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. Author manuscript; available in PMC: 2024 Feb 1.
Published in final edited form as: Pain Manag Nurs. 2022 Dec 21;24(1):27–34. doi: 10.1016/j.pmn.2022.11.001

Pilot investigation of somatosensory functioning and pain catastrophizing in pediatric spinal fusion

Christine B Sieberg 1,2,3, Claire E Lunde 1,2,4, Cindy Wong 1, Juliana Manganella 1, Angela R Starkweather 5, Navil Sethna 1,2,6,7, Mallory A Perry-Eaddy 8,9,10
PMCID: PMC9925410  NIHMSID: NIHMS1853033  PMID: 36564325

Abstract

Purpose:

Chronic post-surgical pain (CPSP) is a significant concern and contributes to the opioid epidemic; however, little is known about CPSP in young people. Identifying biobehavioral risk factors is crucial for pain prevention and developing more effective interventions for vulnerable populations.

Design:

This prospective study aimed to identify sensory, psychological, and demographic factors that may increase the risk of CPSP after spinal fusion surgery for children and adolescents with idiopathic scoliosis.

Methods:

32 children and adolescents completed quantitative sensory testing (QST) and the Pain Catastrophizing Scale – Child (PCS-C) pre-and 4–6 months post spinal fusion surgery. QST included mechanical pain sensitivity, mechanical pain thresholds, and pressure pain thresholds on the back and the hand/forearm (non-pain body site). Between-group differences were assessed using an independent samples t-test. Pearson’s correlations and stepwise linear regression were used to assess the relationship between variables at both time points.

Results:

56% (n=18) of patients endorsed pain 4–6 months post-surgery. They were more sensitive to mechanical detection on both a control non-pain site (r= −2.87, p = .004) and the back (r= −1.83, p = .04), as well as pressure pain (r=−2.37, p = .01) on the back. This group also reported worse pain scores pre-surgery. Pre-surgery helplessness positively correlated with preoperative pain (r= .67 p<.001), and age was negatively correlated with the post-surgical catastrophizing total score (r=−.39, p = .05), suggesting that younger patients endorsed more pain-related worry after surgery.

Conclusions:

Patients who present with pain during their preoperative appointment may need to be monitored with increased vigilance throughout the perioperative period, possibly with bedside QST and psychological questionnaires, which nurses could administer. Biobehavioral interventions targeting pain intensity and feelings of helplessness and anxiety during the preoperative period may alleviate the transition to CPSP. Although this study generated novel and important findings regarding the biopsychosocial factors associated with CPSP in children and adolescents with idiopathic scoliosis following spinal fusion surgery, some limitations require cautious interpretation and replication in future studies.

Keywords: Adolescent idiopathic scoliosis, spinal fusion, chronic postsurgical pain, quantitative sensory testing, pain catastrophizing

The problem: Pediatric chronic postsurgical pain

Chronic post-surgical pain (CPSP) is a public health crisis. It is defined as pain lasting longer than two months post-surgery and affects up to 80% of adults who have undergone surgery (Kehlet, Jensen, & Woolf, 2006; Kehlet & Rathmell, 2010; Williams, Howard, & Liossi, 2017). Approximately 25% of adults referred to chronic pain clinics identified surgery as the antecedent to their chronic pain (Crombie, Davies, & Macrae, 1998). Additionally, despite nearly 4 million pediatric surgeries every year in the US (Rabbitts & Groenewald, 2020), there is a dearth of research on pediatric CPSP and risks for CPSP in adulthood. The resultant effects on synaptic plasticity compound the impact of pediatric CPSP during critical developmental stages that will likely persist into adulthood (Brattberg, 2004; Walker, Dengler-Crish, Rippel, & Bruehl, 2010). Another alarming problem and consequence of CPSP relate to the current opioid epidemic in the United States, with the rate of opioid overdoses tripling in the last 20 years and continuing to rise (Rudd, Seth, David, & Scholl, 2016). The perioperative use of opioids (intraoperative and postoperative) may contribute to this process (Sieberg, Karunakaran, Kussman, & Borsook, 2022). Complicating this crisis is the number of opioids prescribed to pediatric patients after surgery (Harbaugh et al., 2018), which may lead to prescription opioid misuse (Pielech et al., 2020). Research also reflects an association between medical use of prescribed opioids during adolescence and later nonmedical opioid use in adulthood (McCabe et al., 2017).

