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

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).

Predicting Health-Related Quality of Life Outcomes Following Major Scoliosis Surgery in Adolescents: A Latent Class Growth Analysis

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To identify patient trajectories of recovery defined by change in health-related quality of life (HRQOL) following surgery for adolescent idiopathic scoliosis (AIS). To explore possible predictors of trajectory membership.

METHODS

Adolescent patients scheduled to undergo spinal fusion for AIS were enrolled in the Post-Operative Recovery following Spinal Correction: Home Experience (PORSCHE) study. Responses to the Pediatric Quality of Life Inventory-version 4 (PedsQL-4.0) were collected prior to surgery and 4 to 6 weeks, 3, 6, and 12 months post-operatively. Latent class growth analyses identified patient subgroups based on their unique trajectories of physical health (PH) and psychosocial health (PSH) outcomes using the PedsQL-4.0 subscale scores. Predictors included demographic, clinical, and psychosocial factors.

RESULTS

Data from up to 190 patients were included (87.4% female; mean±SD age = 14.6 ± 1.9 years). Three trajectory subgroups were identified for PH and 4 trajectories were found for PSH, with a majority of patients scoring within the established range of healthy adolescents 12 months post-surgery. Increased child and parent pain catastrophizing, child trait anxiety and previous hospitalizations were associated with poorer PH outcomes, whereas increased child and parent pain catastrophizing, child state and trait anxiety, and parent state and trait anxiety were associated with poorer PSH trajectories.

CONCLUSIONS

The PH and PSH trajectories identified in this study and the factors associated with their membership may inform surgical decision-making for AIS while facilitating patient and family counselling regarding peri-operative recovery and expectations.

Sensitivity and Specificity of a Neuropathic Screening Tool (Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, S-LANSS) in Adolescents With Moderate-Severe Chronic Pain

Neuropathic screening tools improve recognition of neuropathic pain in adults. Although utilized in pediatric populations, the sensitivity, specificity and methodology of screening tool delivery have not been compared in children. We evaluated the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) in adolescents (10-18 years) referred to a tertiary pediatric pain clinic. History and examination by specialist clinicians and multidisciplinary assessment informed classification of the primary pain type. In a prospective cohort, scores were obtained at interview (S-LANSS interview; n = 161, 70% female), and following substitution of self-reported signs with examination findings in the primary pain region (Leeds Assessment of Neuropathic Symptoms and Signs, LANSS examination). Secondly, we retrospectively retrieved questionnaires self-completed by adolescents at their initial clinic appointment (S-LANSS self-completed; n = 456, 73% female). Thirdly, we explored relationships between patient-reported outcomes and S-LANSS scores. S-LANSS interview scores varied with pain classification, and S-LANSS self-completed scores were similarly highest with neuropathic pain (median [interquartile range]: 18 [11, 21]) and complex regional pain syndrome (21 [14, 24]), variable with musculoskeletal pain (13 [7, 19]) and lowest with visceral pain (6.5 [2, 11.5]) and headache (8.5 [4, 14]). As in adults, the cutpoint score of 12/24 was optimal. Sensitivity was highest with inclusion of examination findings and lowest with self-completion (LANSS examination vs S-LANSS interview vs S-LANSS self-completed: 86.3% vs 80.8% vs 74.7%), but specificity was relatively low (37.8% vs 36.7% vs 48%). High S-LANSS scores in non-neuropathic groups were associated with female sex and high pain catastrophizing. The S-LANSS is a sensitive screening tool for pain with neuropathic features in adolescents, but needs to be interpreted in the context of clinical evaluation (clinicaltrials.gov NCT03312881). PERSPECTIVE: This article reports high sensitivity of the S-LANSS screening tool for identifying pain with neuropathic features in adolescents with moderate-severe chronic pain. However, as sensitivity is lower than in adult populations, further interdisciplinary evaluation is necessary to inform diagnosis and management.

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.

Preoperative Patient Education and Smaller Prescription Quantity Reduce Opioid Use After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Results of a Prospective Study

BACKGROUND

Most opioids prescribed postoperatively are unused. Leftover opioids are a major source of nonmedical opioid use among adolescents. Postoperative opioid use has also been associated with prescription quantity. Our purpose was to evaluate the effect of preoperative patient education and implementation of evidence-based prescribing guidelines on opioid use and pain level after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

AIS patients aged 10 to 17 years undergoing PSF were prospectively enrolled [postintervention cohort (POST-INT)]. Previous data on 77 patients showed median consumption of 29 doses of oxycodone after PSF [preintervention cohort (PRE-INT)]. All eligible patients during the study period were discharged with 30 doses of oxycodone and standard nonopioid analgesics. Only study participants received education on postoperative pain control. Demographics, radiographic/surgical data, pain level, and patient-reported outcomes were collected. Requests for opioid refills were documented.

