Factors Leading to Persistent Postsurgical Pain in Adolescents Undergoing Spinal Fusion: An Integrative Literature Review

Back Pain in Adolescents and Young Adults with Idiopathic Scoliosis-Identifying Factors Associated with Significant Pain-A Multivariate Logistic Regression Analysis

(1) Background: Previous data show that patients with idiopathic scoliosis (IS) can be classified into two groups according to pain intensity. This paper aims to determine which factors can independently predict the likelihood of belonging to a high-level pain group. (2) Methods: The study used a prospective, multicenter, cross-sectional design. Two-hundred and seventy-two patients with IS (mean age 18.1 years) (females 83.5%) were included. The sample was divided into two groups. The PAIN group comprised 101 patients (37.1%) with an average NRS of 5.3. The NO-PAIN group consisted of 171 patients (62.9%) with an average NRS of 1.1. Data on various factors such as comorbidities, family history, curve magnitude, type of treatment, absenteeism, anxiety, depression, kinesiophobia, family environment, and social relationships were collected. Statistical analysis consisted of multivariate logistic regression analysis to identify independent predictors of high-level pain. (3) Results: In the final model, including modifiable and non-modifiable predictors, age (OR 1.07 (1.02-1.11)); Absenteeism (OR 3.87 (1.52-9.87)), HAD anxiety (OR 1.18 (1.09-1.29)) and an indication for surgery (OR 2.87 (1.28-6.43)) were associated with an increased risk of pain. The overall model is significant at p = 0.0001 level and correctly predicts 72.6% of the responses. (4) Conclusions: Age, an indication for surgery, anxiety, and work/school absenteeism are the variables that independently determine the risk of belonging to the high-level pain group (NRS > 3).

Photos Sculpt the Stories of Youth: Using Photovoice to Holistically Capture the Lived Experiences and Pain of Youth Who Underwent Spinal Fusion Surgery

Spinal fusion surgery is one of the most common major surgical procedures in youth. Adolescent idiopathic scoliosis (AIS) is the most frequent reason for corrective spinal fusion. AIS (∼25%-47% of cases) and spinal fusion surgeries are associated with pain, including the development of new onset chronic pain for up to 15% of youth. This research used photovoice approaches to explore the journeys of youth from before, during, and after spinal fusion surgery, to demonstrate their experiences both of and beyond pain. Twenty participants were recruited from a previous study conducted by the senior author's lab. Participants captured photos/videos in their daily life (Phase 1); collected previously taken photos/videos from before/during/after their surgery (Phase 2); and participated in individual interviews to reflexively discuss the meaning behind photos/videos (Phase 3). Before interviews, a questionnaire was administered to assess pain characteristics. Nineteen girls/women with scoliosis and one boy/man with kyphosis (12-19 years old, Mage = 16 years) participated; they identified as white (80%), other (15%), and Southeast Asian (5%). The researchers used a reflexive thematic analysis approach, which generated five themes: (1) body aesthetic versus machine; (2) expectations and anticipation of surgery/outcomes; (3) desire of normalcy and freedom; (4) navigating a hoped-for positive surgery experience; and (5) the journey sculpts identity formation and sense of self. Findings support youth advocacy, underscoring the need to validate youth concerns and inform healthcare professionals of the importance of individualized care. Youth perspectives highlighted opportunities for optimizing surgery/healthcare experiences and the psychosocial impacts of scoliosis on body image and appearance.

Pain during the first year after scoliosis surgery in adolescents, an exploratory, prospective cohort study

Objective

Approximately 50% of adolescents who have undergone scoliosis surgery still experience severe pain one year postoperatively. We explored the postoperative pain trajectory and the potential value of preoperative Thermal Quantitative Sensory Testing (T-QST) as predictor of chronic postsurgical pain after scoliosis surgery.

Design

Single-center prospective cohort study in adolescents undergoing scoliosis surgery.

Outcomes

Prevalence of chronic postsurgical pain (CPSP) one year after scoliosis surgery and postsurgical pain course during this year. The need for rescue medication and the relationship between pre-operative T-QST, acute pain and CPSP.

