Neurosurgical management for chronic and end-of-life pain in children: A systematic review

Abstract

Introduction: Chronic and end-of-life pain in children is underreported and undermanaged. Current guidelines for pediatric chronic pain include medical and interventional modalities; however, the inclusion of neurosurgical treatments is uncommon and inconsistent. This systematic review presents the literature, and we provide recommendations for the role of neurosurgical procedures in treating chronic and end-of-life pain in children.

Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines using three databases: PubMed, Embase, and Scopus. We included 40 studies presenting neurosurgical procedures for the treatment of chronic and end-of-life pain in children.

Results: Thirty-one (77.5%) manuscripts focused on the treatment of neuropathic pain, five (12.5%) focused on nociceptive pain, and four (10%) treated mixed pain conditions. The most common neurosurgical procedure was intrathecal opioid therapy via pump placement (29.3%), followed by spinal cord stimulation (26.8%). Neuropathic pain syndromes were primarily treated with neurostimulation (58%), demonstrating good efficacy. Ablative procedures (40%) were most effective for nociceptive pain syndromes. Both chordotomy and intrathecal pumps provided subjective pain relief for mixed pain syndromes. The quantification of procedural efficacy, including pain outcomes and grading scales, varied significantly across studies.

Conclusion: Neurosurgical treatments for chronic pediatric pain are safe, although broad efficacy cannot be determined due to sparse literature and inadequately quantified pain responses. Guidelines for escalating chronic and end-of-life pain management in pediatric patients should be updated to include neurosurgical treatments and appropriate outcome scales. Focused research on appropriate patients, available neurosurgical therapies, and pediatric outcomes is warranted.

Keywords: analgesia; intrathecal; neurosurgical procedures; pediatric pain; spinal cord; stimulation.

FIGURE 1

Funnel plot of pain diagnoses reported in the included studies, from most commonly (top) to least commonly (bottom) reported. ACNES, anterior cutaneous nerve entrapment syndrome; CRPS, chronic regional pain syndrome; NTOS, neurogenic thoracic outlet syndrome. *other includes studies (Aram 2001, Bakr 2022, and Kim 2018) including patients with multiple etiologies of chronic pain these include cancer/metastatic disease, hematologic conditions, severe trauma causing lasting injury, chronic low back pain, spinal cord injury, musculoskeletal conditions, cerebral palsy.

FIGURE 2

Funnel plot of neurosurgical procedures for pain reported in the included studies, from most commonly (top) to least commonly (bottom) reported. DREZ, dorsal root entry zone; DRG, dorsal root ganglion; MM, midline myelotomy.

FIGURE 3

Efficacy of neurosurgical procedures reported in the included studies. The first column (dark blue, left) indicates the type of pain (neuropathic, nociceptive, or mixed) and the number of neurosurgical procedures by study employed. The middle column (light blue, middle) reports the type of procedure. The last column (right) reports the efficacy, with effective indicated in green, not quantified in yellow, and not effective in red. Efficacy was determined using only quantitative measures of pain control, defining effectiveness as a ≥50% reduction in the numeric pain score. DBS = deep brain stimulation; DREZ, dorsal root entry zone; PRF, pulsed radiofrequency; SCS, spinal cord stimulation.