RESULTS

Forty-nine patients were enrolled. POST-INT was divided into low (L, ≤8 doses), average (AVE, 9-25), and high (H, >25) opioid use groups. Demographics, radiographic/surgical data, pain level, and patient-reported outcomes were similar between the groups. However, there was a difference in days of oxycodone use, doses consumed in the first week, and leftover doses ( P <0.001). Comparison to the PRE-INT L (≤16 doses), AVE (17 to 42), and high (H, >42) use groups showed that POST-INT L and AVE consumed less oxycodone (L: P =0.002; AVE: P <0.001). Also, the overall POST-INT cohort had fewer mean days of oxycodone use (5.6 vs. 8.9, P <0.001) and doses used in the first week (14 vs. 23, P <0.001) compared with the PRE-INT cohort. Subanalysis showed fewer study participants requested and received an opioid refill [3/49 patients (6%)] compared with eligible patients who declined to participate, withdrew, or missed enrollment [8/35 patients (23%)] ( P =0.045).

CONCLUSIONS

Preoperative patient education and smaller prescription quantity successfully reduced opioid use while maintaining excellent pain control after PSF for AIS. Setting expectations regarding postoperative pain management is critical, as nonstudy participants were significantly more likely to request an opioid refill.

LEVEL OF EVIDENCE

Level II-therapeutic.

Patterns of internalizing symptoms and disability functioning in children and adolescents

Despite findings from previous studies, there is still little consistent knowledge regarding the co-occurrence patterns of somatic, depressive and anxiety symptoms in childhood and adolescence. Moreover, functional disability due to somatic symptoms at different concomitant levels of depression and anxiety is understudied. The present study examined the co-occurrence patterns of somatic symptoms and symptoms of depression and anxiety, in children and adolescents using two-step cluster analysis. Differences in functional disability due to somatic symptoms were tested with ANCOVA controlling for gender and age. The sample comprised 1127 Italian children and adolescents (48.7% males, n = 549) aged 8-16 years (M_age = 11.7, SD = 2.37). Data were collected using the Children Somatization Inventory-24, the Children Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders, and the Functional Disability Inventory. A four-cluster solution based on the co-occurrence of internalizing symptoms best fit the data. The four clusters were labelled as follows: cluster 1: "High somatic symptoms and average depression/anxiety"; cluster 2: "High somatic symptoms and high depression/anxiety"; cluster 3: "Average somatic symptoms and above average depression/anxiety"; and cluster 4: "Low somatic symptoms and low depression/anxiety". Significant differences between the four groups according to gender and age were shown. Participants with high levels of somatic, depressive, and anxiety symptoms reported greater functional disability due to somatic symptoms than the other three groups. Our findings indicate that children and adolescents who demonstrate high symptoms of depression and anxiety also reported higher levels of disability in daily life due to somatic symptoms.

How back pain intensity relates to clinical and psychosocial factors in patients with idiopathic scoliosis

OBJECTIVE

A pain intensity of 3 can reliably distinguish idiopathic scoliosis (IS) patients with acceptable pain or not. This research aims to analyze psychosocial, family and quality of life differences in patients according to their pain status.

MATERIAL AND METHODS

Patients with IS, without previous surgery, Cobb ≥ 30° and age (12-40) were included in the study. They completed the questionnaires Numerical Rate Scale (NRS), Tampa Scale for Kinesiophobia (TSK)-11, SRS22r, Hospital Anxiety-Depression Scale (HADS), COMI item 7 (work/school absenteeism) and family APGAR. Comorbidities and family health history were collected. Analysis of covariance was performed to compare means between the PAIN (NRS > 3), (NRS <  = 3) groups controlling for the effect of age and the magnitude of the curve.

RESULTS

In total, 272 patients were included. 37.1% belonged to the PAIN group (PG). The PG showed a significantly higher Cobb grade and age than the NO-PAIN group. After controlling for these variables, the PG had worse pain, mental health and SRS22-subtotal values. However, they did not differ in function or self-image. PG showed higher levels of kinesiophobia, anxiety, depression, absenteeism from work/school and impact on social/family environment. PG patients reported a higher prevalence of comorbidities and family history of nonspecific spinal pain.