Corrective spinal fusion surgery for adolescent idiopathic scoliosis is one of the most invasive surgical procedures (Al-Mohrej, Aldakhil, Al-Rabiah, & Al-Rabiah, 2020). Pain related to adolescent idiopathic scoliosis has been well-researched (Bailey, Howard, El-Hawary, & Chorney, 2021; Bastrom, Marks, Yaszay, & Newton, 2013; Beeckman et al., 2021; Chabot et al., 2021; Connelly et al., 2014; Ocay et al., 2020; Voepel-Lewis et al., 2018). However, determining which patients develop CPSP and why is less clear, and the resultant effects on quality of life, and physical and emotional functioning can endure for years (Rullander, Jonsson, Lundström, & Lindh, 2013). The most significant risk factor identified for CPSP after spinal fusion surgery is the severity of pre-surgical pain (Walker, 2015), suggesting that alterations in somatosensory functioning, such as hyperalgesia, may play a role in CPSP, which warrants further investigation.

The Lancet recently published a commission on pediatric pain (Eccleston et al., 2021) and called to action the delivery of four transformative goals over the next decade; to make pain matter, understood, visible, and better. Specifically, there is a need to identify the underlying mechanisms focusing on peripheral and central pathologies contributing to chronic pain in young people. Further, Sieberg et al. propose an 8-step model aimed at the ongoing and continuous evaluation and treatment of pre-mitigating factors, objective assessment of pain chronification, and rehabilitative treatment processes to prevent pediatric CPSP. These are roles that nurses from the clinic, operating room post-anesthesia care unit, and the wards may assist and lead in data collection and pain management (Sieberg et al., 2022).

Who is at risk for CPSP?

Hyperalgesia is defined as reduced pain thresholds or extreme sensitivity to feeling pain (Yam et al., 2018). In adult and pediatric pain research, psychological risk factors such as anxiety, depression, pain-related fear, catastrophizing, and stress contribute to hyperalgesia. All these factors have known neurological underpinnings that may impact the brain and nervous system’s processing of pain, including altered pain sensitivity to maintain a chronic pain state after surgery (Edwards, Campbell, Jamison, & Wiech, 2009; Starkweather & Pair, 2013) and which may result in decreased quality of life. How children and adolescents with a developing nervous system compare to adult patients undergoing surgery is unknown. Therefore, it is necessary to devise age-appropriate treatments and prevent long-term pain (Sieberg et al., 2022). Identifying factors that may influence hyperalgesia and CPSP in children and adolescents with idiopathic scoliosis may result in innovative interdisciplinary personalized approaches for pain management throughout the perioperative course. The goal of personalized approaches would be to reduce the incidence of CPSP and improve pain outcomes and quality of life for children and adolescents undergoing spinal fusion surgery.

Pain catastrophizing and CPSP

Pain catastrophizing is the tendency to magnify, ruminate about, or feel helpless to pain (Theunissen, Peters, Bruce, Gramke, & Marcus, 2012). Pain catastrophizing has been well-studied in pediatric surgical studies on pain (Chidambaran et al., 2017; Miller, Meints, & Hirsh, 2018; Newton-John, 2022; Pagé, Stinson, Campbell, Isaac, & Katz, 2013; Rabbitts, Zhou, Groenewald, Durkin, & Palermo, 2015); however, there have been conflicting results. Most studies suggest that pediatric pain catastrophizing does not play a significant role in transitioning to CPSP; however, the opposite seems to be true for adults with CPSP (Katz, 2015; Katz & Seltzer, 2009; Suer, Philips, Kliethermes, Scerpella, & Sehgal, 2022) and previous research in pediatrics undergoing spinal fusion surgery has shown that catastrophizing may predict pain levels pre-and post-surgery (Birnie, Chorney, & El-Hawary, 2017). In support of the hypothesis of this study, previous research indicates that higher perceived levels of stress, anxiety, and catastrophizing preoperatively translate to a higher incidence of pain sensitivity and postoperative pain severity (Chieng et al., 2013).

QST, pain catastrophizing, and CPSP

Preoperative pain, surgery type, psychological factors, age at surgery, opioid use, and post-traumatic stress disorder have been identified as critical and persistent postoperative pain risk factors for adolescents with idiopathic scoliosis (Connelly et al., 2014; Sangesland, Støren, & Vaegter, 2017; Starkweather et al., 2016). Quantitative Sensory Testing (QST) is commonly used to investigate somatosensory system functioning by analyzing temperature, touch, and pain sensitivity, as well as constructs such as descending pain inhibition on specific body regions (Treede, 2019). Research using QST has highlighted variability in pain sensitivity and modulation as a putative phenotypic contributor to the risk for the development of CPSP (Braun et al., 2021; Wilder-Smith, 2011). Teles and colleagues (2019) reported the presence of sensitization in nociceptive pathways revealing a high prevalence of impaired pain modulation in patients with adolescent idiopathic scoliosis presenting with chronic back pain.

