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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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2
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Sim NYW, Chalkiadis GA, Davidson AJ, Palmer GM. A systematic review of the prevalence of chronic postsurgical pain in children. Paediatr Anaesth 2024. [PMID: 38738779 DOI: 10.1111/pan.14918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024]
Abstract
Two prior reviews highlight the scarcity and conflicting nature of available data on chronic postsurgical pain in children, reporting a wide prevalence range of 3.2% to 64% (at ≥3 months). This updated systematic review aimed to consolidate information on the prevalence of pediatric chronic postsurgical pain. A thorough literature search of full English-text publications from April 2014 to August 2021 was conducted using Ovid MEDLINE, PubMed, and Cochrane Database of Systematic Reviews, with search terms: postoperative pain, child, preschool, pediatrics, adolescent, chronic pain. Seventeen relevant studies were identified. Most assessed chronicity once greater than 3 months duration postoperatively (82%), were predominantly prospective (71%) and conducted in inpatient settings (88%). The surgeries examined included orthopedic (scoliosis and limb), urological, laparotomy, inguinal, and cardiothoracic procedures, involving numbers ranging from 36 to 750, totaling 3137 participants/2792 completers. The studies had wide variations in median age at surgery (6 days to 16 years), the percentage of female participants (unspecified or 12.5% to 90%), and follow-up duration (2.5 months to 9 years). Various pain, functional, psychosocial, and health-related quality of life outcomes were documented. Chronic postsurgical pain prevalence varied widely from 2% to 100%. Despite increased data, challenges persist due to heterogeneity in definitions, patient demographics, mixed versus single surgical populations, diverse perioperative analgesic interventions, follow-up durations and reported outcomes. Interpretation is further complicated by limited information on impact, long-term analgesia and healthcare utilization, and relatively small sample sizes, hindering the assessment of reported associations. In some cases, preoperative pain and deformity may not have been addressed by surgery and persisting pain postoperatively may then be inappropriately termed chronic postsurgical pain. Larger-scale, procedure-specific data to better assess current prevalence, impact, and whether modifiable factors link to negative long-term outcomes, would be more useful and allow targeted perioperative interventions for at-risk pediatric surgical patients.
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Affiliation(s)
- Nicholle Y W Sim
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Clayton, Victoria, Australia
| | - George A Chalkiadis
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew J Davidson
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Greta M Palmer
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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3
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Fons RA, Hainsworth KR, Michlig J, Jablonski M, Czarnecki ML, Weisman SJ. Perioperative methadone for posterior spinal fusion in adolescents: Results from a double-blind randomized-controlled trial. Paediatr Anaesth 2024; 34:438-447. [PMID: 38288667 DOI: 10.1111/pan.14843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 12/22/2023] [Accepted: 01/05/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Posterior spinal fusion is the most common surgical procedure performed for correction of adolescent idiopathic scoliosis in the United States. Intraoperative methadone has been shown to improve pain control in adult patients undergoing complex spine surgery, and current pediatric studies show encouraging results; however, prospective randomized-controlled trials are lacking in the pediatric literature. AIMS We conducted a single-center double-blind randomized-controlled trial to compare intraoperative use of methadone to morphine in pediatric patients undergoing posterior spinal fusion. METHODS A total of 47 adolescents undergoing posterior spinal fusion were randomized (stratified by sex) to either a methadone (n = 25) or morphine (n = 22) group. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain severity, opioid-related side effects, and ratio of patient-controlled analgesia injections: attempts as a behavioral index of uncontrolled pain. RESULTS Patients in the methadone group consumed less total opioid postoperatively (median [interquartile range], 0.3 mg/kg [0.1, 0.5]) than patients in the morphine group (0.3 mg/kg [0.2, 0.6]), median difference [95% confidence interval] -0.07 [-0.2 to 0.02]; (p = .026). Despite the lower amount of opioid used postoperatively, pain scores for the methadone group (3.5 [3.0, 4.3]) were not significantly different from those in the morphine group (4.0 [3.2, 5.0]; p = .250). Groups did not differ on opioid-related side effects. CONCLUSIONS A two-dose intraoperative methadone regimen resulted in decreased opioid consumption compared to morphine. Although the clinical significance of these results may be limited, the analgesic equipoise without increased opioid-related side effects and potential for a lower incidence of chronic pain may tip the balance in favor of routine methadone use for adolescents undergoing posterior spinal fusion.
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Affiliation(s)
- Roger A Fons
- Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Wauwatosa, Wisconsin, USA
| | - Keri R Hainsworth
- Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Wauwatosa, Wisconsin, USA
| | - Johanna Michlig
- Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Wauwatosa, Wisconsin, USA
| | - Megan Jablonski
- Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Wauwatosa, Wisconsin, USA
| | | | - Steven J Weisman
- Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin, USA
- Children's Wisconsin, Wauwatosa, Wisconsin, USA
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Payas A, Bal E, Ekinci D, Batın S. The effect of spinal correction surgery on the tractography data of the pain pathway in scoliosis patients: a preliminary report. J Chem Neuroanat 2024; 138:102432. [PMID: 38685392 DOI: 10.1016/j.jchemneu.2024.102432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVE Pain in individuals with opered scoliosis is usually evaluated with a postural analysis or questionnaire. In this study, we evaluated pain in individuals with scoliosis who underwent spinal correction surgery by tractography and compared it with individuals with non-opered scoliosis and healthy individuals. DESIGN Fifteen healthy individuals, 15 non-operated scoliosis patients and 15 operated scoliosis patients were included in the study. METHODS All female participants in this prospectively planned study used their right hand as the dominant hand. Bilateral tractography analysis of the pain pathways was performed with DSI Studio software using brain magnetic resonance images (MRI) of the participants. Statistical analysis of the study was performed with IBM SPSS 23.0 and p<0.05 values were considered significant. RESULTS It was observed that the tractography values of the operated scoliosis group were similar to the control group (p˃0.05). In the non-operated scoliosis group, tractography findings related to nerve conduction velocity such as fiber count, fiber ratio and axial diffusivity (AD) were found to be higher than the other two groups (p<0.05). Fractional anisotropy (FA) values of the unoperated scoliosis group were significantly different between the pain pathways projected from the right/left side of the body (p<0.05). CONCLUSION The fact that the pain path tractography values of patients with scoliosis who underwent surgery were similar to those of healthy individuals may be evidence of decreased pain sensation reaching the brain. Surgery may be a good choice in the treatment of pain in patients with scoliosis.
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Affiliation(s)
- Ahmet Payas
- Amasya University, Faculty of Medicine, Department of Anatomy, Amasya, Turkey.
| | - Emre Bal
- Fatih Sultan Mehmet Education and Training Hospital, Orthopedics and Traumatology Department, İstanbul, Turkey
| | - Duygu Ekinci
- Health Sciences University Kayseri City Training and Research Hospital, Department of Child Health and Diseases, Kayseri, Türkiye
| | - Sabri Batın
- Kayseri City Education and Training Hospital, Orthopedics and Traumatology Department, Kayseri, Turkey
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Bagó J, Matamalas A, Pizones J, Betegón J, Sánchez-Raya J, Pellisé F. Back Pain in Adolescents and Young Adults with Idiopathic Scoliosis-Identifying Factors Associated with Significant Pain-A Multivariate Logistic Regression Analysis. J Clin Med 2024; 13:2366. [PMID: 38673638 PMCID: PMC11051538 DOI: 10.3390/jcm13082366] [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: 03/13/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
(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).
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Affiliation(s)
- Juan Bagó
- Spine Group, Vall d’Hebron Institut de Recerca (VHIR), Hospital Vall d’Hebron, 08035 Barcelona, Spain
| | | | - Javier Pizones
- Orthopaedic Surgery, Hospital La Paz, 28046 Madrid, Spain;
| | - Jesús Betegón
- Orthopaedic Surgery, Complejo Asistencial Universitario, 24008 León, Spain;
| | - Judith Sánchez-Raya
- Physical Medicine and Rehabilitation, Hospital Vall d’Hebron, 08035 Barcelona, Spain;
| | - Ferran Pellisé
- Spine Surgery Unit, Hospital Vall d’Hebron, 08035 Barcelona, Spain;
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Kerr J, Abraham E, Vandewint A, Bigney E, Hebert J, Richardson E, El-Mughayyar D, Chorney J, El-Hawary R, Porsche Study Group, McPhee R, Manson N. Predicting Health-Related Quality of Life Outcomes Following Major Scoliosis Surgery in Adolescents: A Latent Class Growth Analysis. Global Spine J 2024; 14:902-913. [PMID: 36128633 DOI: 10.1177/21925682221126451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Jack Kerr
- Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John's, NL, A1B 3V6, Canada
| | - Edward Abraham
- Department of Surgery, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Canada East Spine Centre, Saint John, NB, Canada
- Saint John Orthopaedics, Saint John, NB, Canada
- Horizon Health Network, Saint John, NB, Canada
| | - Amanda Vandewint
- Canada East Spine Centre, Saint John, NB, Canada
- Horizon Health Network, Saint John, NB, Canada
| | - Erin Bigney
- Canada East Spine Centre, Saint John, NB, Canada
- Horizon Health Network, Saint John, NB, Canada
| | - Jeffrey Hebert
- Faculty of Kinesiology, University of New Brunswick, Fredericton, NB, Canada
| | - Eden Richardson
- Canada East Spine Centre, Saint John, NB, Canada
- Horizon Health Network, Saint John, NB, Canada
- Canadian Spine Outcomes and Research Network, Markham, ON, Canada
| | - Dana El-Mughayyar
- Canada East Spine Centre, Saint John, NB, Canada
- Horizon Health Network, Saint John, NB, Canada
- Faculty of Kinesiology, University of New Brunswick, Fredericton, NB, Canada
| | - Jill Chorney
- Mental Health and Addictions Program, IWK Health Centre, Halifax, NS, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Ron El-Hawary
- Department of Surgery, IWK Health Centre, Halifax, NS, Canada
| | - Porsche Study Group
- McGill University, Montreal, QC, Canada
- Stollery Children's Hospital, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
- McMaster University, Hamilton, ON, Canada
- Alberta Children's Hospital, Calgary, AB, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Ste. Justine Hospital, Montreal, QC, Canada
| | - Rory McPhee
- Canada East Spine Centre, Saint John, NB, Canada
- University of New Brunswick, Saint John, NB, Canada
| | - Neil Manson
- Department of Surgery, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Canada East Spine Centre, Saint John, NB, Canada
- Saint John Orthopaedics, Saint John, NB, Canada
- Horizon Health Network, Saint John, NB, 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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de Leeuw TG, Boerlage AA, van West HM, Renkens JJM, van Rosmalen J, Staals LME, Weber F, Tibboel D, de Wildt SN. Pain during the first year after scoliosis surgery in adolescents, an exploratory, prospective cohort study. Front Pediatr 2024; 12:1293588. [PMID: 38312922 PMCID: PMC10834739 DOI: 10.3389/fped.2024.1293588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
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.
