain (CPSP) is defined as pain that persists after a surgical procedure and has a significant impact on quality of life. Previous studies show the importance of psychological factors in CPSP, yet the majority of studies focused solely on negative emotions. This longitudinal observational study aims to broaden this knowledge base by examining the role of emotional state, emotion variability, emotion regulation and emotion differentiation on the child and the parent level for the development CPSP, and to describe pain and emotion-related trajectories following surgery. METHODS AND ANALYSIS We intend to include 280 children and adolescents aged 8-18 years with a planned orthopaedic surgery and their parents. A total of five assessment time points is planned: 3 weeks before surgery (baseline), 2 weeks after surgery (post) and 3 months (follow-up (FU) 1), 6 months and 12 months after surgery. At baseline and post only, children and parents are asked to complete a daily diary thrice a day for a week where they rate their current emotional state and their pain severity (children only). Emotional state ratings will be used to calculate indices of emotion variability, emotion regulation and emotion differentiation. Children and parents will complete questionnaires at each time point, including measures on quality of life, social support, sleep, and symptoms of anxiety and depression.To predict development of CPSP, generalised linear regression models will be used, resulting in ORs and 95% CIs. Pearson product-moment correlations between predictors and outcomes will be evaluated at each time point. The primary outcome of the prediction model is CPSP at FU1. For the trajectory analysis, the classification method K-means for longitudinal data will be used to determine clusters in the data. ETHICS AND DISSEMINATION The Ethics Committee of the Canton of Zurich, Switzerland, has approved the study (ID: 2023-01475). Participants will be compensated, and a dissemination workshop will be held. TRIAL REGISTRATION NUMBER NCT05816174.
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Affiliation(s)
- Jana Hochreuter
- Department of Psychosomatics and Psychiatry, University Children's Hospital, University of Zurich, Zurich, Switzerland
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland
- Children's Research Centre University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas Dreher
- Department of Pediatric Orthopedics and Traumatology, University Children's Hospital, Zurich, Switzerland
- Department of Pediatric Orthopedics, Orthopedic University Hospital Balgrist, Zurich, Switzerland
| | | | - Sandro Canonica
- Department of Pediatric Orthopedics and Traumatology, University Children's Hospital, Zurich, Switzerland
- Department of Pediatric Orthopedics, Orthopedic University Hospital Balgrist, Zurich, Switzerland
| | - Cosima Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
- Faculty of Health, Plymouth University, Plymouth, UK
| | - Ulrike Held
- Department of Biostatistics and Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Jennifer Rabbitts
- Anesthesiology, Perioperative and Pain Medicine, Pediatric Anesthesiology, Stanford University, Stanford, California, USA
| | - Helen Koechlin
- Department of Psychosomatics and Psychiatry, University Children's Hospital, University of Zurich, Zurich, Switzerland
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland
- Children's Research Centre University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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Ilharreborde B, Simon AL, Shadi M, Kotwicki T. Is scoliosis a source of pain? J Child Orthop 2023; 17:527-534. [PMID: 38050593 PMCID: PMC10693849 DOI: 10.1177/18632521231215861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
Purpose Pain in scoliosis is definitely a hot topic with growing popularity. The literature remains very controversial, with a pain prevalence ranging from 23% to 90%, but this can be explained by the great heterogeneity of the numerous series. The aim of this review was to report results from the literature regarding pain in relation to scoliosis regardless of the etiology. Methods A bibliographic search in Medline and Google database from 2003 to March 2023 was performed. Relevant literature was analyzed, summarized, and discussed based on authors' experience. A 1-year prospective series of adolescent idiopathic scoliosis patients was also included to compare with the existing literature. Results A total of 126 adolescent idiopathic scoliosis patients were included, with a mean preoperative Cobb angle of 64.5° (range, 45°-112°). Reported pain prevalence was 34.1%. Pain and no-pain groups were very different in their self-reported experience, with a very low mean visual analogue scale score of 0.5 (± 0.6) in the no pain group, while visual analogue scale averaged 5.6 (± 1.2) in the pain group (p < 0.001). No significant difference was found between groups regarding the most relevant demographic and radiological parameters. Conclusion Evidence-based literature on "scoliosis as a source of pain" remains ambiguous. There seems to be a consensus on the lack of direct relationship between deformity magnitude and back pain intensity. A comprehensive evaluation of the patient is therefore necessary before any treatment, including medical history, clinical examination, and relevant imaging for any child with scoliosis and back pain. Level of evidence Level VI.