Study aims and design

Quantitative sensory testing (QST) and pain catastrophizing have not been assessed pre-and post-surgically in children and adolescents with idiopathic scoliosis undergoing spinal fusion surgery. This knowledge gap needs to be addressed to establish personalized precision approaches for young people presenting for this invasive surgery (Sieberg et al., 2022). The present study aimed to address these gaps by exploring psychophysical functioning in children and adolescents with idiopathic scoliosis before and after spinal fusion surgery.

A prospective, descriptive longitudinal study was completed to examine the biological and psychosocial risk factors of CPSP in adolescents undergoing spinal fusion surgery. The central hypothesis is that hyperalgesia, measured by subjective pain intensity score and QST, significantly increases an individual’s CPSP risk. The secondary hypothesis is that pain catastrophizing contributes to pain sensitivity and the CPSP transition.

Methods

This study employed a prospective, descriptive design. We recruited and tested 32 adolescents diagnosed with idiopathic scoliosis before surgery and ±4–6 months after undergoing spinal fusion surgery at two free-standing children’s hospitals in the Northeast region of the United States.

a. Enrollment, inclusion, and exclusion criteria.

Institutional Review Board approval from each site was obtained before data collection. Written parental consent and verbal participant assent were provided. The study included participants between the ages of 10–17 years old. Adolescent idiopathic scoliosis is diagnosed in children between the ages of 10 and 18 years, with approximately 80% of all pediatric cases of idiopathic scoliosis falling into this category (Konieczny et al., 2013). All participants had confirmed idiopathic scoliosis and were scheduled for spinal fusion surgery. Only English-speaking participants were included. Participants were excluded if they reported any diagnosed chronic pain conditions or conditions involving loss of sensation and impairment, as these conditions would influence sensory perceptions and their QST responses (Cruz-Almeida & Fillingim, 2014; Weaver et al., 2022).

b. Procedure.

Study participants reported general demographics and current and previous medical history at the pre-surgery visit. They also self-reported pain intensity on a numeric scale of 0–10, completed the Pain Catastrophizing Score – Child (PCS-C) (Crombez et al., 2003; Pielech et al., 2014), and QST before and 4–6 months after spinal fusion surgery. The QST protocol was adapted from the German Research Network on Neuropathic Pain (Rolke et al., 2006) to take less time to complete and reduce the burden for the current study’s younger pain sample. The pre-established protocol (Starkweather et al., 2016) included pressure pain thresholds, mechanical pain detection, and mechanical pain thresholds.

Preoperative and postoperative pain intensity

a. Numeric rating scale.

Current pain intensity of the back was assessed using a standardized pain intensity assessment, which included self-report pain scores given on the Numeric Rating Scale (NRS) (Krebs, Carey, & Weinberger, 2007). Participants who reported 0 were grouped as “no pain,” and any rating >0 was grouped as “pain.”

Quantitative sensory testing (QST)

All QST tests were performed on a control site of the participant’s anterior non-dominant forearm, the dorsum of the hand (randomized left or right), or the nail bed (randomized left or right), and the pain/test site of the adolescent’s lower back. On the lower back, the QST was randomized to be performed 3cm left or right of the surgical site. Each test was performed three times on the non-pain control (forearm/hand) and pain/test site (lumbar spine region). The study included a pain and non-pain body site for the QST to assess central sensitization, a condition of the central nervous system that causes increased responsiveness of nociceptors and is associated with developing and maintaining chronic pain (Latremoliere & Woolf, 2009). Alterations in pain thresholds in patients with CPSP can be caused using central and peripheral mechanisms leading to hyperalgesia (Staud, 2011).

a. Pressure Pain Threshold (PPT).

An electronic pressure algometer was used to gradually induce increasing pressure at a rate of 3 Newton/second until the participant reported pain. The maximum amount of pressure able to be applied was 100 Newtons. This test was performed three times on the forearm (hospital 1) or the dorsum of the hand (hospital 2). The test was then completed on the lumbar spine, defined as 3 cm to either left or right side of the surgical incision site. The test was conducted three times, and an average score was derived for both the pain/surgical and non-pain sites. Results are reported in Newtons.

b. Mechanical pain detection (MDT) and mechanical pain threshold. (MPT).