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Affiliation(s)
- Thomas G. de Leeuw
- Department of Anesthesiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Anneke A. Boerlage
- Department of Anesthesiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Neonatal and Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Hanneke M. van West
- Department of Orthopedic Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Jeroen J. M. Renkens
- Department of Orthopedic Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, Netherlands
| | - Lonneke M. E. Staals
- Department of Anesthesiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Frank Weber
- Department of Anesthesiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Neonatal and Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Saskia N. de Wildt
- Department of Neonatal and Pediatric Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Pharmacology and Toxicology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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9
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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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Isaac L, Rosenbloom BN, Tyrrell J, Ruskin DA, Birnie KA. Development and expansion of a pediatric transitional pain service to prevent complex chronic pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1173675. [PMID: 38028427 PMCID: PMC10651731 DOI: 10.3389/fpain.2023.1173675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child's pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for >3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Jennifer Tyrrell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Danielle A. Ruskin
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kathryn A. Birnie
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, Calgary, AB, Canada
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11
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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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12
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Terkawi AS, Ottestad E, Altirkawi OK, Salmasi V. Transitional Pain Medicine; New Era, New Opportunities, and New Journey. Anesthesiol Clin 2023; 41:383-394. [PMID: 37245949 DOI: 10.1016/j.anclin.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Chronic postsurgical pain (CPSP), also known as persistent postsurgical pain (PPSP), is pain that develops or increases in intensity after a surgical procedure and lasts more than 3 months. Transitional pain medicine is the medical field that focuses on understanding the mechanisms of CPSP and defining risk factors and developing preventive treatments. Unfortunately, one significant challenge is the risk of developing opioid use dependence. Multiple risk factors have been discovered, with the most common, and modifiable, being uncontrolled acute postoperative pain; preoperative anxiety and depression; and preoperative site pain, chronic pain, and opioid use.
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Affiliation(s)
- Abdullah Sulieman Terkawi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Einar Ottestad
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Omar Khalid Altirkawi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vafi Salmasi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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13
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An JK, Berman D, Schulz J. Back pain in adolescent idiopathic scoliosis: A comprehensive review. J Child Orthop 2023; 17:126-140. [PMID: 37034188 PMCID: PMC10080242 DOI: 10.1177/18632521221149058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/10/2022] [Indexed: 04/11/2023] Open
Abstract
Purpose Adolescent idiopathic scoliosis (AIS) is a common spinal deformity that affects millions of children worldwide. A variety of treatment algorithms exist for patients based on radiographic parameters such as the Cobb angle and the Risser stage. However, there has been a growing focus on nonradiographic outcomes such as back pain, which can cause functional disability and reduced quality of life for patients. In spite of this, back pain in AIS is poorly characterized in the literature. We aimed to summarize various factors that may influence back pain in AIS and the impact of different treatment methods on pain reduction. Methods A comprehensive systematic review was undertaken using the PubMed and Cochrane database. Keywords that were utilized and combined with "Adolescent Idiopathic Scoliosis" included, "back pain," "treatment," "biomechanics," "biochemistry," "epidemiology," and "biopsychosocial." The literature was subsequently evaluated and deemed relevant or not relevant for inclusion. Results A total of 93 articles were ultimately included in this review. A variety of contradictory literature was present for all sections related to epidemiology, underlying biomechanics and biochemistry, biopsychosocial factors, and treatment methodologies. Conclusion Back pain in AIS is common but remains difficult to predict and treat. The literature pertaining to causative factors and treatment options is heterogeneous and inconclusive. Longer-term prospective studies combining biopsychosocial intervention in conjunction with existing curve correction techniques would be meaningful.
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Affiliation(s)
- Juhyung K An
- College of Medicine, SUNY Downstate
Health Sciences University, Brooklyn, NY, USA
| | - Daniel Berman
- Department of Orthopedic Surgery,
Montefiore Medical Center, Bronx, NY, USA
- Daniel Berman, Apt 18L, 353 East 83rd
Street, New York, NY 10028, USA.
| | - Jacob Schulz
- Department of Orthopedic Surgery,
Montefiore Medical Center, Bronx, NY, USA
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14
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O'Neill N, Ghessese S, Hedequist D, Lins L, Birch C, Hresko MT, Emans J, Karlin L, Cornelissen L, Glotzbecker M. Quantitative Sensory Changes Following Posterior Spinal Fusion to Treat Adolescent Idiopathic Scoliosis. J Pediatr Orthop 2023; 43:218-226. [PMID: 36737054 DOI: 10.1097/bpo.0000000000002362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Sensory changes surrounding the incision frequently develop after posterior spinal fusion (PSF) to treat adolescent idiopathic scoliosis (AIS). Anecdotally, patients may experience sensory changes on the chest wall. Such postsurgical sensory changes are not well described quantitatively. This study aims to evaluate the presence, intensity, and duration of mechanical sensory changes in AIS patients postoperatively. METHODS A prospective cohort of AIS patients, 10 to 21 years old, was followed. Quantitative sensory testing (QST) included touch detection threshold [mechanical detection threshold (MDT)] and pain detection threshold (MPT), using VonFrey monofilaments and pinprick stimulators. QST was performed at 3 sites at T6: the right and left chest at the nipple line and adjacent to the incision below the inferior angle of the scapula. QST at the thenar eminence was the control. QST was collected at baseline, 3 days, 1, and 6 months postoperative. RESULTS Thirty-four patients (21% males; mean age: 14.9 years old; median preoperative curve: 58 degrees) completed all testing. Mean deformity correction was 64% (SD: 10.4). Adjacent to the incision site, MDT was significantly higher compared with baseline at 3 days and 1 month ( P < 0.001) but not at 6 months ( P = 0.19), whereas MPT was significantly higher at 3 days, ( P < 0.001), 1 month ( P < 0.001), and 6 months ( P = 0.001). For the chest wall in all patients, MPT was higher on the left chest at 3 days ( P = 0.04) and on the right chest at 3 days ( P = 0.022) and 1 month ( P = 0.05). For patients with right-sided curves, MDT ( P = 0.01) and MPT ( P = 0.015) overall were significantly higher on the concave side (left) chest postoperatively. CONCLUSIONS PSF is associated with sensory disturbances that are detectable within days, persist at 1 month, and improve at 6 months postoperatively adjacent to the incision and on the chest wall. We suspect that these sensory changes are transient. Describing postoperative sensory changes will help us better set postoperative expectations for patients undergoing PSF. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Nora O'Neill
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Semhal Ghessese
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Laura Lins
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Craig Birch
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - John Emans
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Lawrence Karlin
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Michael Glotzbecker
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
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15
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Irianto KA, Firas NR, Binti CGS, Tinduh D, Sakti YM, De Vega B. The impact of spinal fusion of adolescent idiopathic scoliosis in Salah (Islamic Prayer) movement: a case-control study. F1000Res 2023; 11:1054. [PMID: 38765242 PMCID: PMC11099510 DOI: 10.12688/f1000research.124255.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND Corrective spine surgery is widely accepted for treating severe adolescent idiopathic scoliosis (AIS). Postoperative spinal range of motion (ROM) could be affected after such surgery. In certain populations, such as Muslims, this ROM change can impact daily life, as it may affect the five-times-a-day prayer (Salah). This study aims to assess the influence of spinal fusion (SF) in Adolescent Idiopathic Scoliosis (AIS) during the daily Islamic prayer (Salah). METHODS SF-AIS patients were videoed while performing Salah prayer. The kinematic documentation was assessed and compared to Salah movements of a control group of age-matched Muslim AIS patients, who had not had surgery. The prayer quality changes were subjectively classified into improved, no change/remained, and worsened, according to the Global Perceived Effect (GPE). Functional outcome and pain were assessed by the Scoliosis Research Society Questionnaire Version 30 (SRS-30). RESULTS Thirty-nine women and five men (mean age±SD: 14.8±2.3 years) met the inclusion criteria, and unoperated AIS patients were used as control (twenty-two women, mean age±SD: 15.32±1.43 years). The prostrations ROM of the SF-AIS group differed significantly from the control group (p<0.05). The GPE of the prayer movement showed improvement in 36.4%, no change in 59.1%, and worsening in 4.5% of the SF-AIS patients. The worsened group had a significantly lower bowing ROM and higher prostrations ROM compared to all groups of prayer quality changes (p<0.05). SRS-30 scores showed good outcomes (function 4.0±0.2, pain 4.2±0.5), along with the overall bowing ROM and prostrations ROM (84.2±12.0° and 53.4±9.6°, respectively). Moreover, a significant moderate positive correlation between the bowing ROM and pain (r=0.417, p=0.007) was also found. CONCLUSION Spinal fusion positively affects AIS Islamic patients in maintaining their daily Salah movement, ROM and prayer quality. Prayer quality assessment should be given extra attention as an adjuvant of the SRS-30 questionnaire to evaluate Muslim patients.
