Godhwal P, Gupta A, Sirohi A, Gupta N. Chronic postsurgical pain in children: Current evidence and clinical perspectives. World J Clin Pediatr 2026; 15(3): 119840 [DOI: 10.5409/wjcp.119840]
Corresponding Author of This Article
Nishkarsh Gupta, Professor, Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Room No. 139 FF IRCH, New Delhi 110029, Delhi, India. drnishkarsh@rediffmail.com
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Godhwal P, Gupta A, Sirohi A, Gupta N. Chronic postsurgical pain in children: Current evidence and clinical perspectives. World J Clin Pediatr 2026; 15(3): 119840 [DOI: 10.5409/wjcp.119840]
Poonam Godhwal, Aarzoo Sirohi, Nishkarsh Gupta, Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
Anju Gupta, Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
Author contributions: Godhwal P, Gupta A, and Gupta N contributed to study conception, definition of intellectual content, and literature search; Godhwal P and Gupta A contributed equally to this manuscript as co-first authors; Godhwal P, Gupta A, Sirohi A, and Gupta N contributed to manuscript preparation, editing, review, and final approval.
AI contribution statement: AI tools were used during manuscript preparation. Specifically, Microsoft Copilot and Grammarly were utilized for language editing, grammar correction, and rephrasing of selected sections to improve clarity and readability.
Conflict-of-interest statement: None of the authors report relevant conflicts of interest for this article.
Corresponding author: Nishkarsh Gupta, Professor, Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Room No. 139 FF IRCH, New Delhi 110029, Delhi, India. drnishkarsh@rediffmail.com
Received: February 7, 2026 Revised: March 17, 2026 Accepted: June 12, 2026 Published online: September 9, 2026 Processing time: 176 Days and 18.6 Hours
Abstract
The chronification of acute pain following surgery is increasingly recognized, with a reported prevalence of 10%-63%, likely reflecting the increasing number of surgical interventions performed in the pediatric population. This pain is more severe after high-risk surgeries, such as spine surgery, hernia repair, and thoracotomy. Currently, the literature reports highly variable definitions of chronic postsurgical pain (CPSP) owing to a lack of objective diagnostic parameters. The International Association for the Study of Pain defines CPSP as “chronic pain that develops or increases in intensity after surgery or a tissue injury and persists beyond three months, without other causes”. This pain can be localized to the surgical field or referred to the affected nerve domain. Similarly, the reported incidence of CPSP in children is largely from low-quality studies and varies between 20% and 50% in the studied population. Its neuropathic features are strongly associated with psychological consequences, functional limitations, and adverse long-term health outcomes. Potential risk factors in the pediatric population include psychosocial behaviors, pre-existing pain, postsurgical pain intensity, and the type of surgery performed. Proposed pathophysiological mechanisms include a pro-inflammatory state after surgery, leading to altered peripheral and central sensitization, genomic factors, epigenetic modifications, and altered brain physiology associated with chronic pain. Understanding the pathophysiology helps target interventions for pre-existing pain, surgery-related pain, anxiety, and opioid-induced hyperalgesia. Preoperative protocolized analgesic strategies, cognitive behavioral therapy, and acupuncture have been tried with varied success rates, although concrete data are lacking. The literature on regional analgesia is still limited in the pediatric population and represents a potential area for further research. Furthermore, rehabilitation interventions addressing postoperative trajectories with early referral to transitional pain clinics may offer promising avenues for improving outcomes. There is a significant knowledge gap, a scarcity of available data on CPSP, and difficulties in addressing pain in the pediatric population, underscoring the need for this review.
Core Tip: Chronic postsurgical pain (CPSP) may occur in up to 80% of the pediatric population. It is more severe after high-risk surgeries, such as spinal surgery, hernia repair, and thoracotomy. Potential risk factors in the pediatric population include psychosocial behaviors, pre-existing pain, postsurgical pain intensity, and the type of surgery performed. Proposed pathophysiological mechanisms include a proinflammatory state leading to altered peripheral and central sensitization, genomic factors, epigenetic modifications, and altered brain physiology associated with chronic pain. Preoperative protocolized analgesic strategies, cognitive behavioral therapy, and acupuncture have been attempted with varied success rates. Despite growing recognition of CPSP in children, a significant knowledge gap remains, which we aim to address in this review.
