Chronic Postsurgical Pain in Children and Adolescents: A Call for Action

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.

Keywords: chronic postsurgical pain; pain management; pediatrics; perioperative care; secondary pain.

Figure 1

Schematic diagram illustrating the mechanistic factors thought to be associated with the development of chronic postsurgical pain (CPSP). Proteins: regulation of inflammation through neurotransmitters, receptors, and cytokines; Genomics (genetics/epigenetics): heritable genes and modification of gene expression; Brain physiology: structural and functional brain changes associated with the chronification of pain.

Figure 2

Algorithmic Approach and Timeline for Chronic Postsurgical Pain (CPSP) Evaluation. Icons represent examples of pediatric pain trajectories, pathways, and outcomes. Green boxes represent the optimal pathway towards favorable pain recovery outcomes. Grey icon represents a patient without significant preoperative risk factors. This patient experienced ongoing or increasing pain at 2 weeks postoperatively and was appropriately referred for multidisciplinary treatment. This patient will either recover or develop chronic postsurgical pain. Blue icon represents a patient without significant preoperative risk factors and expected postoperative pain recovery. Navy icon represents a patient identified as high risk during preoperative risk stratification. This patient received appropriate preoperative optimization followed by expected postoperative pain recovery and appropriate pain resolution.