Von Frey filaments (Optihair2-Set, Marstock Nervtest, Germany) were used to apply force without puncture on the skin on the dorsum of the hand (right hand if the last digit of Medical Record Number was even, left if the last digit was odd for Hospital 1) and the non-dominant forearm (anterior) for participants from Hospital 2. MDT and MPT were conducted in the exact location of the back as the PPT (described above). These round filaments have a 0.5mm diameter blunt end and generate a force ranging from 0.25 to 512 grams. MDT was assessed by increasing filament diameter (force) until the stimulus was initially felt by the participant on non-pain and pain sites three times. The filament size was recorded and averaged. The filament recorded as the MDT was used in the MPT test. MPT was then assessed by increasing diameter (force) until the stimulus first became painful, described as 2 out of 10 on the NRS. Results for both tests are reported in grams.

Self-report questionnaires

a. Pain catastrophizing.

The PCS-C, a 13-item self-report questionnaire, was used to assess thoughts and emotions in response to perceived painful events (Crombez et al., 2003; Pielech et al., 2014). Similar to the original adult-specific PCS (Sullivan et al., 2001), the pediatric version is rated on a five-point scale yielding a maximum possible score of 52. There are three subscales: rumination, magnification, and helplessness. Higher scores indicate higher levels of pain catastrophizing and/or rumination, magnification, or helplessness. The PCS-C showed good internal consistency (α =.87–.90) in children with and without pain. It also correlated highly with pain intensity (r=.49) and disability (r=.50) in children with chronic pain (Crombez et al., 2003). The PCS-C has been frequently used in pediatric surgical studies (Esteve, Marquina-Aponte, & Ramírez-Maestre, 2014; Gabrielle Pagé, Stinson, Campbell, Isaac, & Katz, 2012).

Data analyses

Participants were dichotomized as no pain 4–6 months after surgery (NRS = 0) or yes pain 4–6 months after surgery (NRS > 0). The following four analyses were completed (1) Descriptive statistics for age, sex, and race was used to characterize the study sample. (2) Pearson’s correlations were used to determine the relationships between pain intensity, age, QST scores, and pain catastrophizing. (3) Between-group differences for sex and self-report back pain scores were assessed via independent samples t-test pre-and post-surgery. (4) A one-way ANOVA was performed to compare the effect of pre-and post-surgery QST and PCS-C scores on postoperative back pain scores. No mathematical correction was made for multiple comparisons. Statistical analyses were performed using SPSS software ver. 28.0 (IBM, Armonk, NY, USA).

Results

a. Demographics.

(1) 32 children and adolescents (7 males and 25 females) were included in this study. Their mean age was 14 years (range 10–17 years; SD=1.3 years). Three participants were lost to follow-up and did not complete the post-operative study visit for unknown reasons. One participant’s parent withdrew from the study due to a lack of time to complete the study visit. See Table 1 for demographics and pre-and post-surgical back pain intensity scores. The participants underwent similar in-patient pain treatments, which involved combinations of opioids and non-opioid medications, epidural analgesia, patient-controlled analgesia, antispasmodics (i.e., diazepam), and anxiolytics (i.e., lorazepam), at patient-specific doses (per kg). Comprehensive medical chart reviews assessed their pain treatments.

Table 1 -. Demographics and Self-report Pain Scores.

Female, male, and total sample demographics and self-report pain scores are described in Table 1. Self-report pain scores were given to participants on the Numeric Rating Scale (NRS), a standardized pain intensity assessment (mild: 1–3; moderate: 4–6; severe: 7–10) (Krebs et al., 2007) on a scale of 0 (no pain) to 10 (worst pain imaginable).

Demographics
Males
n=7		 Females
n=25		 Total
n=32
Age (years): mean (SD) 15.0 (1.3)
Range: 14–17		 13.6 (1.7)
Range: 10–16		 13.9 (1.7)
Range: 10–17
Race White, n = 6
Black, n = 1
Asian, n = 0		 White, n = 22
Black, n = 2
Asian, n = 1		 White, n = 28
Black, n = 3
Asian, n = 1
Self-report numeric pain score: scale 0 (no pain) to 10 (worst pain)
Presurgical: Mean (SD) 0.9 (1.2)*
Range: 0 to 3		 2.4 (2.5)*
Range: 0 to 8		 2.1 (2.4)
Range: 0 to 8
4–6 months post-surgical: Mean (SD) 0.9 (1.6)
Range 0 to 4		 2.0 (2.1)
Range: 0 to 7		 1.7 (2.1)
Range: 0 to 7
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*

Indicates p < 0.05 between self-report pain scores.

b. Pain intensity scores – NRS.

(2) Age was not associated with mean preoperative pain scores nor postoperative pain scores, r= .14, p = .431; r= .18, p = .34 respectively. (3) Female participants showed a significantly higher preoperative pain score compared to males (t(21.5) = −2.26, p = .02), but no sex differences were found after surgery. See Table 1.

c. Pediatric Pain Catastrophizing Scale – Child.