CONCLUSIONS

Patients with IS and unacceptable pain constitute a group with a different incidence of psychological, social, family and comorbidities factors than those with acceptable pain. In contrast, the severity of IS was not substantially different between the groups. This profile is similar to that observed in patients with nonspecific spinal pain.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

Pain Catastrophizing Throughout the Perioperative Period in Adolescents With Idiopathic Scoliosis

OBJECTIVES

Pain catastrophizing in children and adolescents has been associated to unfavorable postsurgical outcomes. However, pain catastrophizing is rarely measured throughout the perioperative period. Using a prospective longitudinal approach, the present study aimed to identify how pain catastrophizing changes over the perioperative period in pediatric surgical patients with adolescent idiopathic scoliosis.

MATERIALS AND METHODS

Adolescent patients undergoing spinal fusion surgery completed the Pain Catastrophizing Scale for Children and additional questionnaires to assess pain intensity, state and trait anxiety, and kinesiophobia before surgery, and 1, 2, 5 days, 6 weeks, and 6 months after surgery.

RESULTS

Patients who had higher levels of pain catastrophizing before surgery were more likely to be anxious, avoid activity that may cause pain, report higher pain intensity before surgery and anticipate more pain after surgery. Low pain catastrophizers increased into a moderate level of pain catastrophizing before decreasing after discharge from the hospital. Meanwhile, moderate and high pain catastrophizers both decreased into lower and moderate levels of catastrophizing, respectively, after discharge from the hospital.

DISCUSSION

These findings demonstrate that pain catastrophizing in adolescents changes over the perioperative period. Observing changes in pain catastrophizing throughout the perioperative period may help in recognizing when patients are most vulnerable during this time. Decreasing pain catastrophizing before surgery or in the acute postoperative period through therapies that target pain catastrophizing may help reduce the patient's likelihood of experiencing unfavorable postoperative outcomes.

Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis

PURPOSE

Enhanced Recovery after Surgery (ERAS) pathways have been shown to decrease length of stay (LOS) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to compare immediate post-operative outcomes following an ERAS pathway with a traditional pathway for AIS.

METHODS

A prospective dual-center study of patients treated using an ERAS pathway (203 patients) or a traditional discharge (TD) pathway (73 patients) was performed with focus on pain at discharge, quality of life at one month, and return to school/work.

RESULTS

LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). Length of surgery (4.8 h TD vs. 2.8 h, p < 0.001) and EBL (500 cc vs. 240 cc, p < 0.001) were greater in the TD group, likely related to larger curve magnitudes ((62.0° TD vs. 54.0° ERAS, p < 0.001), a higher percentage of patients undergoing osteotomies (94% vs. 46%, p < 0.001) and more levels fused (11.4 ± 1.6 vs. 10.1 ± 2.6, p < 0.001) in the TD group. Regression analysis showed no difference in Visual Analog Score (VAS) score at discharge or quality of recovery using the QOR9 instrument between groups at follow up. There was no difference in return to school (p = 0.43) and parents' return to work (p = 0.61) between the groups.

CONCLUSION

Patients managed with an ERAS pathway had similar pain scores at discharge than those managed with a TD pathway. Both groups showed evidence of rapid return to normalcy by the first follow up visit.

Clinical Correlates of Opioid Prescription Among Pediatric Patients With Chronic Pain

INTRODUCTION

Up to 17%-20% of pediatric patients with chronic pain are prescribed opioid pharmacotherapy and face an increased risk of opioid misuse in adulthood. Little is known about the way clinical presentation may influence which children with chronic pain are prescribed opioids. This study examines the associations between child's and caregiver's report of child's pain, physical function, and socioemotional indices with opioid prescriptions in pediatric patients initiating treatment for chronic pain.

METHODS

Participants were 1,155 pediatric patients (71.26% female, n=823) aged 8-17 years and 1 of their caregivers (89% mothers) who presented for evaluation at a tertiary care pediatric pain clinic. Data were collected from 2015 to 2019 and analyzed in 2020.

