Pediatric Regional Anesthesia and Chronic Postoperative Pain
Recent literature has established that regional anesthesia in the pediatric population is safe and effective for acute postoperative pain control. Publications from the Pediatric Regional Anesthesia Network (PRAN) have largely established the safety profile of peripheral nerve blocks and neuraxial procedures in the pediatric population, performed while under general anesthesia and while awake.[1-2] Although the techniques offer advantages in helping to control acute postoperative pain, the question of whether regional anesthesia offers advantages in decreasing the development of chronic postsurgical pain (CPSP) is still unresolved.
“The question of whether regional anesthesia offers advantages in decreasing the development of chronic postsurgical pain is still unresolved.”
The incidence and prevalence of CPSP in the pediatric population have previously been poorly described. Typically, CPSP is defined as pain affecting the surgical area for more than 3 months postoperatively. Unfortunately, the literature largely varies when describing other aspects of CPSP such as pain severity, frequency, and social, physical, and functional limitations. In recent studies, follow-up data also largely omit important social, mental, and physical limitation as a result of CPSP. Clinically relevant outcomes other than the presence of pain include physical limitations, school days missed, social isolation, and pain-related anxiety. These data points have been largely absent from the limited retrospective and prospective studies available.
The prevalence of CPSP in the adult population can range from 20–80%, depending on the type of surgery. In a recent publication, Batoz et al sought to prospectively evaluate the incidence of CPSP in the pediatric population aged 6–18 years. After observing 258 children, they found a 10.9% prevalence of CPSP. Previous reports by Pagé et al and Aasvang et al found similar results when they looked at mixed surgical procedures with a 22% prevalence and inguinal hernia repairs with a 13.5% prevalence, respectively.
Evidence suggests that preemptively preventing peripheral and central sensitization to noxious stimulation by a multimodal analgesic approach can help limit the development of chronic pain. Regional and neuraxial anesthesia have been a key component to various multimodal approaches in various enhanced recovery protocols. Paravertebral blocks and epidural anesthesia have been found to be effective in reducing the occurrence of CPSP in the adult population, although mixed results have been published regarding other types of regional blocks.[8,9] Unfortunately, no high-quality study to date has evaluated the effect of regional or neuraxial anesthesia on the development of CPSP in pediatric population. Batoz et al reported that 163 of 258 patients underwent some type of regional nerve block. Of those 163 patients, 19 (11.7%) went on to develop CPSP. They reported that regional anesthesia was not found to be a risk factor for developing CPSP, although their study was not designed to determine the effects that regional anesthesia may have on the development of CPSP. Thus, no inferences can be made regarding the potential positive or null benefit this population would possibly obtain.
Common types of pediatric surgical procedures that seem to have a propensity for the development of CPSP are major orthopedic procedures, thoracotomies, and inguinal hernia repairs. These surgeries often lend themselves readily to peripheral or neuraxial regional anesthesia techniques as part of multimodal pain regimens. Previously mentioned studies have identified acute pain after surgery as a risk factor for developing CPSP in adults.
Recent advancements in the understanding and implementation of multimodal analgesia in adults in enhanced recovery protocols have led to reduced postoperative pain scores, earlier hospital discharges, and reduced opioid consumption. The development of enhanced recovery programs and use of regional and neuraxial techniques could help reduce the development of CPSP in the pediatric population. Currently, evidence is insufficient to support or oppose regional anesthesia in the pediatric population as a potential adjunct to limit CPSP. Although PRAN has clearly demonstrated the safety of pediatric regional anesthesia, continued work is needed to demonstrate how pediatric regional and neuraxial anesthesia may affect acute postoperative pain and CPSP.
- Taenzer AH, Walker BJ, Bosenberg AT, et al. Asleep versus awake: does it matter—pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network. Reg AnesthPain Med 2014;39:279– 283. doi: 10.1097/AAP.0000000000000102.
- Suresh S, Long J, Birmingham P, De Oliveira GS. Are caudal blocks for pain control safe in children: an analysis of 18,650 caudal blocks from the pediatric regional anesthesia network (PRAN) database. Anesth Analg 2015;120(1):151– 156. doi: 10.1213/ANE.0000000000000446.
- Nikolajsen L, Brix LD. Chronic pain after surgery in children. Curr Opin Anesthesiol 2014;27(5):507–512. doi: 10.1097/ACO.0000000000000110.
- Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother 2009;9(5):723–744. doi: 10.1586/ern.09.20.
- Batoz H, Semjen F, Bordes-Demolis M, Bernard A, Nouette-Gaulain K. Chronic postsurgical pain in children: prevalence and risk factors: a prospective observational study. Br J Anaesth 2016; 117(4):489–496. doi: 10.1093/bja/aew260.
- Pagé MG, Stinson J, Campbell F, et al. Identification of pain-related psychological risk factors for the development and maintenance of pediatric chronic postsurgical pain. J Pain Res 2013; 6:167–180. doi: 10.2147/JPR. S40846.
- Aasvang EK, Kehlet H. Chronic pain after childhood groin hernia repair. J Pediatr Surg 2007;42:1403–1408. doi: 10.1016/j.jpedsurg.2007.03.042.
- Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth 2013;111(5):711–720. doi: 10.1093/bja/aet213.
- Bong CL, Samuel M, Ng JM, Ip-Yam C. Effects of preemptive epidural analgesia on post-thoracotomy pain. J Cardiothorac Vasc Anesth 2005;19:786–793. doi: 10.1053/j.jvca.2005.08.012.
- Shah PM, Johnston L, Sarosiek B, et al. Reducing readmissions while shortening length of stay: the positive impact of an enhanced recovery protocol in colorectal surgery. Dis Colon Rectum 2017;60(2):219–227. doi: 10.1097/ DCR.0000000000000748.