Results

Thirty-nine patients (mean age 13.9 years; SD 1.9 years) completed the study. One year postoperatively, ten patients (26%) self-reported pain [numeric rating scale (NRS) score ≥ 4]) when moving and two (5%) when in rest. Four of these patients (10.3%) experienced neuropathic pain. The pre-operative cold pain threshold was lower (p = 0.002) in patients with CPSP at 12 months. Preoperative cold and heat pain thresholds were correlated with the number of moderate or severe pain reports (NRS ≥ 4) in the first week postoperatively (r -.426; p = 0.009 and r.392; p = 0.016, respectively).

Conclusions

One year after scoliosis surgery, a significant part of patients (26%) still reported pain, some with neuropathic characteristics. Better diagnosis and treatment is needed; our study suggests that T-QST could be further explored to better understand and treat children with this negative outcome.

Novel Interdisciplinary Enhanced Recovery after Surgery Protocol Implementation in Paediatric Orthopaedics

The enhanced recovery after surgery (ERAS) protocol is not routine management in paediatric orthopaedics. Cultural differences or assumptions about the financing of medical care in different countries encourage creative adaptation of general assumptions in local communities. The aim of this study was to compare the quality of the perioperative period before and after the introduction of an interdisciplinary protocol adopted to organisational conditions. A group of 4098 children were included in the "before-after" observational study. The data of 1553 patients (BEFORE group) were analysed in terms of compliance with the enhanced recovery after surgery protocol guidelines and the time and cost of hospitalisation over a 20-month period. A novel interdisciplinary protocol was developed, including an education and training app called BackOnFeet (BOF®), standardised hospital management, and the introduction of methods novel to Poland (intraoperative nerve cryoanalgesia in children). A further 2545 patients (AFTER group) were reassessed over a period of 20 months. It was found that the groups differed in hospitalisation time (p < 0.001), type of procedures, and percentage ratio of costs incurred to revenue generated. The usefulness of the BOF® app as an effective educational tool was demonstrated. The optimisation of perioperative management in paediatric orthopaedics based on novel tools and the interdisciplinary ERAS protocol is possible and brings tangible benefits in psychological, organisational, and financial terms.

Pilot Investigation of Somatosensory Functioning and Pain Catastrophizing in Pediatric Spinal Fusion Surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a significant concern and contributes to the opioid epidemic; however, little is known about CPSP in young people.

DESIGN

This prospective study aimed to identify sensory, psychological, and demographic factors that may increase the risk of CPSP after spinal fusion surgery for children and adolescents with idiopathic scoliosis.

METHODS

32 children and adolescents from two children's hospitals completed quantitative sensory testing (QST) and the Pain Catastrophizing Scale Child (PCS-C) pre-and 4-6 months post spinal fusion surgery. Between-group differences were assessed using an independent samples t-test. Pearson's correlations and stepwise linear regression were used to assess the relationship between variables at both time points.

RESULTS

56% of patients endorsed pain post-surgery. They were more sensitive tomechanical detection on both a control non-pain site (r = -2.87, p = .004) and the back (r = -1.83, p = .04), as well as pressure pain (r=-2.37, p = .01) on the back. This group also reported worse pain scores pre-surgery. Pre-surgery helplessness positively correlated with preoperative pain (r = .67 p < .001), and age was negatively correlated with the post-surgical catastrophizing total score (r =-.39, p = .05), suggesting that younger patients endorsed more pain-related worry after surgery.

CONCLUSIONS

Patients who present with pain during their preoperative appointment may need to be monitored with increased vigilance throughout the perioperative period, possibly with bedside QST and psychological questionnaires, which nurses could administer. Biobehavioral interventions targeting pain intensity and feelings of helplessness and anxiety during the preoperative period may alleviate the transition to CPSP.

Factors associated with increased back pain in primary thoracic adolescent idiopathic scoliosis 10 years after surgery

PURPOSE

To identify the prevalence and predictors of nonspecific back pain in primary thoracic adolescent idiopathic scoliosis (AIS) patients at 10 years after surgery.