Table 2 outlines the mean PCS-C scores and clinical reference cutoffs (low, moderate, and high, Table 3) (Pielech et al., 2014) for males, females, and the entire sample. (2) A Pearson correlation showed baseline feelings of helplessness were positively correlated with preoperative pain (r= .67 p<.001) and was also positively correlated with the total preoperative PCS-C score (r= .51 p<.004). There were no significant correlations between preoperative rumination, magnification, and preoperative pain. A Pearson’s correlation showed age was negatively correlated with postoperative PCS-C total scores (r=−.39, p = .05). However, there were no significant correlations between age and preoperative PCS-C total scores.

Table 2 -. Pain Catastrophizing Scale – Child Version (PCS-C).

Pre and post-surgery PCS-C scores are described as the sum across the three subscales to derive a total score ranging from 0–52. A higher score reflects higher levels of catastrophic thinking (Crombez et al., 2003). There are three clinical reference points: low (0–14), moderate (15–25), and high (26 and greater) catastrophizing (Pielech et al., 2014).

Preoperative Postoperative
Clinical reference n (%) Males
n=7		 Females
n=23		 Total
n=30		 Males
n=5		 Females
n=22		 Total
n = 27
Low 4 (57%) 10 (44%) 14 (47%) 4 (80%) 12 (55%) 16 (59%)
Moderate 3 (43%) 7 (30%) 10 (33%) 1 (20%) 6 (27%) 7 (26%)
High 0 (0%) 6 (26%) 6 (20%) 0 (0.0%) 4 (18%) 4 (15%)
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Table 3 – Pain Catastrophizing Scale Subscale Scores – Child Version (PCS-C).

PCS-C means and SD for each time point by male, female, and the total sample. Total scores were calculated using the sum across the subscales of helplessness, magnification, and rumination. The range of the PSC-C score is 0–52.

Preoperative Postoperative
Males
n=7		 Females
n=23		 Total
n=30		 Males
(n=5)		 Females
(n=21)		 Total
n = 26
Total PCS-C score 11.0 (7.87 16.61 (9.35) 15.30 (9.21)* 7.20 (7.19) 14.55 (10.05) 13.19 (9.90)
Helplessness 3.29 (2.21) 5.74 (4.35) 5.17 (4.06)* 1.0 (2.24) 1.71 (198) 1.58 (2.00)
Magnification 2.57 (3.05) 2.70 (3.13) 2.67 (3.06) 5.0 (2.35) 7.38 (4.51) 6.92 (4.25)
Rumination 5.14 (3.39) 8.17 (3.47) 7.47 (3.64) 1.20 (2.68) 5.10 (4.64) 4.35 (4.56)
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*

Indicates p < 0.05 when pre-surgery scores were compared to post-surgery scores.

a. Quantitative sensory testing.

QST was performed pre-surgery and 4–6 months post-surgery. Table 4 outlines the means and standard deviations of each QST test completed. The PPT, MDT, and MPT means increased in both groups between the preoperative to postoperative time points for the control site and back. Participants were dichotomized as no pain after surgery (self-report NRS = 0; (n) = 14) or pain after surgery (NRS > 0 (n) = 18, range = 1 to 7/10) with some patients endorsing mild to severe pain. (2) Participants with postoperative pain showed significantly higher pain sensitivity before surgery (r= −2.75, p = .01).and after surgery (r= −7.20, p < .001). To evaluate the relationships between pain catastrophizing and the QST measures, Pearson’s correlation was used to examine associations between preoperative PCS-C total and subscale scores and QST at each time point. There are no significant correlations to report. (3) Independent samples t-test showed that those with pain after surgery were more sensitive to mechanical detection than those without pain on the non-pain site (r= −2.87, p = .004) and the pain-site (r= −1.83, p = .04). Additionally, participants with pain after surgery were more sensitive to pressure pain preoperatively on their back (r=−2.37, p = .01). (4) A one-way ANOVA revealed that there was a statistically significant difference in pre-surgery MDT (F(1,30) = [8.3], p = .007) and post-surgery (F(1,30) = [5.6], p = .02) on the non-pain and the pain-site between the two groups (no pain vs pain 4–6 months post-surgery).

Table 4 -. Quantitative Sensory Testing (QST) Scores.

QST means and standard deviations (SD) were calculated by averaging the scores for the three trials completed on each body site. QST included mechanical detection thresholds (MDT), mechanical pain thresholds (MPT), and pressure pain thresholds (PPT). Means and SDs are reported by each time point (pre-and-post-surgery) for males, females, and the total sample. MDT and MPT values indicate the mean gram of the von Frey filament used. PPT values indicate the amount of pressure in Newtons reported by participants.