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Affiliation(s)
- Brice Ilharreborde
- Pediatric Orthopaedic Department, CHU Robert Debré, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Anne-Laure Simon
- Pediatric Orthopaedic Department, CHU Robert Debré, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Milud Shadi
- Department of Spine Disorders and Paediatric Orthopaedics, University of Medical Sciences, Poznan, Poland
| | - Tomasz Kotwicki
- Department of Spine Disorders and Paediatric Orthopaedics, University of Medical Sciences, Poznan, Poland
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Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
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Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
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Duff IT, Krolick KN, Mahmoud HM, Chidambaran V. Current Evidence for Biological Biomarkers and Mechanisms Underlying Acute to Chronic Pain Transition across the Pediatric Age Spectrum. J Clin Med 2023; 12:5176. [PMID: 37629218 PMCID: PMC10455285 DOI: 10.3390/jcm12165176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic pain is highly prevalent in the pediatric population. Many factors are involved in the transition from acute to chronic pain. Currently, there are conceptual models proposed, but they lack a mechanistically sound integrated theory considering the stages of child development. Objective biomarkers are critically needed for the diagnosis, risk stratification, and prognosis of the pathological stages of pain chronification. In this article, we summarize the current evidence on mechanisms and biomarkers of acute to chronic pain transitions in infants and children through the developmental lens. The goal is to identify gaps and outline future directions for basic and clinical research toward a developmentally informed theory of pain chronification in the pediatric population. At the outset, the importance of objective biomarkers for chronification of pain in children is outlined, followed by a summary of the current evidence on the mechanisms of acute to chronic pain transition in adults, in order to contrast with the developmental mechanisms of pain chronification in the pediatric population. Evidence is presented to show that chronic pain may have its origin from insults early in life, which prime the child for the development of chronic pain in later life. Furthermore, available genetic, epigenetic, psychophysical, electrophysiological, neuroimaging, neuroimmune, and sex mechanisms are described in infants and older children. In conclusion, future directions are discussed with a focus on research gaps, translational and clinical implications. Utilization of developmental mechanisms framework to inform clinical decision-making and strategies for prevention and management of acute to chronic pain transitions in children, is highlighted.
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Affiliation(s)
- Irina T. Duff
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21218, USA;
| | - Kristen N. Krolick
- Department of Anesthesia, Cincinnati Children’s Hospital, Cincinnati, OH 45242, USA; (K.N.K.); (H.M.M.)
| | - Hana Mohamed Mahmoud
- Department of Anesthesia, Cincinnati Children’s Hospital, Cincinnati, OH 45242, USA; (K.N.K.); (H.M.M.)
| | - Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children’s Hospital, Cincinnati, OH 45242, USA; (K.N.K.); (H.M.M.)
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Lavand’homme P. Chronic pain after surgery and trauma: current situation and future directions. ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.4.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Chronic post-surgical pain (CPSP) stands as a major health issue. The unchanged incidence over the last two decades underlines both the failure of predictive models developed until now and the lack of efficacy of common “preventive” strategies (pharmacotherapy and regional analgesic techniques) applied in current clinical practice. The recognition of CPSP as a disease and the release of a common definition of the condition is an important progress in the field. CPSP predictive scores exist but none has presently demonstrated an impact on patient care. New clinical directions based on the resolution of postoperative pain, a complex and highly dynamic process supported by individual pain trajectories, argue for predictive models and preventive strategies extended to the subacute pain period i.e. after hospital discharge.
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