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Affiliation(s)
- Komang Agung Irianto
- Surabaya Orthopedic Traumatology Hospital, Surabaya, East Java, 60213, Indonesia
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga/ Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia
| | - Naufal Ranadi Firas
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga/ Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia
| | | | - Damayanti Tinduh
- Department of Physical Medicine and Medical Rehabilitation, Faculty of Medicine, Universitas Airlangga/ Dr.Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia
| | - Yudha Mathan Sakti
- Department of Orthopedic and Traumatology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ Dr. Sardjito General Hospital, Sleman, Yogyakarta Special Region, 55281, Indonesia
| | - Brigita De Vega
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, London, NW3 2PS, UK
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16
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Walter CM, Lee CS, Moore DL, Abbasian N, Clay SJ, Mecoli MD, Olbrecht VA, Batra M, Ding L, Yang F, Nair M, Huq A, Simpson BE, Brown RL, Garcia VF, Chidambaran V. Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery. J Pediatr Surg 2023; 58:397-404. [PMID: 35907711 DOI: 10.1016/j.jpedsurg.2022.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery. METHODS Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression. RESULTS Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions. DISCUSSION/CONCLUSION Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Charlotte M Walter
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - David L Moore
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Niekoo Abbasian
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Smokey J Clay
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| | - Marc D Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vanessa A Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Meenu Batra
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Fang Yang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Manu Nair
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Abraar Huq
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Blair E Simpson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, MLC 3024, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Rebeccah L Brown
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Victor F Garcia
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
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17
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Sieberg CB, Lunde CE, Wong C, Manganella J, Starkweather AR, Sethna N, Perry-Eaddy MA. Pilot Investigation of Somatosensory Functioning and Pain Catastrophizing in Pediatric Spinal Fusion Surgery. Pain Manag Nurs 2023; 24:27-34. [PMID: 36564325 PMCID: PMC9925410 DOI: 10.1016/j.pmn.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Christine B Sieberg
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts; Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
| | - Claire E Lunde
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts; Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Nuffield Department of Women's and Reproductive Health, Medical Sciences Division, University of Oxford, Oxford, England
| | - Cindy Wong
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts
| | - Juliana Manganella
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts
| | | | - Navil Sethna
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts; Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Mayo Family Pediatric Pain Rehabilitation Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Mallory A Perry-Eaddy
- University of Connecticut, School of Nursing, Storrs, Connecticut; University of Connecticut, School of Medicine, Department of Pediatrics, Storrs, Connecticut; University of Connecticut, Institute for Collaboration on Health, Intervention, and Policy (InCHIP), Storrs, Connecticut; Pediatric Intensive Care Unit, Connecticut Children's, Hartford, CT
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18
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Merchant S, Prows CA, Yang F, Ding L, MacDonald J, Zhang X, Sadhasivam S, Garcia V, Sturm P, Chidambaran V. Association of CYP2D6 genotype predicted phenotypes with oxycodone requirements and side effects in children undergoing surgery. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1262. [PMID: 36618804 PMCID: PMC9816853 DOI: 10.21037/atm-2022-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/23/2022] [Indexed: 11/21/2022]
Abstract
Background Oxycodone is a commonly used oral opioid in children for treating postoperative pain. Highly polymorphic gene CYP2D6 metabolizes oxycodone into its more potent metabolite, oxymorphone. We hypothesized that altered activity due to CYP2D6 polymorphisms will influence oxycodone requirements {relative oxycodone use [oxycodone morphine equivalents (MEq)/total MEq] to maintain analgesia} (primary outcome) and risk for oxycodone induced side-effects such as respiratory depression (RD) and emesis (secondary outcomes). We also explored the influence of genotype availability and provider guidance on oral opioid prescription patterns. Methods Patients who underwent Nuss procedure and spine fusion with CYP2D6 genotyping results available preoperatively were included. Data on demographics, genotypes, oral opioids, pain scores, RD and emesis were collected. Univariate and multivariable regression for comparison of CYP2D6 genotype predicted poor, ultrarapid, intermediate metabolizers (PM, UM and IM) phenotype with normal metabolizers (NM) for outcomes were performed. Stratified logistic regression was conducted in low (oxycodone/total MEq <0.5) and high (and oxycodone/total MEq >0.5) oxycodone use groups for RD and emesis, with application of firth correction due to quasi-complete separations. Breslow-Day test was used to evaluate odds ratios for prescribing genotype directed opioid between control group (2012-15) (where providers were alerted to genotyping results availability but not directed to use them while prescribing) and genotype directed groups (2016-18) (where providers were directed to use the genotyping results available to them while prescribing oxycodone after surgery). Results Of 193 subjects (age 15.9±0.25 years, 28.5% female, 93.78% White; 101 NM, 76 IM, 10 PM and 6 UM), 77.72% underwent pectus surgery. CYP2D6 phenotype was associated with oxycodone MEq/total MEq requirements (P<0.001). Both PM and UM phenotypes had lower oxycodone requirements compared to NM [-0.316 (SE 0.098), P=0.005 and -0.432 (SE 0.113), P<0.001 respectively]. CYP2D6 phenotype was associated with RD in high use oxycodone group (P=0.018) but not low use oxycodone groups (P=0.634). No phenotype association was found for emesis. Oxycodone was prescribed to 91.24% of NM/IM vs. 66.67% of PM/UM (P=0.129) in control group and 94.64% of NM/IM vs. 28.57% of PM/UM (P<0.001) in the genotype-directed group. PM/UM phenotypes in genotype directed group had a lower chance of being prescribed oxycodone (effect size =-2.775; SE 1.566; P=0.076). Conclusions Our findings suggest CYP2D6 genotypes are associated with oxycodone requirements for analgesia and may influence risk for RD. Genotype availability and guidance likely influence oral opioid prescription pattern after surgery. Our findings are limited by small sample size for UM/PM groups.
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Affiliation(s)
- Soroush Merchant
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Cynthia A. Prows
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Fang Yang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA;,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA;,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | | | - Xue Zhang
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Victor Garcia
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Sturm
- Division of Orthopedic Surgery, Department of Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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19
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Stratton C, Tyrrell J, Goren R, Lalloo C, Isaac L. The "STOP Pain" Questionnaire: using the Plan-Do-Study-Act model to implement a patient-family preferences-informed questionnaire into a pediatric transitional pain clinic. J Patient Rep Outcomes 2022; 6:120. [PMID: 36445535 PMCID: PMC9708994 DOI: 10.1186/s41687-022-00520-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/06/2022] [Accepted: 10/07/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Patient engagement is an important tool for quality improvement (QI) and optimizing the uptake of research findings. The Plan-Do-Study-Act (PDSA) model is a QI tool that encourages ongoing evaluation of clinical care, thus improving various aspects of patient care. Ascertaining pediatric patient priorities for a pain questionnaire in the post-acute, or transitional pain, setting is important to guide clinical care since active engagement with the population of interest can optimize uptake. We used the PDSA model to adapt a chronic pain questionnaire for the pediatric transitional pain setting to reflect pediatric patient and parent/guardian preferences and to form an example of how the PDSA model can be used to improve clinical care through patient engagement. METHODS This project employed the PDSA model to adapt the pediatric Ontario Chronic Pain Questionnaire for use in the pediatric Transitional Pain Service (pedTPS) setting. Plan: Following reviewing the Ontario Chronic Pain Questionnaire and literature on pain questionnaire development, goal-based questions, questions on pain location, relevant Patient-Reported Outcomes Measurement Information System (PROMIS®) measures and the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P), informed the questionnaire. Do: The questionnaire and a satisfaction survey were sent to patients and families through Research Electronic Data Capture (REDCap™). STUDY Results from the satisfaction survey were analyzed. Act: Using descriptive statistics employing ordinal mixed-models with random effects, ANOVA, and double-blinded qualitative thematic coding, questionnaire preferences were analyzed and the questionnaire was adapted accordingly before implementation into the (pedTPS). RESULTS Eighty-eight questionnaires and satisfaction surveys were analyzed from 69 respondents (32 patients; 37 parents/guardians). Sixty-six (75.00%) surveys indicated satisfaction with the questionnaire. A combined 77 (87.50%) "strongly agreed" (25/88) or "agreed" (52/88) that the questionnaire language was clear. The application of suggested changes to the questionnaire resulted in four versions across the project timeline, which reflected patient and parent/guardian preferences for questions that reflect the themes, "Story"; "Time-Optimal"; and "Pertinent" ("STOP"). There were no statistically significant differences in satisfaction across the versions due to sample size. CONCLUSION Most respondents were satisfied with the questionnaire and prefer "STOP" questions. Future studies will focus on testing the questionnaire for validity and reliability across pedTPS populations.
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Affiliation(s)
- Catherine Stratton
- grid.42327.300000 0004 0473 9646Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, M5G 1X8 Toronto, ON Canada
| | - Jennifer Tyrrell
- grid.42327.300000 0004 0473 9646Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, M5G 1X8 Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Suite 130, M5T 1P8 Toronto, ON Canada
| | - Rachel Goren
- grid.42327.300000 0004 0473 9646Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, M5G 1X8 Toronto, ON Canada
| | - Chitra Lalloo
- grid.42327.300000 0004 0473 9646Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, M5G 1X8 Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Institute for Health Policy, Management & Evaluation, University of Toronto, 155 College St 4th Floor, M5T 3M6 Toronto, ON Canada
| | - Lisa Isaac
- grid.42327.300000 0004 0473 9646Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, M5G 1X8 Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Temerty Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s College Cir, M5S 1A8 Toronto, ON Canada
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20
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Kelly I, Fields K, Sarin P, Pang A, Sigurdsson MI, Shernan SK, Fox AA, Body SC, Muehlschlegel JD. Identifying Patients Vulnerable to Inadequate Pain Resolution After Cardiac Surgery. Semin Thorac Cardiovasc Surg 2022; 36:182-194. [PMID: 36084862 DOI: 10.1053/j.semtcvs.2022.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute postoperative pain (APOP) is often evaluated through granular parameters, though monitoring postoperative pain using trends may better describe pain state. We investigated acute postoperative pain trajectories in cardiac surgical patients to identify subpopulations of pain resolution and elucidate predictors of problematic pain courses. We examined retrospective data from 2810 cardiac surgical patients at a single center. The k-means algorithm for longitudinal data was used to generate clusters of pain trajectories over the first 5 postoperative days. Patient characteristics were examined for association with cluster membership using ordinal and multinomial logistic regression. We identified 3 subgroups of pain resolution after cardiac surgery: 37.7% with good resolution, 44.2% with moderate resolution, and 18.2% exhibiting poor resolution. Type I diabetes (2.04 [1.00-4.16], p = 0.05), preoperative opioid use (1.65 [1.23-2.22], p = 0.001), and illicit drug use (1.89 [1.26-2.83], p = 0.002) elevated risk of membership into worse pain trajectory clusters. Female gender (1.72 [1.30-2.27], p < 0.001), depression (1.60 [1.03-2.50], p = 0.04) and chronic pain (3.28 [1.79-5.99], p < 0.001) increased risk of membership in the worst pain resolution cluster. This study defined 3 APOP resolution subgroups based on pain score trend after cardiac surgery and identified factors that predisposed patients to worse resolution. Patients with moderate or poor pain trajectory consumed more opioids and received them for longer before discharge. Future studies are warranted to determine if altering postoperative pain monitoring and management improve postoperative course of patients at risk of moderate or poor pain resolution.