METHODS

This was a case-control multi-center study. A query of patients who underwent surgical correction of major thoracic AIS between 1997 and 2007 with 10-year follow-up was reviewed. SRS-22 pain scores at 10 years were classified as below normal (≤ 2 standard deviations below average for controls of similar age/sex from published literature) or within/above the control range.

RESULTS

One hundred and seventy-one patients with an average of 10.5 ± 0.8-years follow-up were included. Average age at surgery was 14 ± 2 years. The rate of pain was 23% for males and 11% for females (p = 0.08). Differences in age, 10-year SRS mental health score, and radiographic measures were noted. Of 12 patients who underwent revision surgery, 42% reported below normal pain scores versus 11% in cases without revision (p = 0.012). Classification and regression tree (CART) analysis identified 10-year thoracic curve magnitude and 10-year mental health scores as significant predictors. Thoracic Cobb of ≤ 26° at 10 years was associated with a 7% rate of below normal pain scores compared to 27.5% when the curve was > 26° (OR = 4.8, p < 0.05). Of those with a curve ≤ 26°, no patients had abnormal pain if the SRS mental health score was > 4.2 and 15% had more pain than normal if mental health score was ≤ 4.2 (OR 23, p < 0.05).

CONCLUSION

Increased primary thoracic curve magnitude (> 26°) at 10 years was the primary predictor of increased pain. For patients with less coronal deformity (< 26°), a poor mental health score was associated with an increased rate of pain. Male gender and revision surgery may also play a role in increased pain, however, the overall frequency of these variables were low.

LEVEL OF EVIDENCE

Level 3.

Risk and Resilience Predictors of Recovery After Spinal Fusion Surgery in Adolescents

OBJECTIVE

This prospective study examined risk and resilience predictors of pain and functional recovery in the first 6 months after spinal fusion surgery in adolescents.

METHODS

Adolescents with adolescent idiopathic scoliosis undergoing spinal fusion surgery (n=100, aged 12 to 18 y, 77% girls) completed assessments before surgery and at 3 weeks, 6 weeks, and 6 months after surgery. Recovery trajectories in pain, health-related quality of life (HRQOL), and objectively registered physical activity were identified. Presurgical pain catastrophizing and pain intensity (risk), and psychological flexibility, and postsurgical pain acceptance (resilience) were examined as predictors of recovery.

RESULTS

Latent growth class analyses revealed 4 distinct pain recovery trajectories (ie, Severe-Moderate [11%, n=9], Mild-No [58%, n=49], Moderate-Mild [24%, n=20], and Moderate-Severe [7%, n=6] pain trajectory), 2 HRQOL recovery trajectories; 2 trajectories characterizing recovery in average daily physical activity at moderate-to-vigorous intensity (MVPA); and 3 trajectories characterizing recovery in total physical activity volume characterized by the average daily number of steps. Subsequent multivariate analyses of variance revealed that presurgical pain intensity (partial η2=0.21, P<0.001) and pain catastrophizing (partial η2=0.13, P<0.01) were both predictive of poorer recovery in HRQOL, and pain catastrophizing additionally predicted poorer pain recovery (partial η2=0.15, P<0.05). Psychological flexibility (partial η2=0.25, P<0.001) and postsurgical pain acceptance (partial η2=0.07, P<0.05) were predictive of more favorable recovery trajectories in HRQOL, and psychological flexibility additionally predicted more favorable recovery trajectories in postsurgical pain (partial η2=0.15, P<0.05). Daily MVPA trajectories were not significantly predicted by any of the hypothesized factors, while presurgical pain catastrophizing levels were predictive of a delayed recovery trajectory in the daily amount of steps (partial η2=0.17 P<0.01).

CONCLUSIONS

Presurgical screening could include assessment of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance to identify adolescents who are at risk for poorer recovery. These are potentially modifiable factors that can be targeted in presurgical interventions to prevent poor and foster adaptive outcomes after major surgery in adolescents.

