Preventing pediatric chronic postsurgical pain: Time for increased rigor

Abstract

Chronic postsurgical pain (CPSP) results from a cascade of events in the peripheral and central nervous systems following surgery. Several clinical predictors, including the prior pain state, premorbid psychological state (e.g., anxiety, catastrophizing), intraoperative surgical load (establishment of peripheral and central sensitization), and acute postoperative pain management, may contribute to the patient's risk of developing CPSP. However, research on the neurobiological and biobehavioral mechanisms contributing to pediatric CPSP and effective preemptive/treatment strategies are still lacking. Here we evaluate the perisurgical process by identifying key problems and propose potential solutions for the pre-, intra-, and postoperative pain states to both prevent and manage the transition of acute to chronic pain. We propose an eight-step process involving preemptive and preventative analgesia, behavioral interventions, and the use of biomarkers (brain-based, inflammatory, or genetic) to facilitate timely evaluation and treatment of premorbid psychological factors, ongoing surgical pain, and postoperative pain to provide an overall improved outcome. By achieving this, we can begin to establish personalized precision medicine for children and adolescents presenting to surgery and subsequent treatment selection.

Keywords: analgesia; biomarker; chronic pain; cognitive behavioral therapy; fNIRS; opioids; postoperative pain; surgery.

Figure 1.

Proposed sequential process in preventing and treating chronic pain in the surgical patient. The program encompasses a process that involves ongoing and continuous evaluation and treatment of premitigating factors to premorbid status, injury and immediate postinjury treatments (including perisurgical processes), objective assessment of pain chronification, and treatment rehabilitative processes.

Figure 2.

fNIRS-based brain measures of acute and/or ongoing pain measured during the various perioperative states. The measured brain states at each perioperative stage can be both intrinsic and extrinsic. Intrinsic brain state often refers to the brain in the absence of external stimuli, such as during persistent ongoing pain. In contrast, extrinsic brain state refers to the brain during an acute stimulus, intervention, or treatment.