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Affiliation(s)
- Ian Kelly
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kara Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pankaj Sarin
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amanda Pang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Martin I Sigurdsson
- Department of Anesthesiology and Critical Care Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Stanton K Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amanda A Fox
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, University of Texas Southwestern, Dallas, Texas
| | - Simon C Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, Massachusetts
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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21
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Chidambaran V, Simpson B, Brower L, Hanke R, Mecoli M, Lane B, Williams S, McKenna E, Bates C, Kraemer A, Sturm P, Brown R, Dunseath L, Vogel C, Garcia V. Design and implementation of a novel patient-centered empowerment approach for pain optimisation in children undergoing major surgery. BMJ Open Qual 2022; 11:bmjoq-2022-001874. [PMID: 35853668 PMCID: PMC9301787 DOI: 10.1136/bmjoq-2022-001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/11/2022] [Indexed: 11/03/2022] Open
Abstract
Background Paediatric surgery is a stressful experience for patients and caregivers. While standardised protocols are the norm, patient-centred approaches are needed to empower patients/caregivers for an optimal perioperative pain experience. To address this gap, we employed a patient-centred approach using design thinking (DT) methodology to develop insights, map processes, identify opportunities and design solutions for individualised empowerment tools. Methods In consultation with DT experts, a multidisciplinary team of stakeholders (healthcare providers, patients who underwent pectus excavatum/scoliosis surgery and their caregivers), were invited to participate in surveys, interviews and focus groups. The project was conducted in two sequential stages each over 24 weeks—involving 7 families in stage 1 and 16 patients/17 caregivers in stage 2. Each stage consisted of three phases: design research (focus groups with key stakeholders to review and apply collective learnings, map processes, stressors, identify influencing factors and opportunities), concept ideation (benchmarking and co-creation of new solutions) and concept refinement. Results In stage 1, mapping of stress/anxiety peaks identified target intervention times. We identified positive and negative influencers as well as the need for consistent messaging from the healthcare team in our design research. Current educational tools were benchmarked, parent-child engagement dyads determined and healthcare-based technology-based solutions conceived. The ‘hero’s journey’ concept which has been applied to other illness paradigms for motivation successfully the was adapted to describe surgery as a transformative experience. In stage 2, patient and caregiver expectations, distinct personas and responses to perioperative experience were categorised. Educational tools and an empowerment tool kit based on sensorial, thinking, relaxation and activity themes, tailored to parent/child categories were conceptualised. Conclusion DT methodology provided novel family centred insights, enabling design of tailored empowerment toolkits to optimise perioperative experience. Adapting the hero’s journey call to adventure may motivate and build resilience among children undergoing surgery.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Blair Simpson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Laura Brower
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rachel Hanke
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marc Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Blake Lane
- Live Well Collaborative, College of Design, Architecture, Art, and Planning, Cincinnati, OH, USA
| | - Sara Williams
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Emily McKenna
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christina Bates
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aimee Kraemer
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Sturm
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Department of Orthopedics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rebeccah Brown
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Linda Dunseath
- Live Well Collaborative, College of Design, Architecture, Art, and Planning, Cincinnati, OH, USA
| | - Craig Vogel
- Live Well Collaborative, College of Design, Architecture, Art, and Planning, Cincinnati, OH, USA
| | - Victor Garcia
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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22
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Ellyson AM, Gordon G, Zhou C, Rabbitts JA. Trajectories, Risk Factors, and Impact of Persistent Pain After Major Musculoskeletal Surgery in Adolescents: A Replication Study. THE JOURNAL OF PAIN 2022; 23:995-1005. [PMID: 34974171 PMCID: PMC9232895 DOI: 10.1016/j.jpain.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 06/03/2023]
Abstract
Studies have identified high rates of chronic postsurgical pain in adolescents. Characterizing patterns of pain in the transition from acute to chronic following major surgery may pinpoint critical periods of recovery. This observational study modelled pain trajectories over 1-year following surgery to attempt replication of prior work and evaluate baseline psychosocial factors and 12-month health outcomes. Adolescents 10 to 18 years completed electronic daily pain reporting for 7 days and self-reported health outcomes, at 5 assessment timepoints. Group-based trajectory modelling identified two trajectories with similar starting points in-hospital but distinct recovery courses at home. Pain declined steadily in one group across the study period ("Declining Pain"; estimated probability,18.9%), but pain increased after hospital discharge and remained high through 12-months in the other group ("High and Persistent Pain"; estimated probability,81.1%). Pre-surgery pain (Aor = 1.86, P = .001) and sleep quality (Aor = 0.49, P = .029) were associated with the High and Persistent pain trajectory in multivariate regressions. This trajectory was associated with lower total quality of life (B=-9.79, P = .002), physical health (B = -15.93, P < .001), psychosocial health (B = -6.73, P = .06), and greater fatigue (B = -13.61, P = .001). This study replicated prior findings identifying two post-surgical pain trajectories with diverging pain in the first two weeks. Clinical detection of those with increasing pain and early intervention may interrupt persistence of pain. PERSPECTIVE: This article replicates a prior study identifying distinct post-surgical pain trajectories, Declining Pain and High and Persistent Pain. The High and Persistent pain trajectory is associated with pre-surgery pain, pre-surgery sleep quality, and lower quality of life (total, physical, and psychosocial health as well as fatigue) at 12-month follow-up.
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Affiliation(s)
- Alice M Ellyson
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Grace Gordon
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington; University of Washington College of Arts and Sciences, Seattle, Washington
| | - Chuan Zhou
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Jennifer A Rabbitts
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington.
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23
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Dourson AJ, Willits A, Raut NG, Kader L, Young E, Jankowski MP, Chidambaran V. Genetic and epigenetic mechanisms influencing acute to chronic postsurgical pain transitions in pediatrics: Preclinical to clinical evidence. Can J Pain 2022; 6:85-107. [PMID: 35572362 PMCID: PMC9103644 DOI: 10.1080/24740527.2021.2021799] [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: 08/21/2021] [Revised: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/02/2022]
Abstract
Background Chronic postsurgical pain (CPSP) in children remains an important problem with no effective preventive or therapeutic strategies. Recently, genomic underpinnings explaining additional interindividual risk beyond psychological factors have been proposed. Aims We present a comprehensive review of current preclinical and clinical evidence for genetic and epigenetic mechanisms relevant to pediatric CPSP. Methods Narrative review. Results Animal models are relevant to translational research for unraveling genomic mechanisms. For example, Cacng2, p2rx7, and bdnf mutant mice show altered mechanical hypersensitivity to injury, and variants of the same genes have been associated with CPSP susceptibility in humans; similarly, differential DNA methylation (H1SP) and miRNAs (miR-96/7a) have shown translational implications. Animal studies also suggest that crosstalk between neurons and immune cells may be involved in nociceptive priming observed in neonates. In children, differential DNA methylation in regulatory genomic regions enriching GABAergic, dopaminergic, and immune pathways, as well as polygenic risk scores for enhanced prediction of CPSP, have been described. Genome-wide studies in pediatric CPSP are scarce, but pathways identified by adult gene association studies point to potential common mechanisms. Conclusions Bench-to-bedside genomics research in pediatric CPSP is currently limited. Reverse translational approaches, use of other -omics, and inclusion of pediatric/CPSP endophenotypes in large-scale biobanks may be potential solutions. Time of developmental vulnerability and longitudinal genomic changes after surgery warrant further investigation. Emergence of promising precision pain management strategies based on gene editing and epigenetic programing emphasize need for further research in pediatric CPSP-related genomics.
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Affiliation(s)
- Adam J. Dourson
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
| | - Adam Willits
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Namrata G.R. Raut
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
| | - Leena Kader
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Erin Young
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael P. Jankowski
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Vidya Chidambaran
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
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24
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Ellyson AM, Powelson EB, Groenewald CB, Rabbitts JA. Healthcare utilization and costs among pediatric patients with chronic postsurgical pain after major musculoskeletal surgery. Paediatr Anaesth 2022; 32:577-578. [PMID: 35075715 PMCID: PMC9269163 DOI: 10.1111/pan.14402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Alice M. Ellyson
- Department of Pediatrics, University of Washington, Seattle, Washington, USA,Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Elisabeth B. Powelson
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA,Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Cornelius B. Groenewald
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA,Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Rabbitts
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington, USA
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25
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Rosenbloom BN, Katz J. Modeling the transition from acute to chronic postsurgical pain in youth: A narrative review of epidemiologic, perioperative and psychosocial factors. Can J Pain 2022; 6:166-174. [PMID: 35711297 PMCID: PMC9196786 DOI: 10.1080/24740527.2022.2059754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A growing number of studies have identified high rates of pediatric chronic postsurgical pain (CPSP) after major surgery. Pediatric CPSP is associated with pain-related distress and comorbid mental health outcomes, such as anxiety and depression. From a biopsychosocial perspective, youth factors, such as genetics, epigenetics, sex, presurgical pain, sleep, anxiety, and pain catastrophizing, as well as parent factors, such as cognitive appraisals of their child’s pain expression and pain catastrophizing, converge and lead to chronic pain disability. A comprehensive and testable psychosocial model of the transition from acute to chronic pediatric postsurgical pain has not been developed. This narrative review begins by evaluating the epidemiology and trajectories of pediatric CPSP and moves on to examine the more influential psychosocial models that have been proposed to understand the development of pediatric CPSP. Much of the literature to date has been conducted on adolescents undergoing spinal fusion. To conceptualize the transition from acute to chronic pain in youth, a combined diathesis-stress and interpersonal fear avoidance model is presented. Novel areas of future research include the potential influence that siblings and peers have on a youth’s development of CPSP as well as the influence of gender.
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26
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Boyer ER, Novaczyk ZB, Novacheck TF, Symons FJ, Burkitt CC. Presence and predictors of pain after orthopedic surgery and associated orthopedic outcomes in children with cerebral palsy. PAEDIATRIC AND NEONATAL PAIN 2022; 4:44-52. [PMID: 35546914 PMCID: PMC8975226 DOI: 10.1002/pne2.12067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/28/2021] [Accepted: 12/05/2021] [Indexed: 12/29/2022]
Abstract
While children with cerebral palsy (CP) may undergo 8‐22 orthopedic surgeries in their lifetime, little is known about the associated pain. We aimed to assess the pain presence before and one year after lower extremity orthopedic surgery, predictors of pain presence at follow‐up, and the association between pain and orthopedic outcomes related to surgery. This retrospective study included 86 children with CP (M age = 10.0 years, SD = 3.2; range = 4.1‐17.3 years, Gross Motor Functional Classification System (GMFCS) level I‐III) who underwent orthopedic surgery and had completed questionnaires at gait analyses before (M = 2.7 months; range = 0.0‐5.7) and after surgery (M = 11.8 months; range = 9.0‐14.9). Pain presence, location, and Pediatric Outcomes Data Collection Instrument (PODCI) scores were documented before and after surgery at gait analyses. Pain prevalence was 60% at baseline and 56% at follow‐up. Significant predictors of pain presence at follow‐up included (1) pain presence at baseline (range of odds ratios [OR] across any/all locations = 3.22 to 15.54), (2) older age (range of OR for any pain, back, knee, and foot pain = 1.24‐1.26), (3) female sex (decreased OR for males for ankle pain = 0.12), (4) having hip surgery (decreased OR for foot pain = 0.20), and (5) lower GMFCS level (OR for foot pain = 0.41). Changes in PODCI Sports and Physical Function scores were associated with changes in hip and knee pain (P < .03); PODCI scores worsened for patients who had pain at both time points and improved for patients who had pain at baseline but not follow‐up. Pain was present for over half of the participants before and after orthopedic surgery. Pain presence at follow‐up was predicted by pain presence at baseline. Pain and functional outcomes were correlated at follow‐up. Prospective studies examining perioperative pain experience and factors predicting pain outcomes are warranted.
