SPPM Annual Meeting - Award Winning Abstracts

Pediatric Pain Screening Tool: A Simple Nine-item Questionnaire Predicts Functional and Chronic Postsurgical Pain Outcomes After Spine Surgery in Children

Suryakumar Narayanasamy, MD;1 Arjunan Ganesh, MD;2 Kumar Sathyamoorthy, MD;3 Kristie Geisler, CCRC IV;1 Bobbie Stubbeman, CCRC IV;1 Debbie Wolf, APRN;1 Vidya Chidambaran, MD, MS1
(Submitted by Suryakumar Narayanasamy, MD)
1Department of Anesthesia, Cincinnati Children's Hospital,
2Children’s Hospital of Philadelphia,
3Atrium Health, Levine Children’s Hospital

Chronic postsurgical pain (CPSP) defined by the International Association for Study of Pain (IASP), as pain lasting longer than three months after surgery is a sizeable problem in children, with an incidence of 14.5-38%.1 This implies that of 1.5 million children who undergo major surgery every year in the United States, about 225,000–600,000 children are at risk for developing CPSP2. Anxiety sensitivity2, parentral3 and child catastrophizing, sleep disturbances, depression3, and functional disability are important predictors of CPSP but require multiple long questionnaires to be administered for evaluation which is time consuming and impractical to be administered in the preoperative setting for screening individuals at risk for CPSP.

We conducted a prospective study to evaluate a composite, abbreviated, clinically friendly tool - pediatric pain screening tool (PPST)4 - as a predictor of long-term pain, disability and quality of life in opioid naive subjects undergoing spine fusion. Higher PPST scores have been used to risk stratify children with chronic pain, but not CPSP. We hypothesized that PPST as a single measure will correlate with each predictor component of CPSP and be predictive CPSP.

After IRB approval and parental consent, 59 healthy non-obese subjects with an American Society of Anesthesiologists (ASA) physical status ≤2 (mild systemic disease), aged 10–18 years with idiopathic scoliosis undergoing posterior spine fusion in three major pediatric hospitals were included in the study. Patients with history of chronic pain and who used opioids in the past 6 months were excluded from the study.  We recorded demographics and surgical data and administered questionnaires for pain measures, disability (Functional disability index (FDI)), Child anxiety sensitivity index (CASI), and pediatric quality of life (PedsQL) preoperatively and at two to six months after surgery. Outcomes assessed were CPSP (NRS >3/10) at two to six months post-surgery, FDI and PedsQL scores. The correlation between PPST and other predictors were assessed using pearson’s correlation coeffiecient, association of functional and CPSP outcomes with PPST scores were assessed by univariate logistic regression method. We also examined differences in outcomes based on cut-off of PPST>2.

The cohort had a mean age of 14.6 years (SD 1.69) and was 83% female. The incidence of CPSP was 25%. PPST scores ranged from 0 to 7 (mean 2.03±2.1).  We found that PPST scores positively correlated with CASI (p<0.0001), preoperative FDI (p=<0.0001) and pain scores (p<0.0001) and negatively with PedsQL measures (p<0.0001). Higher preoperative PPST scores (total, physical and psychosocial sub-scores) were significantly associated with outcomes: higher functional disability (p<0.001) and lower quality of life measures (p<0.0001) 6 months after surgery. While PPST scores were higher in CPSP vs control groups, PPST physical scores were significantly associated with development of CPSP (p=0.02). Further, functional outcomes at two to six months (FDI and PedsQL scores) were significantly different (p = 0.02 and <0.001 respectively) between the high risk and low risk group based on a PPST cut-off of >2.

In summary, PPST correlates well with other established psychosocial and clinical variables and may help predict the development of CPSP and especially functional correlates of CPSP. We conclude that PPST is a simple, nine-item screening questionnaire which could be used clinically preoperatively to stratify risk for CPSP so targeted psychological and pharmacological preventive measures could be used to target those at high risk. Multivariable regression using larger populations are necessary to validate our findings.

References:

  1. Landman Z, Oswald T, Sanders J, Diab M, Group SDS: Prevalence and predictors of pain in surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2011; 36: 825-9
  2. Chidambaran V, Ding L, Moore DL, Spruance K, Cudilo EM, Pilipenko V, Hossain M, Sturm P, Kashikar-Zuck S, Martin LJ, Sadhasivam S: Predicting the pain continuum after adolescent idiopathic scoliosis surgery: A prospective cohort study. European Journal of Pain 2017; 21: 1252-1265
  3. Rabbitts JA, Fisher E, Rosenbloom BN, Palermo TM: Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis. J Pain 2017; 18: 605-614
  4. Simons LE, Smith A, Ibagon C, Coakley R, Logan DE, Schechter N, Borsook D, Hill JC: Pediatric Pain Screening Tool: rapid identification of risk in youth with pain complaints. Pain 2015; 156: 1511-8

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