RESULTS

Binary logistic regression analyses investigated the relative contribution of child's demographic, pain, and Patient-Reported Outcome Measurement Information System measures to opioid prescription status; separate models were conducted for child's and caregiver's report. Across child and caregiver models, findings were that child's age (older), pain duration (longer; child's report only), and increased physical limitations (mobility challenges and pain interference; caregiver's report only) were the most salient clinical correlates of positive opioid status. Contrary to the existing literature on adults with chronic pain, socioemotional indices (anxiety, depression, peer functioning) were nonsignificant.

CONCLUSIONS

A greater understanding of how clinical presentation may relate to prescribed opioid pharmacotherapy informs the field's conceptualization of the sequelae of opioid use and misuse in the context of pediatric chronic pain.

The Effects of Pulmonary Risk Factors on Hospital Resource Use After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Correction

OBJECTIVE

The aim of this study was to determine the impact of preoperative pulmonary risk factors (PRFS) on surgical outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients with AIS undergoing PSF were identified. Patients were then categorized by whether they had recorded baseline PRF or no-PRF. Patient demographics, comorbidities, intraoperative variables, complications, length of stay, discharge disposition, and readmission rate were assessed.

RESULTS

A total of 4929 patients were identified, of whom 280 (5.7%) had baseline PRF. Compared with the no-PRF cohort, the PRF cohort had higher rates of complications (PRF, 4.3% vs. no-PRF, 2.2%; P = 0.03) and longer hospital stays (PRF, 4.6 ± 4.3 days vs. no-PRF, 3.8 ± 2.3 days; P < 0.001), yet, discharge disposition was similar between cohorts (P = 0.70). Rates of 30-day unplanned readmission were significantly higher in the PRF cohort (PRF, 6.3% vs. no-PRF, 2.7%; P = 0.009), yet, days to readmission (P = 0.76) and rates of 30-day reoperation (P = 0.16) were similar between cohorts. On multivariate analysis, PRF was found to be a significant independent risk factor for longer hospital stays (risk ratio, 0.74; 95% confidence interval, 0.44-1.04; P < 0.001) but not postoperative complication or 30-day unplanned readmission.

CONCLUSIONS

Our study showed that PRF may be a risk factor for slightly longer hospital stays without higher rates of complication or unplanned readmission for patients with AIS undergoing PSF and thus should not preclude surgical management.

A High Psychological and Somatic Symptom Profile and Family Health Factors Predict New or Persistent Pain During Early Adolescence

OBJECTIVES

Persistent or recurrent pain is common among adolescents and is associated with poor functioning. The purpose of this study was to determine whether preteens who present with pain, and higher, co-occurring psychological and somatic symptoms (PSS) are at higher risk for persistent pain than other children.

MATERIALS AND METHODS

We conducted a secondary analysis of the longitudinal Adolescent Brain and Cognitive Development database (version 2.0.1) that includes 11,863 children aged 9 to 12 years. We differentiated children into baseline Pain/PSS profiles using the Child Behavior Checklist assessments of pain, cognitive-fogginess, somatic symptoms, depression, and anxiety and the Sleep Disorder Survey-Children somnolence subscale. We examined whether Pain/PSS profile predicted 1-year new/persistent pain when controlled for child characteristics and intergenerational mental health factors.

RESULTS

Four profiles were differentiated: No Pain/Low PSS, No Pain/High PSS, Pain/Low PSS, Pain/High PSS. Trauma exposure and family symptoms were associated with increased odds of being in the higher PSS groups. Baseline symptom profile predicted 14% of the variance in new/persistent pain at 1-year. Compared with the No Pain/Low PSS group, an increased odds of 1-year new or persistent pain was found in children with No Pain/High PSS (adjusted odds ratio [OR]: 1.44; [95% confidence interval: 1.14, 1.82]), Pain/Low PSS (adjusted OR: 4.69 [4.01, 5.48]) and Pain/High PSS (adjusted OR: 5.48 [4.35, 6.91]).

DISCUSSION

Preteen children with higher comorbid Pain/PSS symptomology were at higher risk for new or persistent pain at 1 year when controlled for important child and family characteristics. Findings support the importance of considering co-occurring symptoms when evaluating children with pain.

Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis

This article reviews and summarizes current evidence and knowledge gaps regarding postoperative analgesia after pediatric posterior spine fusion for adolescent idiopathic scoliosis, a common procedure that results in severe acute postoperative pain. Inadequate analgesia may delay recovery, cause patient dissatisfaction, and increase chronic pain risk. Despite significant adverse effects, opioids are the analgesic mainstay after scoliosis surgery. However, growing emphasis on opioid minimization and enhanced recovery has increased adoption of multimodal analgesia (MMA) regimens. While opioid adverse effects remain a concern, MMA protocols must also consider risks and benefits of adjunct medications. We discuss use of opioids via different administration routes and elaborate on the effect of MMA components on opioid/pain and recovery outcomes including upcoming regional analgesia. We also discuss risk for prolonged opioid use after surgery and chronic post-surgical pain risk in this population. Evidence supports use of neuraxial opioids at safe doses, low-dose ketorolac, and methadone for postoperative analgesia. There may be a role for low-dose ketamine in those who are opioid-tolerant or have chronic pain, but the evidence for preoperative gabapentinoids and intravenous lidocaine is currently insufficient. There is a need for further studies to evaluate pediatric-specific optimal MMA dosing regimens after scoliosis surgery. Questions remain regarding how best to prevent acute opioid tolerance, opioid-induced hyperalgesia, and chronic postsurgical pain. We anticipate that this timely update will enable clinicians to develop efficient pain regimens and provide impetus for future research to optimize recovery outcomes after spine fusion.

The relationship between parental factors, child symptom profile, and persistent postoperative pain interference and analgesic use in children

OBJECTIVES

Both parental and child factors have been previously associated with persistent or recurrent postoperative pain in children. Yet, little is known about the relative contribution of parent factors or whether child symptom factors might impact the association between parent factors and long-term pain. The aim of this study was to explore the associations between parent factors, child symptomology, and the child's long-term pain outcomes after surgery.

METHODS

This prospective, longitudinal study included parents and their children who were scheduled to undergo spinal fusion for underlying scoliosis. Parents completed baseline surveys about their pain history, pain relief preferences (ie, preference to relieve their child's pain vs avoid analgesic risks), and pain catastrophizing (ie, beliefs about their child's pain). Children were classified previously into high vs low symptom profiles at baseline based on their self-reported pain, catastrophizing, fatigue, depression, and anxiety. Children were assessed 1-year after surgery for their long-term pain interference scores and analgesic use. Serial regression modeling was used to explore whether associations between parent factors and the outcomes were changed when accounting for child factors.

RESULTS

Seventy-six parent/child dyads completed all surveys. Parental preferences and catastrophizing were atemporally associated with the child's baseline psychological-somatic symptom profile. Though parent and child factors were both associated with the long-term pain outcomes, when all three factors were accounted for, the associations between parent factors and long-term pain was fully attenuated by the child's profile.

DISCUSSION

These findings suggest that the relationship between parent factors and long-term postoperative pain outcomes may be dependent on the child's symptom profile at baseline. Since there may be bidirectional relationships between parent and child factors, interventions to mitigate long-term pain should address child symptoms as well as parental factors.

A Conceptual Model of Biopsychosocial Mechanisms of Transition from Acute to Chronic Postsurgical Pain in Children and Adolescents

Acute and chronic pain are highly prevalent and impactful consequences of surgery across the lifespan, yet a comprehensive conceptual model encompassing biopsychosocial factors underlying acute to chronic pain transition is lacking, particularly in youth. Building on prior chronic postsurgical pain models, we propose a new conceptual model of biopsychosocial mechanisms of transition from acute to chronic postsurgical pain. This review aims to summarize existing research examining key factors underlying acute to chronic postsurgical pain transition in order to guide prevention and intervention efforts aimed at addressing this health issue in children. As pain transitions from acute nociceptive pain to chronic pain, changes in the peripheral and central nervous system contribute to the chronification of pain after surgery. These changes include alterations in sensory pain processing and psychosocial processes (psychological, behavioral, and social components), which promote the development of chronic pain. Patient-related premorbid factors (eg, demographic factors, genetic profile, and medical factors such as premorbid pain) may further modulate these changes. Factors related to acute injury and recovery (eg, surgical and treatment factors), as well as biological response to surgery (eg, epigenetic, inflammatory, and endocrine factors), may also influence this process. Overall, longitudinal studies examining temporal pathways of biopsychosocial processes including both risk and resiliency factors will be essential to identify the mechanisms involved in the transition from acute to chronic pain. Research is also needed to unravel connections between the acute pain experience, opioid exposure, and sensory pain processing during acute to chronic pain transition. Furthermore, future studies should include larger and more diverse samples to more fully explore risk factors in a broader range of pediatric surgeries. The use of conceptual models to guide intervention approaches targeting mechanisms of transition from acute to chronic pain will significantly advance this field and improve outcomes for children and adolescents undergoing surgery.

