American Society of Regional Anesthesia and Pain Medicine November 2017 - 54
Pediatric Regional Anesthesia and Chronic Postoperative Pain
R
ecent 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 incidence and prevalence of CPSP in the pediatric population
have previously been poorly described.3 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.4 In a recent publication,
Batoz et al5 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 al6 and Aasvang et al7 found similar results when they
looked at mixed surgical procedures with a 22% prevalence and
inguinal hernia repairs
with a 13.5% prevalence,
respectively.
Jacob Bray, MD
Resident
Department of Anesthesiology
University of Virginia Health System
Charlottesville, Virginia
Section Editor: Lynn Kohan, MD
patients, 19 (11.7%) went on to develop CPSP.5 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.4
"The question of whether regional
anesthesia offers advantages in
decreasing the development of chronic
postsurgical pain is still unresolved."
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 al5 reported that 163 of 258 patients
underwent some type of regional nerve block. Of those 163
54
Lynda Wells, MD
Associate Professor
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.10 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.
American Society of Regional Anesthesia and Pain Medicine
2017
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