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Affiliation(s)
- Elizabeth R. Boyer
- Gillette Children’s Specialty Healthcare St. Paul MN USA
- Department of Orthopedic Surgery University of Minnesota Minneapolis MN USA
| | | | - Tom F. Novacheck
- Gillette Children’s Specialty Healthcare St. Paul MN USA
- Department of Orthopedic Surgery University of Minnesota Minneapolis MN USA
| | - Frank J. Symons
- Department of Educational Psychology University of Minnesota Minneapolis MN USA
| | - Chantel C. Burkitt
- Gillette Children’s Specialty Healthcare St. Paul MN USA
- Department of Educational Psychology University of Minnesota Minneapolis MN USA
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27
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Mathias EG, Pai MS. Anxiety and Pain in Children Undergoing Surgery: A Scoping Review. J Perianesth Nurs 2022; 37:545-550. [DOI: 10.1016/j.jopan.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/21/2021] [Accepted: 10/03/2021] [Indexed: 01/17/2023]
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28
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Powelson EB, Chandra NA, Jessen-Fiddick T, Zhou C, Rabbitts J. A Brief Measure Assessing Adolescents' Daily In-Hospital Function Predicts Pain and Health Outcomes at Home After Major Surgery. PAIN MEDICINE 2022; 23:1469-1475. [PMID: 35201357 PMCID: PMC9434145 DOI: 10.1093/pm/pnac033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Pain-related function, an important component of pain assessment, is not systematically assessed in the hospital in part because of a lack of clinically meaningful measures of pain-related function. This prospective cohort study examined whether adolescents' pain-related function during hospitalization, measured daily with the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) is associated with pain and health-related quality of life (HRQOL) 2 weeks following surgery. DESIGN Adolescents undergoing major musculoskeletal surgery (N = 93) completed YAPFAQ (11 items) daily for up to three days in-hospital following surgery. Adolescents self-reported health-related quality of life on the pediatric quality of life inventory and pain intensity on a NRS at baseline (pre-surgery) and two-weeks following surgery. Regression models examined mean YAPFAQ and YAPFAQ rate of change as predictors of two-week outcomes, adjusting for sex, surgery type, and baseline pain/HRQOL. RESULTS Higher mean YAPFAQ scores (poorer function) were associated with higher pain intensity (β = 0.2, p = 0.04) and poorer HRQOL (β = -0.3, p = 0.01) at home 2 weeks following surgery. YAPFAQ rate of change was not associated with 2-week outcomes. CONCLUSIONS Implementation of the YAPFAQ with in-hospital assessments to measure pain-related function will allow more comprehensive pain assessment. In-hospital YAPFAQ scores can predict important postsurgical outcomes at home and inform post-hospital care. PERSPECTIVE This article provides validation of a measure of pediatric pain-related function, the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) to predict important post-hospital outcomes after surgery.
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Affiliation(s)
- Elisabeth B Powelson
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Nuria Alina Chandra
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington.,Paul G. Allen School of Computer Science and Engineering, University of Washington, Seattle, Washington
| | - Tricia Jessen-Fiddick
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington
| | - Chuan Zhou
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Jennifer Rabbitts
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.,Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington
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29
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Birnie KA, Stinson J, Isaac L, Tyrrell J, Campbell F, Jordan IP, Marianayagam J, Richards D, Rosenbloom BN, Clement F, Hubley P. Mapping the current state of pediatric surgical pain care across Canada and assessing readiness for change. Can J Pain 2022; 6:108-120. [PMID: 35692556 PMCID: PMC9176261 DOI: 10.1080/24740527.2022.2038031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Preventing pediatric chronic postsurgical pain is a patient, parent/caregiver, health care professional, and policymaker priority. Poorly managed presurgical and acute postsurgical pain are established risk factors for pediatric chronic postsurgical pain. Effective perioperative pain management is essential to prevent the transition from acute to chronic pain after surgery. Aims The aim of this study was to identify current pediatric surgical pain management practices and assess health system readiness for change at health care institutions conducting pediatric surgery in Canada. Methods An online survey was completed by 85 multidisciplinary health care professionals (nurses, surgeons, anesthesiologists, allied health) from 20 health institutions in Canada regarding institutional pre- and postsurgical pediatric pain care, specialty pain services, and Organizational Readiness for Implementing Change (ORIC). Results Of all specialty pain services, acute and chronic/complex pain services were most common, primarily with physician and nursing involvement. Alignment to recommended practices for pediatric pre- and postsurgical pain care varied (38.1%–79.8% reported “yes, for every child”), with tertiary/quaternary children’s hospitals reporting less alignment than other institutions (community/regional or rehabilitation hospitals, community treatment centers). No significant differences were reported between health care institutions serving pediatric populations only versus those also serving adults. Health care professional experience/practice was the most reported strength in pediatric surgical pain care, with inconsistent standard of care the most common gap. Participants “somewhat agreed” that their institutions were committed and capable of change in pediatric surgical pain care. Conclusions There is a continued need to improve pediatric pain care during the perioperative period at Canadian health care institutions to effectively prevent the development of pediatric postsurgical pain.
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Affiliation(s)
- Kathryn A. Birnie
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4
- Department of Community Health Sciences, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4
- Alberta Children’s Hospital Research Institute, 3330 Hospital Dr NW, Calgary, AB T2N 4N1
| | - Jennifer Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, 686 Bay St., Toronto, ON M5G 0A4
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON M5T 1P8
| | - Lisa Isaac
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children555 University Ave, Toronto, ON M5G 1X8
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward St., Toronto, ON M5G 1E2
| | - Jennifer Tyrrell
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON M5T 1P8
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children555 University Ave, Toronto, ON M5G 1X8
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children555 University Ave, Toronto, ON M5G 1X8
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward St., Toronto, ON M5G 1E2
| | | | | | - Dawn Richards
- Five02Labs, Inc., #502 – 25 Ritchie Ave, Toronto, ON M6R 2J6
| | - Brittany N. Rosenbloom
- Child Health Evaluative Sciences, The Hospital for Sick Children, 686 Bay St., Toronto, ON M5G 0A4
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4
| | - Pam Hubley
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON M5T 1P8
- The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8
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Newton-John T. Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective. Can J Pain 2022; 6:143-152. [PMID: 35528040 PMCID: PMC9067468 DOI: 10.1080/24740527.2022.2038032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child’s quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.
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Affiliation(s)
- Toby Newton-John
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney NSW 2008. Australia
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31
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Narayanasamy S, Yang F, Ding L, Geisler K, Glynn S, Ganesh A, Sathyamoorthy M, Garcia V, Sturm P, Chidambaran V. Pediatric Pain Screening Tool: A Simple 9-Item Questionnaire Predicts Functional and Chronic Postsurgical Pain Outcomes After Major Musculoskeletal Surgeries. THE JOURNAL OF PAIN 2022; 23:98-111. [PMID: 34280572 PMCID: PMC8783955 DOI: 10.1016/j.jpain.2021.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 01/03/2023]
Abstract
Reliable, clinic-friendly screening for Chronic postsurgical pain (CPSP) risk is unavailable. Within a prospective, observational study, we evaluated Pediatric Pain Screening Tool (PPST), a concise 9-item questionnaire, as a preoperative screening tool to identify those at higher risk for CPSP (Numerical Rating Scale > 3/10 beyond 3 months post-surgery) and poor function (disability/Functional Disability Inventory [FDI]/quality of life/ Pediatric Quality of Life) after spine fusion and Nuss procedures. Incidence of CPSP was 34.86% (38/109). We confirmed PPST scale stability, test re-test reliability (ICC = 0.68; P< .001); PPST measures were positively correlated with known CPSP risk factors (P< .001) preoperative pain (Pearson or Spearman Correlation Coefficient [SCC]:0.672), Child anxiety sensitivity index (SCC:0.357), Patient Related Outcome Measures Information System pain interference (SCC:0.569), Patient Related Outcome Measures Information System depression (SCC:0.501), Pediatric Quality of Life (SCC:-0.460) and insomnia severity index (SCC0.567). Preoperative PPST and PPST physical sub-scores (median(IQR) were higher in CPSP (2[0.5,4], 1[0,2]) compared to non-CPSP (1[0,3], 0[0,1.5]) groups (P= .026, P= .029) respectively. PPST scores/sub-scores positively correlated with higher FDI at 6 months but only PPST total and PPST psychosocial subscore correlated with higher FDI at 12 months. Based on ROC, optimal PPST cutoff for CPSP was 2 (63.9% sensitivity, 64.7% specificity). CPSP risk was high (48.94% risk) if PPST ≥ 2 (n = 47) and medium (22.81%) if PPST < 2 (n = 57) after spine/pectus surgery. General and risk-strata specific, targeted psychosocial non-pharmacological interventions, need to be studied. Findings need validation in diverse, larger cohorts. CLINICALTRIALS.GOV IDENTIFIER: NCT02998138. PERSPECTIVE: The article supports Pediatric Pain Screening Tool, a simple 9-item questionnaire, as a preoperative screening tool for CPSP and function 6-12 months after spine/pectus surgeries. PPST measures correlate with known risk factors for CPSP. Risk stratification and targeted preventive interventions in high-risk subjects are proposed.
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Affiliation(s)
- Suryakumar Narayanasamy
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Fang Yang
- Department of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lili Ding
- Department of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristie Geisler
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Susan Glynn
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Arjunan Ganesh
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Victor Garcia
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter Sturm
- Division of Orthopedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Factors associated with increased back pain in primary thoracic adolescent idiopathic scoliosis 10 years after surgery. Spine Deform 2022; 10:55-62. [PMID: 34251608 DOI: 10.1007/s43390-021-00384-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/03/2021] [Indexed: 12/24/2022]
Abstract
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.
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Murray CB, Bartlett A, Meyyappan A, Palermo TM, Aaron R, Rabbitts J. A pilot feasibility and acceptability study of an internet-delivered psychosocial intervention to reduce postoperative pain in adolescents undergoing spinal fusion. Can J Pain 2021; 6:12-23. [PMID: 35434455 PMCID: PMC9009921 DOI: 10.1080/24740527.2021.2009334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Spinal fusion surgery is a common and painful musculoskeletal surgery performed in the adolescent population. Despite the known risk for developing chronic postsurgical pain, few perioperative psychosocial interventions have been evaluated in this population, and none have been delivered remotely (via the Internet) to improve accessibility. Aims The aim of this single-arm pilot study was to evaluate the feasibility and acceptability of the first Internet-based psychological intervention delivered during the perioperative period to adolescents undergoing major spinal fusion surgery and their parents. Methods Thirteen adolescents (M age = 14.3; 69.2% female) scheduled for spine fusion surgery and their parents were provided access to the online psychosocial intervention program. The program included six lessons delivering cognitive-behavioral therapy skills targeting anxiety, sleep, and acute pain management during the month prior to and the month following surgery. Feasibility indicators included recruitment rate, intervention engagement, and measure completion. Acceptability was assessed via quantitative ratings and qualitative interviews. Results Our recruitment rate was 81.2% of families approached for screening. Among participating adolescent–parent dyads, high levels of engagement were demonstrated (100% completed all six lessons). All participants completed outcome measures. High treatment acceptability was demonstrated via survey ratings and qualitative feedback, with families highlighting numerous strengths of the program as well as areas for improvement. Conclusions These findings suggest that this online psychosocial intervention delivered during the perioperative period is feasible and acceptable to adolescents and their parents. Given favorable feasibility outcomes, an important next step is to evaluate the intervention in a full-scale randomized controlled trial.
