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264 L. M. W. Webb et al.
epidural anesthesia (CEA), which is the most common pediatric regional anesthesia
technique. CEA historically relied solely on landmark palpation, but recent studies
show the usefulness of US for confirmation of proper local anesthetic placement
[44]. Unossified bones in the pediatric skeleton and decreased adipose tissue allow
US imaging to be highly reliable and effective in children and enhance its diagnostic
utility [ 65]. For example, while MRI remains the gold standard for spine imaging,
improvements in US quality have increased its use in evaluating pediatric spine
anomalies, such that US is the first line modality for spinal cord screening in neonates
and young infants [67].
According to the United States Food and Drug Association, pediatric patients are
more sensitive to cancer risk per unit dose of ionizing radiation, requiring careful
consideration of x-ray use in this population. In addition, pediatric patients have a
longer expected lifetime, increasing the chance of cancer developing from radiation
during their life. Therefore, it is important to consult the age-appropriate radiation
settings for equipment and consider whether radiation exposure is truly necessary for
patient care. Consequently,while an epidurogram is useful for confirmation of correct
epidural or caudal catheter placement in anesthetized patients [68], widespread use
is limited due to logistical restraints, including time, radiation exposure, and the
general efficacy of ultrasound for the same indication.
Nonpharmacologic Pain Management
Though medication administration is an i mportant component of pain therapy,
evidence supports the use of non-pharmacologic adjuncts for reducing pain and
anxiety, while increasing children’s coping and resiliency [11, 12, 69]. Studied
interventions include music, art, and animal therapy, acupuncture and acupres-
sure, hypnosis, child life specialists, pain psychology (e.g. guided-imagery, deep
breathing, biofeedback), physical therapy, use of transcutaneous electrical nerve
stimulation (TENS) unit, virtual reality, distraction, breastfeeding, comfort holds,
and sucrose [11, 12, 69].
Chronic Pain
Chronic pain, generally defined as pain lasting longer than three months, is a signif-
icant problem in the pediatric population. According to a systematic review by King
et al from 2011, pediatric chronic pain is prevalent in specific conditions with the
following ranges: “headache: 8–83%; abdominal pain: 4–53%; back pain: 14–24%;
musculoskeletal pain: 4–40%; multiple pains: 4–49%; other pains: 5–88%” [70].
The prevalence of chronic pain is higher in those with female gender, lower socioe-
conomic status, and increasing age [70]. Patients can experience pain from a vast
number of conditions including illness or injury; complex regional pain syndrome;
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Pain Management in Children 265
and numerous medical conditions such as Sickle Cell Disease, Hypermobile Ehlers
Danlos Syndrome, Juvenile Idiopathic Arthritis, and Epidermolysis Bullosa. Chronic
pain is complex—resulting from an interplay of many variables from neurons and
spinal cord pathways to neurotransmitters to psychosocial and behavioral factors
and more—and, can lead to the development of intensified pain signaling through
central sensitization or hyperexcitability and wind-up phenomena leading to poorly
controlled pain [71]. Chronic pain decreases children’s quality of life and func-
tional status [70–72]. Children with chronic pain are benefited by a multidisciplinary
care model that includes psychologists, physical therapists, and the use of multi-
modal pain pharmacology and procedural intervention [72]. Treatment, therefore,
is primarily directed at patients’ functional improvements in day-to-day skills and
needs, in addition to the reduction of pain [72].
Key Takeaways
1. Medication dosing and management in pediatrics is often off-label and is age-
and weight-dependent based on physiologic changes associated with age and
size.
2. Validated pediatric-specific pain assessment tools are necessary to account for
developmental roadblocks to solely using verbal assessment tools.
3. Anatomic and physiologic considerations specific to infants and children require
careful consideration when placing and dosing regional anesthetics.
4. Effects of medications on brain development in children and adolescents must be
weighed against the necessity of their use in pain management, especially given
the negative effects of poorly treated or uncontrolled pain.
5. Multimodal therapy is effective in treating both acute and chronic pain in the
pediatric population.