Preoperative Postoperative
Males
n=7		 Females
n=25		 Total
n=32		 Males
n=3		 Females
n=25		 Total
n = 28
MDT Grams Non-pain site 2.58 (.32) 2.80 (.55) 2.75 (.51) 2.83 (39) 2.97 (.46) 2.95 (45)
Pain site 2.86 (.99) 3.05 (.76) 3.01 (.80) 3.48 (91) 3.26 (104) 3.28 (101)
MPT Grams Non-pain site 4.41 (.47) 4.95 (1.00) 4.84 (105) 4.62 (120) 5.18 (.99) 5.07 (104)
Pain site 4.65 (.47) 5.07 (.92) 4.98 (.86) 5.20 (64) 5.21 (.90) 5.21 (.87)
PPT Newton Non-pain site 33.92 (12.59)** 20.04 (10.51)** 23.18 (12.30) 42.16 (14.76) 30.69 (16.93) 32. 01 (16.87)
Pain site 25.09 (13.08)* 16.20 (9.54)* 18.21 (10.87) 46.42 (16.73)* 22.36 (14.30)* 25.04 (16.18)
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*

Indicates p < .05 when pre-surgery values were compared to post-surgery.

**

Indicates p <.01 when pre-surgery values were compared to post-surgery.

Discussion

An interdisciplinary approach to pain management in children and adolescents undergoing spinal fusion surgery may aid in improving postsurgical outcomes. As nurses are on the front line, there is a unique need for nurses to systematically assess and collect robust quantitative data within this population throughout the perioperative period. This pilot study aimed to identify sensory and psychological factors that may increase the risk of CPSP in pediatric patients with idiopathic scoliosis after spinal fusion surgery. In many chronic pain conditions, long-term pain outcomes are not often driven by the condition (e.g., radiographic measures, degree of arthritis in a joint, stage of illness), and in the case of surgery, CPSP is not usually attributed to surgical factors such as surgical approach (Sieberg et al., 2017, 2013). Thus, identifying other potential factors is an important area of inquiry.

This study analyzed contextual factors, including age, sex, pain sensitivity, and pain catastrophizing. The sample demographics were consistent with the broader population of pediatrics with adolescent idiopathic scoliosis undergoing spinal fusion surgery and primarily composed of non-Hispanic White females. According to the National Scoliosis Foundation (2007), females are eight times more likely to have a curvature requiring treatment (Janicki & Alman, 2007; “National Scoliosis Foundation,” n.d.). In terms of the prevalence of CPSP in this population, a 2017 systematic review and meta-analysis reported that up to 20% of adolescents experience CPSP after spinal fusion surgery at one year across studies (Rabbitts, Fisher, Rosenbloom, & Palermo, 2017). Within our cohort, 56% of the sample reported pain, with a range of mild to severe at their post-surgical study visit ±4–6 months after surgery.

The central hypothesis was that hyperalgesia, measured by subjective pain intensity score and QST, significantly increases an individual’s CPSP risk. Throughout the perioperative period, mean back pain intensity scores at both time points were higher in the CPSP group compared to the non-CPSP group. Of note, participants in the CPSP group had significantly higher preoperative back pain intensity scores compared to the non-CPSP group (p=0.008), and pain intensity scores were found to be predictive of CPSP status (p<0.005). Similar findings regarding the importance of increased preoperative pain scores on the risk of CPSP have been discussed in an integrative review of the literature (Perry, Starkweather, Baumbauer, & Young, 2018). This review cited preoperative pain as one of the most widely reported predictive factors of CPSP after spinal fusion surgery. This is important information for healthcare clinicians caring for children and adolescents throughout the perioperative period. Early recognition of increased pain scores in the preoperative period is imperative, considering the incidence of preoperative comorbid pain with adolescent idiopathic scoliosis is relatively low (Balagué & Pellisé, 2016; Teles et al., 2019). Specifically, nurses and other clinicians have a unique responsibility to complete pain assessments pre-and post-operatively. Children scheduled for preoperative spinal fusion surgery have preoperative rigorous evaluations, including laboratory tests and physical examinations, to assess overall fitness for the surgical procedure. This preoperative assessment, which may occur over several days, is an opportune time for nurses and clinicians to perform preoperative pain assessments.

Additionally, scoliosis screening is a mandated requirement in United States public schools. Children diagnosed with adolescent idiopathic scoliosis have likely encountered a health professional (e.g., school nurse and physical education teacher.) in a school setting during this screening process. Though screening is mandated, pain assessment during screening is not. Few states have legislature guidelines and/or recommendations for focused pain assessment during scoliosis screening (Perry et al., 2021). Yet, in an evaluation of school nurse documentation, less than 1% of school-aged children’s records have a focused pain score (Quinn et al., 2020). While this 1% was not scoliosis specific, this presents as an opportune time for school nurses to conduct a pain assessment. Similar to the preoperative clinic, this is another high touchpoint where pain screening can easily be ascertained.