Impact of Preoperative Anemia on Outcomes After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

OBJECTIVE

The aim of this study was to investigate the relationship of preoperative anemia and outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients (age 10-18 years) with AIS undergoing PSF were identified. Two cohorts were categorized into anemic and nonanemic cohorts based on age-based and sex-based criteria for anemia. Thirty-day outcomes and readmission rates were evaluated.

RESULTS

A total of 4929 patients were identified, of whom 592 (12.0%) were found to have preoperative anemia. The anemic cohort had a greater prevalence of comorbidities and longer operative times. Compared with the nonanemic cohort, the anemic cohort experienced significantly higher rates of perioperative bleed/transfusion (nonanemic, 67.4% vs. anemic, 73.5%; P = 0.004) and required a greater total amount of blood transfused (nonanemic, 283.2 ± 265.5 mL vs. anemic, 386.7 ± 342.6 mL; P < 0.001). The anemic cohort experienced significantly longer hospital stays (nonanemic, 3.8 ± 2.2 days vs. anemic, 4.2 ± 3.9 days; P = 0.001), yet discharge disposition (P = 0.58), 30-day complication rates (P = 0.79) and unplanned reoperation rates (P = 0.90) were similar between cohorts. On multivariate analysis, anemia was found to be an independent predictor of perioperative bleed/transfusion (odds ratio, 1.36; 95% confidence interval, 1.12-1.66; P = 0.002) as well as a longer length of hospital stay (relative risk, 0.46; 95% confidence interval, 0.25-0.67; P < 0.001) but was not an independent predictor for postoperative complications (P = 0.85).

CONCLUSIONS

Our study suggests that preoperative anemia may be a risk factor for a greater perioperative bleed/transfusion event and slightly longer length of stay; however, it was not associated with greater 30-day complication and readmission rates in patients with AIS undergoing PSF.

A report of the number of adolescents screened as warranting further investigation for depression and social anxiety in a pre-operative cohort with idiopathic scoliosis

INTRODUCTION

Adolescent Idiopathic Scoliosis (AIS) is a common form of scoliosis, causing rotational deformity of the torso in a teenage population. In AIS this happens at a time of particular psychological development and vulnerability and a link between AIS and mental health problems has been observed.

MATERIALS AND METHODS

Over a 6 month period, all patients with AIS aged 10-18 referred to a single spinal deformity centre in the UK were screened for symptoms suggestive of a potential diagnosis of depression and social anxiety.

RESULTS

Of the 33 patients surveyed, 6 (18%) had scores worthy of further assessment for a potential diagnosis of depression and 19 (59%) worthy of further assessment for a potential diagnosis of social anxiety.

DISCUSSION AND CONCLUSION

This small study supports the notion that there is an association between AIS and mental health issues. These initial findings support the practice of routine mental health screening in AIS.

Experimental sleep restriction increases somatic complaints in healthy adolescents

Short duration sleep and somatic complaints (bodily complaints like aches/pains or GI distress) are common in adolescence and may be linked, yet no published studies have tested causation. In this study, healthy adolescents (n = 30; 14-18yrs) completed a three-week, within-subject cross-over experiment. Following a sleep stabilization week, adolescents were randomized (in counterbalanced order) to five nights of 6.5hrs in bed (Insufficient Sleep) or 9.5hrs in bed (Sufficient Sleep), each preceded by a two-night "washout." Somatic complaints were assessed via the Children's Somatic Symptoms Inventory (CSSI-24) and the Pain and Symptom Assessment Tool (PSAT) concluding each condition. Adherence to experimental condition was confirmed via actigraphy. Adolescents slept two fewer hours and reported significantly greater frequency and severity of somatic complaints during the Insufficient Sleep (vs. Sufficient Sleep) condition. Restricting sleep opportunity to a level common in adolescence causally increased somatic complaints in otherwise healthy adolescents. Findings support clinical and preventative efforts to address pervasively inadequate sleep in adolescence.