Citation: Godhwal P, Gupta A, Sirohi A, Gupta N. Chronic postsurgical pain in children: Current evidence and clinical perspectives. World J Clin Pediatr 2026; 15(3): 119840
Millions of children worldwide undergo surgical procedures each year, ranging from minor interventions such as tonsillectomy to complex surgeries including spinal, cardiac, and oncological procedures[1]. These interventions halt disease progression by correcting physical ailments and improving quality of life[2]. Contrary to the beliefs of many parents and surgeons, surgery can result in chronic postsurgical pain (CPSP)[3]. With growing awareness, the International Association for the Study of Pain, in cooperation with the World Health Organization, worked to improve the representation of chronic pain in general (including CPSP), which is now also part of the 11th edition of the International Classification of Diseases (ICD-11). According to ICD-11, CPSP as defined as “pain that develops or increases in intensity after a surgical procedure; persists beyond the healing process (i.e., longer than 3 months); is localized to the surgical field or projected to a referred area; and other causes of pain are excluded,” with specified pain intensity, pain-related distress, and functional interference as overarching elements of pain severity[4,5].
The reported prevalence of CPSP ranges from 10% to 63%, with a pooled prevalence from a recent meta-analysis of 28%, which is higher than the previously reported prevalence of 20%. This increase is attributable to the inclusion of both pain intensity scores and the presence of pain-related distress and functional interference in the overall assessment. Furthermore, incidence rates are highly influenced by the type of surgery, with rates of up to 60% after amputations, 30%-50% after thoracotomies or breast surgeries, and approximately 10% after inguinal hernia repair[5,6].
Risk factors contributing to the development of CPSP may be patient-related or surgery-related, and may not always be modifiable[3]. Pediatric oncology patients are at a higher risk than other surgical children for developing CPSP, owing to both surgical factors (such as amputation, limb-sparing surgeries, and thoracotomies) and co-existing neuropathy secondary to neoadjuvant chemotherapy agents[6]. Awareness of the prevention and management of CPSP is crucial for optimizing postsurgical outcomes, preserving quality of life, and improving functional disability, poor health outcomes, and associated psychological consequences such as low mood, depression, anxiety, and fear of movement, which can lead to functional limitations including reduced participation in daily activities, poorer school attendance, and ultimately adverse overall health outcomes[7,8]. Perioperative efforts should be focused on addressing modifiable factors for the development of CPSP, including preoperative pain intensity and psychosocial factors[6,9,10]. Planning multimodal anesthesia and pain management to effectively control immediate postoperative pain may help reduce the risk of CPSP.
A literature search was conducted using PubMed and Google Scholar using Medical Subject Headings terms and text words pertinent to the pediatric population, CPSP, regional anesthesia, ultrasound-guided nerve blocks, and postoperative pain. This narrative review aims to provide clinicians with a comprehensive overview of the existing and emerging evidence supporting the current understanding of the mechanisms underlying CPSP development, its long-term impact, prevention strategies, and future directions in children and adolescents.
PREVALENCE OF CPSP IN CHILDREN
Although the prevalence of CPSP in the pediatric population varies widely across studies, it results in a substantial and persistent clinical burden (Table 1). Evidence from prospective cohorts and cross-sectional studies conducted predominantly in high-income Western countries demonstrates that CPSP occurs following a range of major surgical procedures, including orthopedic surgeries (particularly spinal fusion and other major musculoskeletal procedures), cardiac surgery, thoracic surgery (including thoracotomy and pectus excavatum repair), abdominal surgeries, and mixed major surgical cohorts[5,11,12]. Prospective data from tertiary pediatric centers have reported moderate-to-severe CPSP with functional interference in approximately 35% of children at 6 months and 38% at 12 months after major surgery[2]. Surgery-specific prevalence estimates are particularly high following spinal fusion for scoliosis (up to 48% at 2 years), thoracic and chest wall procedures (approximately 22%-34%), cardiac surgery via sternotomy (around 21%-34%), and major orthopedic surgery (approximately 13%-28%), whereas abdominal and urologic procedures generally demonstrate lower, but still clinically relevant, rates of CPSP[5,6,13-17].
Table 1 Studies demonstrating the prevalence of chronic postsurgical pain associated with pediatric surgeries.
