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Pain after pediatric surgery.

In an ideal world, children undergoing surgery would experience minimal postoperative pain that lessens in intensity over time and completely resolveswithindays toweeksafter surgery.Unfortunately, this is not the case and many children not only experience poorly controlled postsurgical pain but also go on to develop chronic pain after surgery. Chronic postsurgical pain (CPSP) is a relatively new, yet well-known and common clinical entity with a reported incidence between5%and80% inadult patients after variouscommonsurgical procedures. Based on criteria by the International Association for the Study of Pain, CPSP is a pain syndrome that develops postoperatively and lasts at least 2 months with other causes for pain being excluded; pain continuing from a preexisting disease is also an exclusion. Chronic postsurgical pain is difficult to treat and is thus an important cause for referral to chronic pain facilities. Although well recognized in the adult literature, CPSP has only recently been documented in the literature on recovery from pediatric surgery and most studies have been retrospective in nature. Fortier et al. documented a prevalence rate of 13.3% of CPSP in children aged 2 to 17 years who had undergone general, orthopedic, and urological surgeries in the previous year. More recently, investigators have begun to follow children prospectively to examine the trajectories of pain after surgery. Page et al. assessed postsurgical pain in children undergoing major orthopedic and general surgery up to 12months after their surgical procedures. Nearly, one-quarter of children reported CPSP 12 months after surgery that was moderate to severe in nature and most reported frequency of pain of once a week or greater, with approximately one-third reporting daily pain. In terms of predictors of CPSP, pain severity and unpleasantness predicted the transition from acute to chronic pain and anxiety sensitivity predicted maintenance of CPSP. Similar prospective studies have followed, focusing on the development of CPSP after pediatric spinal fusion surgery, and have reported prevalence rates between 11% and 22%. Risk factors for CPSP in these studies included older age and higher baseline levels of pain and anxiety. It is important to note, however, that most scoliosis patients report preoperative pain; therefore, disentangling the contribution of surgery to the development of CPSP is challenging. In this issue of PAIN, Rabbitts et al. studied a group of children undergoingmajor spine or chest surgery from baseline to 1 year after surgery. The authors identified a significant subgroup of children who developed persistent pain already distinct at 2 weeks after surgery. The authors further found that parent pain catastrophizing at baseline significantly predicted an unfavorable postsurgical pain trajectory, whereas child pain catastrophizing was not associated with postsurgical pain. Furthermore, children in the persistent pain group reported poorer health-related quality of life and functional outcomes at 12 months. This study is of high importance because it suggests that developing preventive strategies that target parents’ cognitions and behaviors around their child’s pain may improve pain and health outcomes in children having major surgeries and perhaps, reduce the risk of CPSP. The work of Rabbitts et al. also contributes significantly to the literature by identifying risk factors for the development of CPSP in children after major surgery. Although substantial work has highlighted risk factors for development of CPSP in adults, including age (direction of relationship varies depending on surgery type), female gender, anxiety, extent of trauma to body, site and extent of surgery, and severe immediate postoperative pain (for reviews see), data on risk factors for children are more limited given the nascent literature on pediatric CPSP, but a recent review by Nikolajsen and Brix suggested that in addition to the factors identified by Rabbitts et al., older age, preoperative pain, acute postoperative pain, and psychological factors such as baseline levels of anxiety in children may predict the transition from acute to chronic pain in children after surgery. We conclude that much more research is needed in this important area. Considering that 1 million children undergo surgery every year and that the prevalence rates for CPSP in childrenmay be as high as 22%, much attention is needed for the development of various interventions to prevent the development of this clinical phenomenon. We commend Rabbitts et al. for their important contribution to the literature and hope that future studies in this area will follow.