Reduced influence of affective disorders on perioperative complication rates, length of hospital stay, and healthcare costs following spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

In the past decade, a gradual transition of health policy to value-based healthcare has brought increased attention to measuring the quality of care delivered. In spine surgery, adolescents with scoliosis are a population particularly at risk for depression, anxious feelings, and impaired quality of life related to back pain and cosmetic appearance of the deformity. With the rising prevalence of mental health ailments, it is necessary to evaluate the impact of concurrent affective disorders on patient care after spinal surgery in adolescents. The aim of this study was to investigate the impact that affective disorders have on perioperative complication rates, length of stay (LOS), and total costs in adolescents undergoing elective posterior spinal fusion (PSF) (≥ 4 levels) for idiopathic scoliosis.

METHODS

A retrospective study of the Kids' Inpatient Database for the year 2012 was performed. Adolescent patients (age range 10-17 years old) with AIS undergoing elective PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were categorized into 2 groups at discharge: affective disorder or no affective disorder. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were assessed. The primary outcomes were perioperative complication rates, LOS, total cost, and discharge dispositions.

RESULTS

There were 3759 adolescents included in this study, of whom 164 (4.4%) were identified with an affective disorder (no affective disorder: n = 3595). Adolescents with affective disorders were significantly older than adolescents with no affective disorders (affective disorder: 14.4 ± 1.9 years vs no affective disorder: 13.9 ± 1.8 years, p = 0.001), and had significantly different proportions of race (p = 0.005). Aside from hospital region (p = 0.016), no other patient- or hospital-level factors differed between the cohorts. Patient comorbidities did not differ significantly between cohorts. The number of vertebral levels involved was similar between the cohorts, with the majority of patients having 9 or more levels involved (affective disorder: 76.8% vs no affective disorder: 79.5%, p = 0.403). Postoperative complications were similar between the cohorts, with no significant difference in the proportion of patients experiencing a postoperative complication (p = 0.079) or number of complications (p = 0.124). The mean length of stay and mean total cost were similar between the cohorts. Moreover, the routine and nonroutine discharge dispositions were also similar between the cohorts, with the majority of patients having routine discharges (affective disorder: 93.9% vs no affective disorder: 94.9%, p = 0.591).

CONCLUSIONS

This study suggests that affective disorders may not have a significant impact on surgical outcomes in adolescent patients undergoing surgery for scoliosis in comparison with adults. Further studies are necessary to elucidate how affective disorders affect adolescent patients with idiopathic scoliosis, which may improve provider approach in managing these patients perioperatively and at follow-up in hopes to better the overall patient satisfaction and quality of care delivered.

Parental Proxy PROMIS Pain Interference Scores are Only Modestly Concordant With Their Child's Scores: An Effect of Child Catastrophizing

OBJECTIVES

Pediatric patients with chronic musculoskeletal conditions such as idiopathic scoliosis awaiting surgical correction can experience pain that interferes with their daily functioning. Reports of this interference are commonly gathered from patients through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Scale and through parent-proxy scores. However, the child and parent/caregiver reports vary. To provide appropriate treatment for young patients with pain, the nature of the discrepancies and under which circumstances the reports differ needs to be understood. This report offers new information on the level of concordance among parent and child report of pain interference within this patient population, and which parent and child characteristics may influence concordance rates.

METHODS

Youth (age=10 to 17 y) with a history of musculoskeletal disorders, including idiopathic scoliosis, under consideration for surgical correction of that scoliosis and parent/caregiver dyads (n=103) completed the PROMIS Pain Interference Scale during an orthopedic presurgical visit. The current data was taken from a larger study examining postsurgical pain among patients undergoing orthopedic surgical procedures to correct scoliosis. The purpose of the current study was to measure the degree of agreement between parent and child reports of pain interference and discovery of relationships among predictors of pain interference score correspondence among dyads.

RESULTS

Correspondence between parent/caregiver and child reports of pain interference was modest (intraclass correlation coefficient=0.530). In total, 46% of dyads had similar pain interference scores, whereas 24% of parents reported higher pain interference in comparison to their child, the remaining 30% reported lower pain interference in relation to their child's report. Among children where discrepancies appeared, using logistic regression models, only child catastrophizing scores were associated with differences in parent and child estimation of child's pain interference scores. No parental characteristics predicted discrepancies between dyad pain interference reports.

DISCUSSION

Parent-proxy and child reports generally correspond, but when discrepant, 24% of parents reported higher pain interference in relationship to the child report of pain interference and 31% noted less intense pain interference than their child's pain interference. Given these results, care should be taken when interpreting parent reports of child pain interference, especially when a child reports higher degrees of pain interference.