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Affiliation(s)
- Caitlin B. Murray
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, WA, USA
| | - Anthea Bartlett
- School of Social and Political Science, The University of Edinburgh, Edinburgh, UK
| | | | - Tonya M. Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, WA, USA
| | - Rachel Aaron
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Rabbitts
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Center for Clinical and Translational Research
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Pestana-Santos M, Pestana-Santos A, Santos MR, Lomba L. Adolescents' perioperative experiences in relation to inpatient and outpatient elective surgery - a qualitative study. Scand J Caring Sci 2021; 36:493-503. [PMID: 34761406 DOI: 10.1111/scs.13046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 10/31/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Perioperative experience can be very distressing in adolescence if not managed properly by healthcare professionals. In the clinical context, the emotional expression of the adolescent is less spontaneous, which makes the assessment of anxiety, pain or even the desire to be involved in the perioperative process, difficult. Listening to their perioperative experiences will permit an understanding of their difficulties and expectations, regardless of the surgical intervention undergone. AIM To explore the adolescents' perioperative experiences in relation to inpatient and outpatient elective surgery. METHODS Qualitative exploratory study, with thematic analysis approach. A purposive sample of 40 adolescents aged 14-18 years and in the perioperative period, from two paediatric surgery settings in a university hospital, was questioned from January to July 2020. Data were collected using a semi-structured interview and analysed inductively with qualitative thematic analysis. RESULTS The data yielded one major theme, five themes, and 14 sub-themes. The major theme, Adolescent in perioperative period, included the five themes: (1) emotional and psychological aspects; (2) physical aspects; (3) social aspects; (4) organizational aspects; (5) previous surgical experience. Adolescents expressed fear of the unknown, anxiety, difficulty in pain control, and feelings of autonomy loss. Issues related to withdrawal from school and friends is also a focus of adolescent concern during the perioperative period. Despite showing satisfaction with the way they were cared for, they complained about the lack of pre- and post-operative preparation. CONCLUSION There are aspects that should be considered when caring for adolescents in perioperative period. As far as possible, programmes to prevent adolescents' anxiety in perioperative period should be designed in a holistic perspective, with aim at the psychological, physical, sociocultural, and organisational aspects.
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Affiliation(s)
- Marcia Pestana-Santos
- Institute of Biomedical Sciences, Abel Salazar of Porto University, Porto, Portugal.,Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal.,Pediatric Department, Coimbra University and Hospital Centre, Coimbra, Portugal
| | | | - Margarida Reis Santos
- Institute of Biomedical Sciences, Abel Salazar of Porto University, Porto, Portugal.,Nursing School of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
| | - Lurdes Lomba
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
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Charalampidis A, Rundberg L, Möller H, Gerdhem P. Predictors of persistent postoperative pain after surgery for idiopathic scoliosis. J Child Orthop 2021; 15:458-463. [PMID: 34858532 PMCID: PMC8582608 DOI: 10.1302/1863-2548.15.210090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/11/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To identify factors contributing to persistent postoperative pain in patients treated surgically for idiopathic scoliosis. METHODS In total, 280 patients aged ten through 25 years at surgery, were identified in the Swedish Spine registry; all having preoperative and postoperative visual analogue scale (VAS) for back pain scores. The patients were divided into a high and low postoperative pain group based on the reported postoperative VAS for back pain scores (by using 45 mm on the 0 mm to 100 mm VAS scale as a cut-off). The patient-reported questionnaire included VAS for back pain, the 3-level version of EuroQol 5-dimensional (EQ-5D-3L) instrument, the EuroQol VAS (EQ-VAS) and the Scoliosis Research Society 22r instrument (SRS-22r). Predictors of postoperative back pain were searched in the preoperative data. RESULTS The 67 (24%) patients that reported high postoperative VAS back pain (> 45 mm) also reported lower postoperative EQ-5D-3L, EQ-VAS and SRS-22r than patients with low postoperative VAS back pain (all p < 0.001). Two preoperative variables were independently associated with postoperative pain; each millimetre increase in preoperative VAS back pain (on the 0 mm to 100 mm scale) was associated with a higher risk of being in the high postoperative back pain group (odds ratio (OR) 1.03; 95% confidence interval (CI) 1.02 to 1.05) and each 1 point decrease on the preoperative SRS-22r mental health (scale from 1 to 5) was associated with a higher risk of being in the high postoperative back pain group (OR 1.68; 95% CI 1.03 to 2.73). CONCLUSION High preoperative back pain and low preoperative mental health are independent predictors of back pain after surgery for idiopathic scoliosis. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anastasios Charalampidis
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Sweden,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden,Correspondence should be sent to Anastasios Charalampidis, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, 141 86 Stockholm, Sweden. E-mail:
| | - Lina Rundberg
- Department of Surgery, Danderyd Hospital, Stockholm, Sweden
| | - Hans Möller
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Sweden,Stockholm Center for Spine Surgery, Stockholm, Sweden
| | - Paul Gerdhem
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Sweden,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
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Helenius L, Yrjälä T, Oksanen H, Pajulo O, Löyttyniemi E, Taittonen M, Helenius I. Pregabalin and Persistent Postoperative Pain Following Posterior Spinal Fusion in Children and Adolescents: A Randomized Clinical Trial. J Bone Joint Surg Am 2021; 103:00004623-990000000-00319. [PMID: 34424869 DOI: 10.2106/jbjs.21.00153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical correction of spinal deformity requires major surgical intervention with extensive manipulation of the spine and neural elements. Persistent postoperative pain affects patient quality of life and can also cause financial burden for patient families and for society. We aimed to investigate the effect of perioperative pregabalin on the incidence of persistent pain following instrumented spinal fusion. METHODS We conducted a randomized, double-blinded, and placebo-controlled single-center clinical trial. Adolescents and children 10 to 21 years old with a spinal deformity who were scheduled for pedicle screw instrumentation and fusion were randomized into either the pregabalin or placebo group. Patients received 2 mg/kg of pregabalin or a placebo twice daily preoperatively and for 5 days postoperatively. The duration of follow-up was 2 years. The primary outcomes were cumulative opioid consumption during the first 48 hours postoperatively and the incidence of persistent postoperative pain over the course of the 2-year follow-up. RESULTS Sixty-four of 77 eligible patients were enrolled in the study, with all patients completing the 2-year follow-up. Thirty-three patients were randomized into the pregabalin group and 31 into the placebo group. There was no significant difference in cumulative 48-hour opioid consumption between the study groups. The Scoliosis Research Society 24-Item Questionnaire pain domain score improved significantly, from a mean value of 3.8 in both groups to 4.3 in the pregabalin and 4.0 in the placebo group at 2 years postoperatively, with no differences between the study groups at any time point (p = 0.317). The Scoliosis Research Society total scores of the study groups were similar (p = 0.678). Back pain, as measured with use of a visual analogue scale, improved significantly (p = 0.001) with no significant differences at any time point (preoperatively and 6 months, 1 year, and 2 years postoperatively). CONCLUSIONS Perioperative pregabalin does not reduce postoperative opioid consumption or the incidence of persistent postoperative pain following instrumented posterior spinal fusion for spinal deformities in an adolescent population. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Linda Helenius
- Department of Anesthesia and Intensive Care, University of Turku and Turku University Hospital, Turku, Finland
| | - Tommi Yrjälä
- Department of Anesthesia and Intensive Care, University of Turku and Turku University Hospital, Turku, Finland
| | - Hanna Oksanen
- Department of Pediatric Orthopedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Pajulo
- Department of Pediatric Orthopedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | | | - Markku Taittonen
- Department of Anesthesia and Intensive Care, University of Turku and Turku University Hospital, Turku, Finland
| | - Ilkka Helenius
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Patel A, Pahys JM, Samdani AF, Newton PO, Bastrom TP, Shah SA, Miyanji F, Hwang SW. Early and late hospital readmissions in adolescent idiopathic scoliosis. Spine Deform 2021; 9:1041-1048. [PMID: 33939169 DOI: 10.1007/s43390-021-00294-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/18/2021] [Indexed: 10/21/2022]
Abstract
STUDY DESIGN Retrospective review of a prospectively collected multicenter database. OBJECTIVES To identify risk factors for early and late readmission of surgically treated patients with adolescent idiopathic scoliosis (AIS). Specific risk factors associated with readmission in patients with AIS remain poorly understood. METHODS Patients with AIS who were operatively treated from 19 centers specializing in the treatment of pediatric spinal deformity were studied. Data from a minimum 2 years of clinical follow-up and any readmission were available for analysis. Characteristics of patients with no readmission, early readmission (< 90 days), and late readmission (> 90 days) were evaluated. Both univariate and multivariate analyses of risk factors for readmission were performed. RESULTS 2049 patients were included in our cohort, with 1.6% requiring early readmission and 3.3% late readmission. In the multivariate analysis, greater preoperative coronal imbalance was associated with early readmission. Longer operative time was associated with late readmission. Finally, greater preoperative pain (SRS-22 pain scale) was associated with both early and late readmission. GI complications accounted for a higher proportion of early readmissions than previously reported in the literature. CONCLUSIONS Preoperative counseling of patients with higher levels of pain and coronal imbalance and the implementation of a thorough postoperative bowel regimen may help optimize patient outcomes. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Akul Patel
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Joshua M Pahys
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad Street, Philadelphia, PA, 19140, USA
| | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad Street, Philadelphia, PA, 19140, USA
| | | | | | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, 3551 N Broad Street, Philadelphia, PA, 19140, USA.
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Julien-Marsollier F, Assaker R, Michelet D, Camby M, Galland A, Marsac L, Vacher T, Simon AL, Ilharreborde B, Dahmani S. Effects of opioid-reduced anesthesia during scoliosis surgery in children: a prospective observational study. Pain Manag 2021; 11:679-687. [PMID: 34102877 DOI: 10.2217/pmt-2020-0100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Florence Julien-Marsollier
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Rita Assaker
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Daphné Michelet
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Matthieu Camby
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Anne Galland
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Lucile Marsac
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Thomas Vacher
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Anne-Laure Simon
- Université de Paris, Paris, France.,Department of Orthopedic Surgery, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Brice Ilharreborde
- Université de Paris, Paris, France.,Department of Orthopedic Surgery, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Souhayl Dahmani
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
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Phenotyping peripheral neuropathic pain in male and female adolescents: pain descriptors, somatosensory profiles, conditioned pain modulation, and child-parent reported disability. Pain 2021; 162:1732-1748. [PMID: 33394878 DOI: 10.1097/j.pain.0000000000002172] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022]
Abstract
ABSTRACT Neuropathic pain (NeuP) can be difficult to diagnose and manage in children. Data regarding prevalence and sex-dependent differences are limited, and more detailed phenotyping is needed. This observational cohort study recruited adolescents (10-17 years) with NeuP or complex regional pain syndrome (CRPS). After pain history and NeuP questionnaires, quantitative sensory testing was performed. Individual z-score plots were calculated with body-region control measures and matched to mechanism-related sensory profiles (sensory loss, thermal hyperalgesia, and mechanical hyperalgesia). Conditioned pain modulation was assessed with pressure pain threshold and a contralateral cold conditioning stimulus, and meaningful conditioned pain modulation defined as twice the standard error of measurement. Patients and parents completed validated questionnaires for child quality of life (QoL), pain catastrophizing, and self-reported anxiety/depression. Males (n = 23) and females (n = 43) with NeuP (n = 52) or CRPS (n = 14) reported moderate-severe pain with neuropathic sensory descriptors. Mixed patterns of sensory gain/loss at pain sites were not sex-dependent. Thermal hyperalgesia was common in both NeuP and CRPS, whereas sensory loss occurred only with NeuP and in a smaller proportion than adult cohorts. Conditioned pain modulation was inhibitory in 54%, facilitatory in 14%, and nonresponders had variable cold conditioning sensitivity. Males and females reported marked impairment of QoL, increased emotional distress, and pain catastrophising. Child-parent QoL scores correlated, but catastrophizing scores were discordant when parents or adolescents reported higher anxiety/depression. NeuP in adolescents is associated with significant pain, physical impairment, and psychosocial impairment. Quantifying alterations in somatosensory profiles, descending modulation, child and parent psychological function will inform individualized therapy and stratification for future clinical trials.