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Perioperative Analgesia for a Patient
Going for Spine Surgery
Michael Louis Ma and Vivian Ip
Abstract Spinal surgery is frequently complicated by significant acute postoper-
ative pain. Suboptimal pain management can lead to persistent post surgical and
chronic pain. There are multiple avenues to perioperatively manage pain including
non-pharmacological, pharmacological and interventional. To optimize the patient
experience, clinicians must strive to incorporate and individualize analgesic regimes,
taking into account all phases of perioperative care. Novel modalities such as
cryotherapy and neuromodulation require further investigation.
Keywords Spinal surgery
· Spine · Pain management · Acute on chronic pain ·
Neuropathic pain · Multimodal analgesia · Opioids · Regional anesthesia
1 Introduction
In this chapter, we will explore the perioperative pain management of patients under-
going spinal surgery. Main areas of focus will be the challenges observed in this
cohort, current treatment modalities, and future developments.
The Struggle
It is estimated that every year “900,000 American and 30,000 Canadian adults
undergo spine surgery” [1]. A retrospective cohort study of 2491 adult patients under-
going lumbar fusion found that 12.8% of opioid naïve patients became long term
M. L. Ma
Department of Anesthesia and Pain Medicine, University of Alberta Hospital, Edmonton, AB,
Canada
V. Ip (
B
)
Department of Anesthesia, Perioperative and Pain Medicine, University of Calgary, Calgary,
Canada
e-mail: hip@ualberta.ca
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_17
271
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272 M. L. Ma and V. Ip
opioid users and that 77.1% of long-term preoperative opioid users continued with
their chronic opioid use [2]. A major contributor to this prolonged requirement for
opioid use may be persistent post-surgical pain. Persistent post-surgical pain occurs
in 10–40% of patients undergoing lumbar spine surgery and is associated with a
50% escalation in healthcare costs [3]. An American 2-year longitudinal cohort
study found that 70% of lumbar fusion patients incurred $9 million in additional
medical claim payments, averaging $9383 per patient, which included pain manage-
ment interventions and the need for long term analgesia [4]. The optimization of
perioperative pain management for patients undergoing spinal surgery is crucial but
remains beset by many challenges. The surgery itself requires major disruption of
various tissue types and the patient cohort is one often suffering with pre-existing
chronic pain treated with preoperative multimodal analgesia and habitual opioid use.
The Surgery
There are four major indications for spinal surgery which include decompression of
the spinal cord or nerve roots, correction of spinal deformity, excision of tumour, and
stabilization following trauma [5]. Excluding minimally invasive procedures, spinal
surgery involves the extensive disruption of subcutaneous tissue, ligaments and bone
to correct these pathologies [6]. Laminectomies, discectomies, spinal fusions, instru-
mentations, scoliosis corrections, and spinal tumor excision are just some of the
common spinal surgeries performed [6]. Significant postoperative pain is routinely
associated with complex spine surgery involving the thoracolumbar regions with
instrumentation, surgery for scoliosis, or laminectomies at three or more levels asso-
ciated with an elevatedrisk of pain symptomology [7]. This severe postoperative pain
is particularly worse within the first three postoperative days. Surgical factors that
increase the chance of postoperative chronic opioid use include lumbar fusion of 4 or
more levels and extended intraoperative times [8]. While these surgical procedures
are known to be uniquely painful, there is an increased interest in shortening hospital
length of stay or conversion to ambulatory procedures that requires attention to pain
management and analgesic treatment that limits the need for opioid analgesics.
The Patient
A high percentage of patients requiring elective spinal surgery suffer with pre-existing
neuropathic and/or chronic pain. These pathologies are notoriously difficult to treat.
As a result, they often preoperatively utilize a wide range of multimodal analgesics
that may include opioids. Some patients may have an opioid use disorder and or
‘recreational drug use’ such as cannabis, in the form of Tetrahydrocannabinol (THC)
oil.
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Perioperative Analgesia for a Patient Going for Spine Surgery 273
Older populations who may be suffering from disc degeneration and or arthritic
pathology frequently have other associated comorbidities which further complicate
analgesic management. Cardiac, renal and liver dysfunction, and polypharmacy may
further impact efforts to optimize pain management.
Psychological components of catastrophization, anxiety and depression, as well
as other predicting factors including female gender, preoperative opioid use, and
pain sensitivity contribute to challenging pain management in this population [9].