Aside from preoperative pain intensity scores being significantly higher, there is validity in assessing pain linearly. Assessing pain throughout the entire perioperative period may assist in predicting CPSP incidence, as suggested in the current study. This study showed significantly higher pain scores in the CPSP group compared to non-CPSP pre-surgery and ±4–6 months post-surgery. Therefore, using the pain scores obtained throughout the perioperative period may assist in the early identification of those who may be at an increased risk. Also, of note, the mean preoperative and postoperative pain scores of CPSP individuals were nearly two points higher than the mean pain scores of those who were classified as non-CPSP. A clinical study conducted by Farrar et al. (2001) describes a difference in pain intensity by two or more points on the numeric rating scale (0–10) as a minimal clinically important difference. The importance of the minimal clinically important difference as a benchmark for clinical significance has been explicated throughout the literature regarding musculoskeletal pain (Salaffi, Stancati, Silvestri, Ciapetti, & Grassi, 2004) and included as a reference in the Initiative for Methods, Measurement and Pain Assessment in Clinical Trials recommendations (Dworkin et al., 2009).

The secondary hypothesis was that pain catastrophizing contributes to pain sensitivity and the CPSP transition. Pain catastrophizing scores were generally higher at each time point in the CPSP group compared to the non-CPSP group. However, the most sensitive indicator of CPSP incidence was preoperative helplessness, which demonstrated significant mean differences between groups (p<0.001), as well as a moderately significant correlation to baseline pain scores (p<0.004) and those with some CPSP (p=0.02). Since preoperative pain is an important indicator of CPSP transition within this sample, preoperative assessment should rely on subjective pain scores and an individual’s emotional well-being. In line with our findings, a study conducted in 2015 (Noel, Rabbitts, Tai, & Palermo, 2015) reported that helplessness was the only correlative factor to a child’s pain intensity and emotional wellness several weeks postoperatively. Therefore, targeted assessment surrounding helplessness characteristics may be useful in understanding who may be at an increased risk of CPSP throughout the perioperative period. This understanding may aid in developing personalized interventions for reducing helplessness throughout the perioperative period to reduce the risk of CPSP and improve postoperative outcomes. Due to its relatively quick completion time, PCS may easily be administered preoperatively. While not routinely given in preoperative clinics, if done, it may aid clinicians in better understanding the postoperative needs of children. This may allow for clinicians to provide adequate anticipatory guidance and improve postoperative outcomes. An interdisciplinary approach is necessary to provide holistic care, including pain recognition and management throughout the perioperative period.

Measures used for QST were not statistically different between both time points, except for pre-surgery pressure thresholds that increased with age (p=.05). Both the CPSP and non-CPSP groups had slightly higher mean mechanical and pressure pain thresholds from the preoperative to postoperative time point. This could suggest that a greater degree of force was needed to initiate a pain sensation after surgery. Interestingly, postoperative MDT on the back was a significant predictor of CPSP status (p=0.02), meaning that it required more force to illicit a noxious or painful stimulus. This contradicts the original hypothesis of hyperalgesia in this population after surgery but could suggest key age and/or developmental differences in pain processing due to developmental plasticity. Indeed, one study found that approximately 67% of adults who had a thoracotomy as a child exhibited hypoesthesia (Williams et al., 2017). However, the effect of developmental factors on nociception, pain, child emotional functioning, and their clinical assessment and treatment is poorly understood and warrants further investigation (Eccleston et al., 2021).

Analysis of relationships between pain catastrophizing and QST measures indicate that increased helplessness was associated with decreased MPT and PPT, meaning that an individual who exhibits high helplessness levels required less mechanical force to experience pain, thus higher pain sensitivity. While more research is warranted in pediatric surgical patients, the importance of this construct in influencing pain outcomes aligns with the literature on adults. Specifically, higher catastrophizing is a risk factor for long-term pain and disproportionately adverse sequelae of pain (e.g., worsening disability and healthcare costs (Edwards, Calahan, Mensing, Smith, & Haythornthwaite, 2011; Khan et al., 2011)). Additionally, catastrophizing is the single most important risk factor that impairs the effectiveness of pain-relieving interventions (Hill, Lewis, Sim, Hay, & Dziedzic, 2007; Karels et al., 2007), and it statistically mediates the prospective influence of factors such as anxiety on pain outcomes (Pinto, McIntyre, Almeida, & Araújo-Soares, 2012). Using the constructs of pain catastrophizing (magnification, rumination, and helplessness) to examine relationships with QST measures provides a novel methodology to explore the psychological contribution to pain sensitivity; thus, larger sample sizes are warranted.