A meta-analysis published by Rabbitts et al[11] estimated a median 12-month CPSP prevalence of approximately 20% following predominantly major procedures, whereas a more recent systematic review by Rosenbloom et al[5] encompassing nearly 3700 children reported individual study estimates ranging from 10% to 63%, with a pooled CPSP prevalence of 28.2% (95% confidence interval: 21.4%-36.1%), comparable rates at 3-5 months (27%) and 6-12 months (29%), and a higher pooled prevalence following spinal fusion surgery (31%). These findings suggest that CPSP develops in approximately one in four to one in three children after major surgery, whereas prevalence following minor procedures is generally below 10%. Notably, the current evidence base is derived almost exclusively from high-income countries, with little to no prevalence data available from India or other low- and middle-income countries, substantially limiting the global generalizability of existing estimates and underscoring a critical gap in pediatric pain research.
RISK FACTORS FOR CPSP IN CHILDREN
Risk factors for CPSP in children are multifactorial. The biopsychosocial model of pain is central to the development and maintenance of CPSP, reflecting the interaction of premorbid child characteristics, surgical and anesthetic exposures, postoperative recovery, and biological and psychosocial influences. Accordingly, these risk factors can be classified into patient-, surgery-, and recovery-related domains and are summarized in Figure 1 and Table 2[11,18]. Another clinically relevant classification is that of modifiable and non-modifiable factors, as shown in Table 3.
Preoperative pain is among the most consistently identified predictors of CPSP in the pediatric population[3,19]. Children who report pain persisting for more than one month before surgery, or who demonstrate higher preoperative pain intensity (e.g., visual analogue scale scores > 30/100), are at significantly increased risk of developing persistent postoperative pain[6,20]. Similarly, pre-existing functional impairment, including pain-related limitations in mobility, daily activities, or school absenteeism, has been associated with poorer long-term pain and functional outcomes[21]. Gender is less consistent as a predictor in pediatric cohorts than in adult populations; however, some evidence suggests an increased risk among girls following specific surgical procedures, although findings remain heterogeneous[22].
Genetic factors have recently been identified as important contributors to inter-individual variability in pain perception and sensitivity. Single-nucleotide polymorphisms in the catechol-O-methyltransferase gene (V108/158M) have been associated with variable pain intensities[23]. Similarly, DNA methylation of the opioid receptor mu 1 promoter region causes gene silencing, which is further exacerbated by repressor element 1 silencing transcription factor and RAD21 expression in chronic neuropathy cell lines, worsening the pain experience[24]. Another mechanism for heightened sensitivity is conditioned pain modulation (CPM), which is influenced by catechol-O-methyltransferase gene variations and can be described as “pain inhibiting pain”. CPM is found to be reduced in patients with postoperative pain syndrome, irritable bowel syndrome, headache, chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Identification of these genes can stratify and individualize the risk-benefit equation for surgeries and procedures and can be used as a screening tool for treatment selection, with less invasive methods potentially preferred in high-risk patients. Yarnitsky et al[25] reported that patients with diabetic neuropathy and less efficient CPM were more likely to respond to duloxetine therapy[26].
SURGICAL AND ANAESTHETIC FACTORS
The type of surgical procedure is a key determinant of CPSP risk. Higher prevalence rates have been reported following major orthopedic surgeries (e.g., limb reconstruction, anterior cruciate ligament repair, and osteotomies), spinal fusion, thoracotomy, cardiac surgery, and selected urologic procedures[27,28]. Procedure-related factors, including the extent of tissue and nerve injury, history of previous surgeries, and operations associated with an inherent risk of nerve damage, further increase the likelihood of developing CPSP. Longer surgical duration and intraoperative complications may also contribute to an increased risk of persistent postoperative pain[2,6,29].
POSTSURGICAL CLINICAL AND PSYCHOSOCIAL FACTORS
Higher pain scores during the early postoperative period, particularly within the first 3 to 7 days after surgery, consistently predict persistent pain at 3 to 12 months postoperatively[20,30,31]. Subsequent chronic pain in some cohorts has been associated with large surgical scars (> 3 cm) and postsurgical orthopedic complications[6]. Another potential contributor is postsurgical opioid consumption. Although this relationship is complex, as increased opioid use may reflect greater underlying pain severity, prolonged or high-dose opioid exposure may influence pain trajectories and contribute to adverse outcomes[11,24,32,33]. Immediate postoperative functional limitations, such as delayed mobilization and difficulties returning to school, further increase the risk of chronic pain and long-term disability[2].