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Rosenbloom BN, Slepian PM, Pagé MG, Isaac L, Campbell F, Stinson J, Katz J. Differential Risk Factor Profiles in the Prediction of General and Pain-Specific Functional Limitations 12 Months after Major Pediatric Surgery. CHILDREN-BASEL 2021; 8:children8050360. [PMID: 33946246 PMCID: PMC8146066 DOI: 10.3390/children8050360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 12/19/2022]
Abstract
Pediatric chronic post-surgical pain is a surgical complication associated with various levels of functional limitation. Two commonly used measures of functional limitations in youth are the Functional Disability Inventory (FDI) and the PROMIS Pediatric Pain Interference Scale (PPIS), where the former is general, and the latter, pain specific. The aim of the present study was to prospectively compare pre-surgical youth and parent risk factors for youth functional limitations, assessed by the FDI and PPIS, 12 months after major pediatric surgery. Risk factors for the FDI and PPIS were compared in 79 dyads consisting of youth (58% female, M = 14.56 years; SD = 2.31) undergoing major surgery and one of their parents. The FDI and PPIS were highly correlated prior to surgery (r = 0.698, p < 0.001) and even more so 12 months after surgery (r = 0.807, p < 0.001). Parent pre-surgical anxiety sensitivity and youth pre-surgical functional disability significantly predicted 12-month FDI (F(6,56) = 4.443, p = 0.001, Adjusted R2 = 0.25), whereas parent pre-surgical anxiety sensitivity, trait anxiety, pain anxiety, as well as youth pain-related anxiety and worry significantly predicted 12-month PPIS (F(6,45) = 4.104, p = 0.002, Adjusted R2 = 0.27). Risk factors for 12-month general and pain-specific functional limitations differ by dyad member and type. Functional limitations in youth after surgery are predicted by youth and parent factors, however the risk factors differ between the FDI and the PPIS.
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Affiliation(s)
- Brittany N. Rosenbloom
- Department of Psychology, York University, Toronto, ON M3J 1P3, Canada;
- Correspondence: (B.N.R.); (J.K.); Tel.: +416-636-2100 (B.N.R.); +416-636-2100 (J.K.)
| | - P. Maxwell Slepian
- Department of Psychology, York University, Toronto, ON M3J 1P3, Canada;
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - M. Gabrielle Pagé
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC H2X 0A9, Canada;
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC H3T 1J4, Canada
| | - Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (L.I.); (F.C.)
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (L.I.); (F.C.)
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Jennifer Stinson
- Department of Anesthesia and Pain Medicine, Child Health Evaluative Sciences Research Institute, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5T 1P8, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, ON M3J 1P3, Canada;
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Psychology, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Correspondence: (B.N.R.); (J.K.); Tel.: +416-636-2100 (B.N.R.); +416-636-2100 (J.K.)
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Chidambaran V, Zhang X, Pilipenko V, Chen X, Wronowski B, Geisler K, Martin LJ, Barski A, Weirauch MT, Ji H. Methylation quantitative trait locus analysis of chronic postsurgical pain uncovers epigenetic mediators of genetic risk. Epigenomics 2021; 13:613-630. [PMID: 33820434 DOI: 10.2217/epi-2020-0424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Overlap of pathways enriched by single nucleotide polymorphisms and DNA-methylation underlying chronic postsurgical pain (CPSP), prompted pilot study of CPSP-associated methylation quantitative trait loci (meQTL). Materials & methods: Children undergoing spine-fusion were recruited prospectively. Logistic-regression for genome- and epigenome-wide CPSP association and DNA-methylation-single nucleotide polymorphism association/mediation analyses to identify meQTLs were followed by functional genomics analyses. Results: CPSP (n = 20/58) and non-CPSP groups differed in pain-measures. Of 2753 meQTLs, DNA-methylation at 127 cytosine-guanine dinucleotides mediated association of 470 meQTLs with CPSP (p < 0.05). At PARK16 locus, CPSP risk meQTLs were associated with decreased DNA-methylation at RAB7L1 and increased DNA-methylation at PM20D1. Corresponding RAB7L1/PM20D1 blood eQTLs (GTEx) and cytosine-guanine dinucleotide-loci enrichment for histone marks, transcription factor binding sites and ATAC-seq peaks suggest altered transcription factor-binding. Conclusion: CPSP-associated meQTLs indicate epigenetic mechanisms mediate genetic risk. Clinical trial registration: NCT01839461, NCT01731873 (ClinicalTrials.gov).
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Xue Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Valentina Pilipenko
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Xiaoting Chen
- Division of Allergy & Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Benjamin Wronowski
- Division of Allergy & Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kristie Geisler
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH 45229, USA
| | - Artem Barski
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Allergy & Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH 45229, USA
| | - Matthew T Weirauch
- Division of Allergy & Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH 45229, USA
| | - Hong Ji
- Department of Anatomy, Physiology & Cell biology, California National Primate Research Center, University of California, Davis, CA 95616, USA
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Chidambaran V, Pilipenko V, Jegga AG, Geisler K, Martin LJ. Systems Biology Guided Gene Enrichment Approaches Improve Prediction of Chronic Post-surgical Pain After Spine Fusion. Front Genet 2021; 12:594250. [PMID: 33868360 PMCID: PMC8044807 DOI: 10.3389/fgene.2021.594250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
Objectives Incorporation of genetic factors in psychosocial/perioperative models for predicting chronic postsurgical pain (CPSP) is key for personalization of analgesia. However, single variant associations with CPSP have small effect sizes, making polygenic risk assessment important. Unfortunately, pediatric CPSP studies are not sufficiently powered for unbiased genome wide association (GWAS). We previously leveraged systems biology to identify candidate genes associated with CPSP. The goal of this study was to use systems biology prioritized gene enrichment to generate polygenic risk scores (PRS) for improved prediction of CPSP in a prospectively enrolled clinical cohort. Methods In a prospectively recruited cohort of 171 adolescents (14.5 ± 1.8 years, 75.4% female) undergoing spine fusion, we collected data about anesthesia/surgical factors, childhood anxiety sensitivity (CASI), acute pain/opioid use, pain outcomes 6-12 months post-surgery and blood (for DNA extraction/genotyping). We previously prioritized candidate genes using computational approaches based on similarity for functional annotations with a literature-derived "training set." In this study, we tested ranked deciles of 1336 prioritized genes for increased representation of variants associated with CPSP, compared to 10,000 randomly selected control sets. Penalized regression (LASSO) was used to select final variants from enriched variant sets for calculation of PRS. PRS incorporated regression models were compared with previously published non-genetic models for predictive accuracy. Results Incidence of CPSP in the prospective cohort was 40.4%. 33,104 case and 252,590 control variants were included for association analyses. The smallest gene set enriched for CPSP had 80/1010 variants associated with CPSP (p < 0.05), significantly higher than in 10,000 randomly selected control sets (p = 0.0004). LASSO selected 20 variants for calculating weighted PRS. Model adjusted for covariates including PRS had AUROC of 0.96 (95% CI: 0.92-0.99) for CPSP prediction, compared to 0.70 (95% CI: 0.59-0.82) for non-genetic model (p < 0.001). Odds ratios and positive regression coefficients for the final model were internally validated using bootstrapping: PRS [OR 1.98 (95% CI: 1.21-3.22); β 0.68 (95% CI: 0.19-0.74)] and CASI [OR 1.33 (95% CI: 1.03-1.72); β 0.29 (0.03-0.38)]. Discussion Systems biology guided PRS improved predictive accuracy of CPSP risk in a pediatric cohort. They have potential to serve as biomarkers to guide risk stratification and tailored prevention. Findings highlight systems biology approaches for deriving PRS for phenotypes in cohorts less amenable to large scale GWAS.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Valentina Pilipenko
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Anil G Jegga
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Kristie Geisler
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Rabbitts JA, Holley AL, Zhou C, Chen L. Physical Activity as a Predictor of Chronic Pain Following Pediatric Spinal Surgery. Clin J Pain 2021; 37:186-193. [PMID: 33273273 PMCID: PMC7867602 DOI: 10.1097/ajp.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 11/11/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES (1) Characterize objective physical activity patterns via actigraphy over 4 months postspinal fusion surgery, and (2) examine associations between activity patterns at 2-week and chronic postsurgical pain (CPSP) status at 4 months. MATERIALS AND METHODS Data from 109 youth (10 to 18 y) who underwent spinal fusion surgery at a children's hospital in the Northwestern United States were analyzed. Youth completed questionnaires and actigraphic assessment of physical activity presurgery, and 2 weeks and 4 months postsurgery. RESULTS Eighteen percent of youth developed CPSP at 4 months. Presurgery physical activity was similar for youth with and without CPSP. At 2 weeks postsurgery, daily activity levels were lower for youth who developed CPSP as compared with those who did not, including lower mean activity (168 vs. 212 counts/min, P=0.01), fewer activity bouts (n=1.7 vs. 2.6, P=0.02), and shorter bout duration (27 vs. 40 min, P=0.02). Differences in activity were maintained at 4 months such that youth with CPSP had lower mean activity (284 vs. 334 counts/min, P=0.03), as well as greater proportion time spent sedentary and lower proportion time in light activity than youth without CPSP. In adjusted models examining 2-week actigraphy as a predictor of 4-month pain status, mean activity (odds ratio=0.99, P=0.04) and number of activity bouts (odds ratio=0.79, P=0.02) were associated with subsequent CPSP status over and above 2-week pain intensity. DISCUSSION Lower activity engagement during the initial weeks following spinal fusion surgery was associated with development of CPSP, suggesting early physical activity limitations as a risk factor for CPSP in youth. Understanding recovery patterns is critical for identifying those at risk for chronic pain and implementing early interventions.