Idiopathic scoliosis: general characteristics and analysis of etiological theories (literature review)

Idiopathic scoliosis is a severe pathology of the musculoskeletal system that affects children and adolescents all over the world. The disease occurs in approximately 0.2-0.6% of the general population, and is the largest subgroup of spinal curvature in humans (70-90% of all known scoliosis cases). In idiopathic scoliosis, a threedimensional deformation of the vertebral column is formed, leading to the formation of a rib hump, curvature of the ribs and chest, asymmetry of the pelvis and impaired development of internal organs. The main feature of the disease is the spontaneous development of deformity during the growth of the child and the tendency to progress. Scoliosis is not only an orthopedic disease, but also a ignificant cosmetic, and, consequently, a psychological and social problem. The standard of treatment for scoliotic disease remains unchanged for a long time: observation, corset treatment and surgical correction. The prognosis for the development of pathology varies depending on the degree of deformation. The corset-therapy, hospitalization, surgery and treatment of chronic back pain have a negative impact on the psychoemotional state of children and adolescents. Despite significant advances in the methods of diagnosis of deformity, improvement of surgical treatment methods and in the study of pathogenesis, the etiological factor of pathology is still unknown. The search for the causes of idiopathic scoliosis covers almost all aspects of its possible origin: genetic, environmental, hormonal, metabolic, biochemical, neurological, and others. In recent decades, relevant theories of the development of scoliosis have been formulated, but none of the theories reveals the essence of the pathological process and has no clear justification. The greatest number of supporters is the genetic theory: genetic factors play a key role in the occurrence and development of idiopathic scoliosis. Understanding the underlying factors of the disease will enable prevention, early diagnosis, and identification of the risk groups of the patients in question.

Effects of opioid-reduced anesthesia during scoliosis surgery in children: a prospective observational study

Aims: Opioid-reduced anesthesia (ORA) was suggested to decrease morphine consumption after adolescent idiopathic scoliosis (AIS) surgery and incidence of chronic pain. Materials & methods: A prospective analysis using the ORA in AIS surgery was performed. Two cohorts were compared: a control group (opioid-based anesthesia) and the ORA group. The main outcome was morphine consumption at day 1. Results: 33 patients operated for AIS using ORA were compared with 36 with opioid-based anesthesia. Morphine consumption was decreased in the ORA group (1.1 mg.kg^-1 [0.2-2] vs 0.8 mg.kg^-1 [0.3-2]; p = 0.02) at day 1. Persistent neuropathic pain at 1 year was decreased in the ORA group (p = 0.02). Conclusion: The ORA protocol is efficient to reduce postoperative morphine consumption in AIS surgery and preventing neuropathic pain.

Impact of Spinal Deformity Characteristics on Patient-reported Outcome Measurement Information System Scores in Patients With Idiopathic Scoliosis Undergoing Posterior Spinal Fusion

INTRODUCTION

The impact of posterior spinal fusion (PSF) on physical function and pain and mental health in pediatric patients as quantified by the Patient-Reported Outcomes Measurement Information System (PROMIS), developed by the National Institute of Health, is largely unknown. The purpose of this study is to report the changes of PROMIS scores for upper extremity (UE), pain interference (PI), mobility (MOB), and peer relationships (PR) after PSF in patients with idiopathic scoliosis (IS), compare postoperative changes in PROMIS PI and Scoliosis Research Society-30 pain scores, and evaluate associations between curve characteristics and PROMIS scores.

METHODS

A retrospective cohort of 122 patients (<18 years old) who underwent PSF for IS was identified through electronic medical record search. PROMIS scores were obtained preoperatively and 6 weeks, 6 months, 1 years, 2 years, and 3 years postoperatively.