Limitations

Although this study generated novel and important findings regarding the biopsychosocial factors associated with CPSP in children and adolescents with idiopathic scoliosis following spinal fusion surgery, some limitations require cautious interpretation and replication in future studies. The major limitation was the small sample size due to challenges with recruitment, with similar challenges reported in previous studies focused on children undergoing surgery (Noel et al., 2015). The small sample sizes prevented us from conducting more sophisticated analyses, such as predictive modeling. Future studies should consider testing a larger sample to use predictive machine learning modeling with low, moderate, and high pain groups. The current study used dichotomous grouping as a no-pain vs. pain group post-surgery, but the pain group did report varying pain severity. Participants’ current pain intensity was assessed on a scale of mild: 1–3; moderate: 4–6; severe: 7–10. Future studies may consider assessing individual pain score differences. The non-pain body site for the QST also differed between the two hospital sites. However, the purpose of the non-pain site was to serve as a control and be an area of non-pain. Heightened QST responses in such an area may suggest a centralized pain phenotype and, thus, a strong predictor of CPSP. This will be an exciting area of future inquiry. Lastly, pain catastrophizing is not thought to be a stable trait with proposed changeability due to pain experience (Durand et al., 2017; Pielech et al., 2014). Future studies should consider including comparable experiences such as hospitalizations, surgeries, and similar postoperative hospital stays in analyses.

Conclusions

Children and adolescents undergoing spinal fusion are under physical and psychological stress. Proper identification of these stressors throughout the perioperative period may improve outcomes, specifically regarding pain and transition to CPSP. Within this cohort of children and adolescents, pain scores remained elevated throughout the perioperative period in those who transitioned to CPSP. Specifically, preoperative pain intensity and helplessness were significant predictors of CPSP transition. Pediatric patients with pain during their preoperative appointment should be monitored with increased vigilance throughout the entire perioperative period. Future studies must determine whether interventions to decrease pain intensity and helplessness during the preoperative period may alleviate postoperative pain and transition to CPSP. Future studies with a larger sample are needed to validate these findings further.

Our findings add to the understanding of the biopsychosocial factors that increase the risk of CPSP in children and adolescents undergoing spinal fusion surgery, particularly the role of preoperative pain intensity scores and helplessness. Such measures may become part of a personalized pain management approach provided by nurses for individuals undergoing surgery to identify and treat risk factors of CPSP and improve function and quality of life outcomes for the thousands of pediatric patients facing surgery each year.

Key practice points.

1. The prevalence and reason why some adolescents transition to chronic postsurgical pain after spinal fusion surgery is unknown.

2. This pilot study aimed to prospectively assess pain sensitivity and pain-related worry in adolescents with idiopathic scoliosis undergoing spinal fusion surgery.

3. 56% of adolescents (n=18) reported some pain 4–6 months post-surgery and were more sensitive to mechanical detection and pressure pain.

4. Biobehavioral interventions targeting pain intensity, feelings of helplessness, and pain-related worry during the preoperative period may alleviate the transition to chronic postsurgical pain.

Clinical implications.

Each year, six million pediatric and adolescent patients undergo surgical procedures that put them at risk of experiencing chronic post-surgical pain (CPSP). Identifying biobehavioral risk factors for CPSP, such as peripheral and central pain sensitivity and pain catastrophizing, would facilitate the development of personalized nursing interventions to improve pain management outcomes. Approximately 3% of U.S. adolescents are diagnosed with idiopathic scoliosis, which is the most common spinal deformity that often requires extensive surgical correction. Nurses may quickly and inexpensively adopt these assessments of pain and pain risk at the bedside to provide more personalized and tailored pain prevention and management.

Acknowledgments:

CBS received support for this research from a K23 Award (K23GM123372) and Supplement (K23GM123372-04S1), as well as an R35 MIRA Award (R35GM142676) and Loan Repayment Award, all from the National Institute of General Medical Sciences, as well a grant from The David Borsook Project, supported by the Cathedral Fund. MPE received financial support from the Jonas Center for Nursing Excellence, Sigma Theta Tau (Mu Chapter) Research Award, the Graduate Assistance in Areas of National Need (GAANN) Fellowship, the Center for the Advancement of Nursing Sciences (CANS)/Eastern Nursing Research Society (ENRS) Dissertation Award and the UConn Center for the Advancement of Managing Pain (CAMP).

Footnotes

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Declarations of conflict of interest: None.

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