Therefore, one of the most important factors in planning perioperative analgesia is
aligning expectations for postoperative pain control with patients in the pre-operative
setting.
2 Treatment Modalities
Analgesic management for patients undergoing spinal surgery is multifaceted. One
must consider pharmacological, non-pharmacological and interventional methods
and how these modalities might be leveraged at various periods during the patient’s
perioperative experience.
Non-pharmacological
•
Education
In the preoperative phase, it is crucial to obtain a thorough history of current and
previous efforts at analgesic management, outline the analgesic options available for
the upcoming procedure, manage the patient’s analgesic expectations and address
concerns surrounding their upcoming surgery. When the clinician can explore the
patient’s beliefs and align their analgesic goals with what is realistic for them before
surgery, effective progression to functional aims in the postoperative period will be
more attainable. As discussed earlier, anxiety may be a significant contributing factor
to analgesic management. Often it is possible to alleviate this apprehension with an
empathetic discussion and teaching. A s ystematic review on the effect of pre-emptive
and preventive psychoeducation on postoperative pain control concluded that there
was strong evidence suggesting a mismatch between pain expectation and physical
sensation can develop in patients who are not fully informed about postoperative pain
[10]. Further to this, patients who opted out of procedural pain education experienced
more frequent uncontrolled pain and longer hospital stays [10]. Horn et al. also found
that preoperative anxiety and pain catastrophizing had negative effects on recovery
and concluded that “an open and sympathetic discussion between providers and
patients is crucial for optimal satisfaction and maximum recovery.” [10].
•
Physical Interventions
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274 M. L. Ma and V. Ip
The use of acupuncture and acupressure as analgesic adjuncts in spinal surgery
patients has demonstrated variable results. A systematic review and meta-analysis of
5 randomized controlled trials (RCTs) studying acupuncture for acute postoperative
pain in patients undergoing back surgery concluded that there was limited evidence
supporting acupuncture treatment in this cohort [11]. However, a recent retrospective
study investigating patients given either meperidine, PCA or acupuncture for post-
operative lumbar spinal surgeries found acupuncture to be non-inferior to the other
2 arms when included as a component of a multimodal analgesic regimen [12].
•
Behavioural Interventions
Perioperative multimodal rehabilitation that includes preoperative education/
prehabilitation and early postoperative mobilization is an important interventional
component of postoperative pain control. Exercise therapy with cognitive behavioural
training is emerging as a useful technique to decrease postoperative disability and
pain. A systematic review with meta-analysis of rehabilitation strategies in patients
undergoing lumbar fusion surgery reviewed 18 RCTs and found promising evidence
that multimodal rehabilitation and exercise therapy were effective in improving
outcomes like decreasing disability and pain-related fear [13].
Pharmacological
Multimodal analgesia has become a widespread strategy when it comes to acute
pain management. The overall aim is to target multiple pain receptors to optimally
decrease pain scores and opioid requirements.
•
Acetaminophen
Acetaminophen is one of the most commonly used analgesics for the treatment
of mild to moderate pain. Acetaminophen acts centrally with inhibitory effects on
cyclooxygenase (COX) isoenzymes as well as serotonergic effects [14]. A dose of
15 mg per kilogram is the standard with a maximum administration of 4 g over a 24 h
period. Acetaminophen is metabolized in the liver primarily via conjugation to sulfate
and glucuronide conjugates later excreted in the urine. Caution and dose adjustments
may be necessary when patients display significant hepatic impairment, particularly
transaminitis, or hepatic disease. Evidence supporting the use of acetaminophen in
spine patients is, unfortunately, scarce. However, acetaminophen is considered low
risk and is typically recommended as part of a multimodal analgesic approach for
a wide array of surgical procedures. The PROcedure-SPECific Pain ManagemenT
(PROSPECT) collaboration recommends acetaminophen as a valuable addition to
multimodal spinal surgery analgesic regimens [7]. The faster onset of intravenous
administration compared to the enteral route may be beneficial in the immediate
postoperative phase but widespread utilization may be limited secondary to cost
disparities that exist between the different routes of administration.
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