RESULTS

The mean age of the cohort was 14.2 ± 1.6 years, and the mean Cobb angle was 62.9 ± 13.8° at surgery. Eighty patients had preoperative PROMIS data. UE and MOB scores were statistically lower at 6 weeks and 6 months postoperatively and returned to baseline with a longer follow-up. PI scores were significantly lower at 1 and 2 years postoperatively. PR was unchanged up to 2 years postoperatively and then showed significant improvement. There was a statistically significant negative relationships between lowest instrumented vertebra and PROMIS UE and MOB scores at 6 weeks and 1 year postoperatively, but not at a longer follow-up. There were no significant differences noted in PI and PR PROMIS scores and lowest instrumented vertebra. PROMIS scores were not statistically associated with the Lenke Classification, number of vertebral levels fused, or percentage coronal correction.

DISCUSSION

Changes in PROMIS functional domains (UE and MOB) postoperatively normalize at longer follow-ups. Changes in PI and PR demonstrated improvements over preoperative values at 1 to 2 years postoperatively. Preoperative coronal and sagittal measures, and the percentage correction did not correlate with any PROMIS scores.

The role of anxiety and related states in pediatric postsurgical pain

Background: Nearly 20% of children and adolescents have pain with disability 1 year after surgery, and they experience poor sleep, school absence, and decreased activities. Negative clinical, psychological, and developmental effects include greater pain medication use, longer recovery, and fear of future medical care. Research has found psychological and family influences (i.e., child and parental anxiety) on pediatric chronic postsurgical pain (CPSP), but a better understanding of the role of perioperative anxiety and its related states in predicting pediatric postsurgical pain is needed. The poor understanding of the causes of child CPSP can lead to misdiagnosis and inadequate treatment, with significant short- and long-term effects. Objectives: The aim of this review was to summarize the literature on children's perioperative anxiety and parental anxiety in relation to acute postsurgical pain, CPSP, and pain trajectories. We also examined other related psychological factors (i.e., anxiety sensitivity, catastrophizing, pain anxiety, and fear of pain) in relation to pediatric acute and chronic postsurgical pain. Lastly, we discuss the interventions that may be effective in reducing children's and parents' preoperative anxiety. Conclusions: Our findings may improve the understanding of the causes of CPSP and highlight the gaps in research and need for further study.

Enhanced recovery after surgical correction of adolescent idiopathic scoliosis

BACKGROUND

Few publications in the literature examine enhanced recovery after scoliosis surgery (ERAS) in children, despite significant scientific interest in adults. The objective of the current study was to describe an ERAS protocol for surgical correction of adolescent idiopathic scoliosis (AIS) and its results.

METHODS

ERAS outcomes were measured in two patient cohorts. Historical controls and ERAS groups were selected from patients managed for scoliosis surgery in 2015 and 2018, respectively. The ERAS protocol included fasting minimization, carbohydrate loading, the avoidance of background morphine infusions, perioperative opioid-sparing protocols, the use of a cooling brace, early physiotherapy, feeding and oral medications, and the early removal of urinary catheters and surgical drains. The main outcome of the study was hospital length of stay.

RESULTS

Overall, 82 controls and 81 ERAS patients were recruited. ERAS protocols were observed in over 80% of patients for almost items. Median length of hospital stay was significantly lower in the ERAS group (- 3 [95% confidence interval: -2; -4] days). Median morphine consumption was reduced by 25% and 35% on days 2 and 3, respectively. The incidence of PONV did not differ between the two groups, and the incidence of constipation decreased slightly but significantly in the ERAS group on day 2. Pain intensity at rest and movement were lower in the ERAS group at day 2 and 3.

CONCLUSIONS

The current study suggests an ERAS protocol after adolescent idiopathic scoliosis surgery is associated with reduced hospital length of stay and improved postoperative care.

The Potential Role of Preoperative Pain, Catastrophizing, and Differential Gene Expression on Pain Outcomes after Pediatric Spinal Fusion

BACKGROUND

Adolescent idiopathic scoliosis is one of the most common spinal deformities in children and adolescents requiring extensive surgical intervention. Due to the nature of surgery, spinal fusion increases their risk of experiencing persistent postsurgical pain. Up to 20% of adolescents report pain for months or years after corrective spinal fusion surgery.