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Affiliation(s)
- Jennifer A. Rabbitts
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children’s Hospital, Seattle, WA, USA
| | - Amy L. Holley
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Chuan Zhou
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, WA, USA
| | - Lucas Chen
- Center for Clinical and Translational Research, Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington College of Arts and Sciences, Seattle, WA
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Association Between Intraoperative Remifentanil Dosage and Postoperative Opioid Consumption in Adolescent Idiopathic Spine Surgery: A Retrospective Cohort Study. Anesth Analg 2021; 133:984-990. [PMID: 33555691 DOI: 10.1213/ane.0000000000005395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adolescent idiopathic scoliosis (AIS) surgery is associated with significant postoperative pain. Remifentanil is a short-acting opioid that is often used as a component of total intravenous anesthesia. Remifentanil has been implicated in acute opioid tolerance and opioid-induced hyperalgesia, resulting in increased postoperative pain and opioid consumption. This retrospective study sought to investigate the relationship between the dose of intraoperative remifentanil and cumulative postoperative opioid consumption through 72 hours following surgery for pediatric AIS patients. METHODS We performed a retrospective chart review of adolescent patients undergoing posterior spine instrumentation under total intravenous general anesthesia at a single major pediatric center between January 2015 and October 2017. The relationship between intraoperative cumulative weight-adjusted remifentanil dose and logarithmic transformation of cumulative weight-adjusted opioid consumption through 72 hours following surgery was examined by regression analysis. A priori determined potential confounding variables were collected, including demographic data, perioperative analgesic agents (ie, ketamine, dexmedetomidine, and acetaminophen), surgical duration, vertebrae instrumented, and blood transfusion. Multivariable linear regression analysis was used to adjust for these possible confounding variables. RESULTS Eighty-nine patients met inclusion criteria, of which 78 had complete data for analysis. Univariable linear regression analysis revealed no association between remifentanil dose and opioid consumption through 72 hours following surgery (slope = 0.79 [95% confidence interval [CI], 0.61-0.98; R2 = 0.0039; P = .588]). After adjustment for possible confounding factors, no relationship between remifentanil dose (regression coefficient (coeff.) -0.08; 95% CI, -1.59 to 1.43; P = .912) and opioid consumption through 72 hours was found (slope =0.90 [95% CI, -0.65 to 2.46]; R2 = 0.1634). Similar results were obtained when the model was repeated for opioid consumption in postanesthesia care unit (PACU). CONCLUSIONS In this study examining adolescent patients undergoing surgery for idiopathic scoliosis, no association was found between the dose of intraoperative remifentanil and postoperative opioid consumption in the context of a propofol-based total intravenous anesthetic and multimodal analgesia. These results provide direction for future prospective controlled studies to further evaluate this relationship.
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Sadhasivam S, Aruldhas BW, Packiasabapathy S, Overholser BR, Zhang P, Zang Y, Renschler JS, Fitzgerald RE, Quinney SK. A Novel Perioperative Multidose Methadone-Based Multimodal Analgesic Strategy in Children Achieved Safe and Low Analgesic Blood Methadone Levels Enabling Opioid-Sparing Sustained Analgesia With Minimal Adverse Effects. Anesth Analg 2021; 133:327-337. [PMID: 33481403 DOI: 10.1213/ane.0000000000005366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Intraoperative methadone, a long-acting opioid, is increasingly used for postoperative analgesia, although the optimal methadone dosing strategy in children is still unknown. The use of a single large dose of intraoperative methadone is controversial due to inconsistent reductions in total opioid use in children and adverse effects. We recently demonstrated that small, repeated doses of methadone intraoperatively and postoperatively provided sustained analgesia and reduced opioid use without respiratory depression. The aim of this study was to characterize pharmacokinetics, efficacy, and safety of a multiple small-dose methadone strategy. METHODS Adolescents undergoing posterior spinal fusion (PSF) for idiopathic scoliosis or pectus excavatum (PE) repair received methadone intraoperatively (0.1 mg/kg, maximum 5 mg) and postoperatively every 12 hours for 3-5 doses in a multimodal analgesic protocol. Blood samples were collected up to 72 hours postoperatively and analyzed for R-methadone and S-methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidene (EDDP) metabolites, and alpha-1 acid glycoprotein (AAG), the primary methadone-binding protein. Peak and trough concentrations of enantiomers, total methadone, and AAG levels were correlated with clinical outcomes including pain scores, postoperative nausea and vomiting (PONV), respiratory depression, and QT interval prolongation. RESULTS The study population included 38 children (10.8-17.9 years): 25 PSF and 13 PE patients. Median total methadone peak plasma concentration was 24.7 (interquartile range [IQR], 19.2-40.8) ng/mL and the median trough was 4.09 (IQR, 2.74-6.4) ng/mL. AAG concentration almost doubled at 48 hours after surgery (median = 193.9, IQR = 86.3-279.5 µg/mL) from intraoperative levels (median = 87.4, IQR = 70.6-115.8 µg/mL; P < .001), and change of AAG from intraoperative period to 48 hours postoperatively correlated with R-EDDP (P < .001) levels, S-EDDP (P < .001) levels, and pain scores (P = .008). Median opioid usage was minimal, 0.66 (IQR, 0.59-0.75) mg/kg morphine equivalents/d. No respiratory depression (95% Wilson binomial confidence, 0-0.09) or clinically significant QT prolongation (median = 9, IQR = -10 to 28 milliseconds) occurred. PONV occurred in 12 patients and was correlated with morphine equivalent dose (P = .005). CONCLUSIONS Novel multiple small perioperative methadone doses resulted in safe and lower blood methadone levels, <100 ng/mL, a threshold previously associated with respiratory depression. This methadone dosing in a multimodal regimen resulted in lower blood methadone analgesia concentrations than the historically described minimum analgesic concentrations of methadone from an era before multimodal postoperative analgesia without postoperative respiratory depression and prolonged corrected QT (QTc). Larger studies are needed to further study the safety and efficacy of this methadone dosing strategy.
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Affiliation(s)
| | - Blessed W Aruldhas
- From the Department of Anesthesia.,Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, India
| | | | - Brian R Overholser
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, Indiana
| | | | | | | | - Ryan E Fitzgerald
- Division of Pediatric Orthopedic Surgery, Department of Orthopedic Surgery
| | - Sara K Quinney
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Obstetrics and Gynecology.,Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, Indiana
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Kelley-Quon LI, Kirkpatrick MG, Ricca RL, Baird R, Harbaugh CM, Brady A, Garrett P, Wills H, Argo J, Diefenbach KA, Henry MCW, Sola JE, Mahdi EM, Goldin AB, St Peter SD, Downard CD, Azarow KS, Shields T, Kim E. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg 2021; 156:76-90. [PMID: 33175130 PMCID: PMC8995055 DOI: 10.1001/jamasurg.2020.5045] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
IMPORTANCE Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking. OBJECTIVE To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery. EVIDENCE REVIEW Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique. FINDINGS Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery. CONCLUSIONS AND RELEVANCE These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.
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Affiliation(s)
- Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Preventive Medicine, University of Southern California, Los Angeles
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | | | - Robert L Ricca
- Department of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Robert Baird
- Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ashley Brady
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Paula Garrett
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Hale Wills
- Division of Pediatric Surgery, Hasbro Children's Hospital, Providence, Rhode Island
- Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jonathan Argo
- Department of Pediatric Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Marion C W Henry
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Kenneth S Azarow
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland
| | - Tracy Shields
- Division of Library Services, Naval Medical Center, Portsmouth, Virginia
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Rabbitts JA, Groenewald CB, Zhou C. Subacute Pain Trajectories following major musculoskeletal surgery in adolescents: A Pilot Study. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2020; 4:3-12. [PMID: 33415314 PMCID: PMC7787390 DOI: 10.1080/24740527.2020.1765692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background: Adolescents who undergo major surgery experience high rates of disabling acute and chronic postsurgical pain (CPSP). However, little is known about the subacute period when acute to chronic pain transition occurs. Aims: The aims of this study were to examine feasibility of electronic daily monitoring of pain and opioid use in adolescents during the first 30 days at home following major surgery and identify target features of subacute pain curves associated with CPSP at 4 months. Methods: Twenty-five youth (10–18 years) undergoing major musculoskeletal surgery reported daily pain severity, interference, and opioid use on the Brief Pain Inventory each evening for 30 days after hospital discharge to form short time series trajectories. At 4 months, youth reported on pain intensity and health-related quality of life. Characteristics of subacute pain severity and interference curves were compared by 4-month CPSP status. Results: At 4 months, 20.8% of youth met criteria for CPSP. During the 30-day monitoring period, youth who went on to develop CPSP reported high pain severity on 45.9% of days compared to 2.9% of days in youth who recovered (P = 0.005) and high pain interference on 49.4% of days vs. 9.7% in youth who recovered (P = 0.01). Pain variability and rate of change were not significantly associated with CPSP in our pilot sample. Conclusions: We found it feasible to collect daily pain data in youth recovering at home after major surgery. Pilot findings suggest that daily electronic monitoring may identify early recovery problems at home after surgery. Larger studies are needed to validate subacute pain trajectory features to identify risk for CPSP.
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Affiliation(s)
- Jennifer A Rabbitts
- Department of Anesthesiology & Pain Medicine.,Center for Clinical and Translational Research
| | - Cornelius B Groenewald
- Department of Anesthesiology & Pain Medicine.,Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, WA, USA
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, WA, USA
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Chow CHT, Schmidt LA, Buckley DN. The role of anxiety and related states in pediatric postsurgical pain. Can J Pain 2020; 4:26-36. [PMID: 33987517 PMCID: PMC7942768 DOI: 10.1080/24740527.2020.1847600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 10/25/2020] [Accepted: 11/04/2020] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Cheryl H. T. Chow
- Department of Psychology, Neuroscience & Behavior, McMaster University, Hamilton, Ontario, Canada
| | - Louis A. Schmidt
- Department of Psychology, Neuroscience & Behavior, McMaster University, Hamilton, Ontario, Canada
| | - D. Norman Buckley
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis. Paediatr Drugs 2020; 22:575-601. [PMID: 33094437 DOI: 10.1007/s40272-020-00423-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
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.
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Siemer LC, Foxen-Craft E, Malviya S, Ramirez M, Li GY, James C, Voepel-Lewis T. The relationship between parental factors, child symptom profile, and persistent postoperative pain interference and analgesic use in children. Paediatr Anaesth 2020; 30:1340-1347. [PMID: 33010105 DOI: 10.1111/pan.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Lauren C Siemer
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Emily Foxen-Craft
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Shobha Malviya
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mark Ramirez
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - G Ying Li
- Department of Orthopedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Chrystina James
- Department of Orthopedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Terri Voepel-Lewis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,School of Nursing, University of Michigan, Ann Arbor, MI, USA
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