AIMS

To examine the influence of preoperative psychosocial factors and mRNA expression profiles on persistent postoperative pain in adolescents undergoing corrective spinal fusion surgery.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Two freestanding academic children's hospitals.

METHODS

Utilizing a longitudinal approach, adolescents were evaluated at baseline (preoperatively) and postoperatively at ±1 month and ±4-6 months. Self-report of pain scores, the Pain Catastrophizing Scale-Child, and whole blood for RNA sequencing analysis were obtained at each time point.

RESULTS

Of the adolescents enrolled in the study, 36% experienced persistent pain at final postoperative follow-up. The most significant predictors of persistent pain included preoperative pain severity and helplessness. Gene expression analysis identified HLA-DRB3 as having increased expression in children who experienced persistent pain postoperatively, as opposed to those whose pain resolved. A prospective validation study with a larger sample size is needed to confirm these findings.

CONCLUSIONS

While adolescent idiopathic scoliosis is not often classified as a painful condition, providers must be cognizant of pre-existing pain and anxiety that may precipitate a negative recovery trajectory. Policy and practice change are essential for early identification and subsequent intervention.

[Progress in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery]

OBJECTIVE

To review the advances in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery.

METHODS

Regular analgesics, drug administrations, and analgesic regimens were reviewed and summarized by consulting domestic and overseas related literatures about perioperative pain management of pediatric and adolescent spinal deformity corrective surgery in recent years.

RESULTS

As for perioperative analgesis regimens of pediatric and adolescent spinal deformity corrective surgery, regular analgesics include non-steroidal anti-inflammatory drugs, opioids, antiepileptic drugs, adrenergic agonists, and local anesthetic, etc. Besides drug administration by mouth, intravenous injection, and intramuscular injection, the administration also includes patient controlled analgesia, epidural injection, and intrathecal injection. Multimodal analgesia is the most important regimen currently.

CONCLUSION

Heretofore, a number of perioperative pain managements of pediatric and adolescent spinal deformity corrective surgery have been applied clinically, but the ideal regimen has not been developed. To design a safe and effective analgesic regimen needs further investigations.

A cluster of high psychological and somatic symptoms in children with idiopathic scoliosis predicts persistent pain and analgesic use 1 year after spine fusion

BACKGROUND

Persistent postoperative pain is a significant problem for many children, particularly for those undergoing major surgery such as posterior spine fusion. More than two-thirds report persistent pain after spine fusion, yet factors that may contribute to poorer outcomes remain poorly understood.

AIMS

This prospective, longitudinal study examined how psychologic and somatic symptoms cluster together in children aged 10-17 years with idiopathic scoliosis, and tested the hypothesis that a higher psychological and somatic symptom cluster would predict worse pain outcomes 1 year after fusion.

METHODS

Otherwise healthy children with idiopathic scoliosis completed preoperative surveys measuring recent pain intensity, pain location(s), somatic symptom severity, painDETECT (neuropathic-type pain symptoms), pain interference, fatigue, depression, anxiety, and pain catastrophizing. Pain outcome data were collected during hospitalization, and at 1 year after surgery.

RESULTS

Ninety-five children completed baseline surveys and a cluster analysis differentiated 28 (30%) with a high symptom profile that included; higher depression, fatigue, pain interference, catastrophizing, and painDETECT scores. High symptom cluster membership independently predicted higher pain interference at 1 year (β 9.92 [95% CI 6.63, 13.2], P < 0.001). Furthermore, children in this high symptom cluster reported significantly higher pain intensity and painDETECT scores, and had a 50% higher probability of continued analgesic use at 1 year compared to those in the Low Symptom Cluster (95% CI 21.3-78.5, P = 0.001).

CONCLUSION

Findings from this exploratory study suggest a need to comprehensively assess children with scoliosis for preoperative signs and symptoms that may indicate an underlying vulnerability for persistent pain. This, in turn may help guide a comprehensive perioperative treatment strategy to mitigate the potential for long-term pain trajectories.