PSYCHOLOGICAL FACTORS
Preoperative anxiety, depressive symptoms, sleep disturbances, and, in particular, pain catastrophizing have been repeatedly associated with persistent postsurgical pain[2,31,34,35]. Pain catastrophizing, characterized by excessive worry and feelings of helplessness in response to pain, shows strong prospective associations with CPSP and may change over time, highlighting its potential as a target for early intervention[31]. Higher levels of parental excessive worry and anxiety regarding their child’s pain are associated with greater pain intensity and functional disability in the months after surgery[29]. Parents with chronic pain or mental health problems may unintentionally model unhelpful coping strategies, which can contribute to the persistence of CPSP in their children[31,36].
MECHANISMS AND PATHOPHYSIOLOGY
CPSP arises from a complex interplay between peripheral and central neurobiological processes, modulated by demographic, genetic, and psychosocial factors. Surgical tissue injury activates and sensitizes peripheral nociceptors, releasing inflammatory mediators such as cytokines, prostaglandins, and neuropeptides. Persistent noxious stimuli can induce peripheral sensitization, lowering the thresholds of nociceptors and amplifying responses to mechanical or thermal stimuli[37,38].
At the spinal and supraspinal levels, repetitive nociceptive input may lead to central sensitization, characterized by increased excitability of dorsal horn neurons, diminished inhibitory control, expansion of receptive fields, and altered descending pain modulation. An additional contributor to chronic pain in children is early nociceptive exposure in the developing nervous system, resulting in long-lasting effects on pain processing[39]. Changes in brain physiology associated with chronic pain may be identified using neuroimaging techniques, which represents a promising area for future research[1].
Neuropathic components are commonly observed following thoracotomy, limb surgery, and complex urologic procedures, where nerves may be transected, stretched, or trapped in scar tissue. Susceptibility to persistent pain may be modulated by genetic and epigenetic factors, including polymorphisms in genes involved in catecholamine metabolism, opioid receptor signaling, and inflammatory pathways, although pediatric data remain sparse[40-42].
Psychological processes such as anxiety, increased pain sensitivity, fear of re-injury, and poor coping mechanisms can amplify the pain experience and contribute to the development of CPSP. Family factors, such as parental exaggeration of pain concerns and overprotectiveness, can also promote ongoing illness behaviors and limit a child’s return to normal activities[31,43]. Figure 2 illustrates the mechanisms and pathophysiological processes underlying CPSP, including peripheral sensitization, central sensitization, neuroinflammation, nerve injury, and psychosocial factors contributing to pain persistence.
Figure 2
Mechanism and pathophysiology of chronic postsurgical pain.
CLINICAL FEATURES OF CPSP IN CHILDREN
CPSP is characterized by pain that persists or emerges following surgery and continues beyond the expected period of tissue healing, generally exceeding 3 months postoperatively. It is localized to the surgical field or a related referred area and cannot be explained by alternative causes, such as infection, disease recurrence, or new pathology. Pain severity ranges from mild to severe, with marked variability depending on the type of surgical procedure performed (Table 4).
Table 4 Phenotypes of chronic postsurgical pain in children.
Type of CPSP
Key characteristics
Symptoms
Onset and course
Surgeries/contexts
Neuropathic CPSP
Pain from nerve injury. Sensory abnormalities present
Children may report continuous pain, intermittent exacerbations, or pain provoked by movement in areas such as incision scars, joints, or along dermatomal distributions. Pain is characterized by burning, tingling, and electric shock-like sensations, consistent with neuropathic or mixed pain phenotypes. Sensory abnormalities, such as hypoesthesia, hyperesthesia, and allodynia, are commonly observed on examination around the surgical incision or within the affected nerve territories.
PSYCHOSOCIAL AND FUNCTIONAL FEATURES
Frequently associated psychological factors include anxiety, depressive symptoms, pain catastrophizing (in both children and parents), and poor sleep quality. Functional impairment is common owing to reduced physical activity, sleep disturbance, decreased participation in sports and school activities, and fear of activity-related pain (kinesiophobia), which can limit rehabilitation and recovery.
PAIN PROFILE AND COURSE
Pain may be continuous or episodic and fluctuates in response to physical or emotional stress. While some children show gradual improvement over 6-12 months, others progress to long-term pain-related disability, emphasizing the need for early identification and multidisciplinary intervention.
MANAGEMENT
Perioperative management of CPSP aims to reduce risk factors such as preoperative anxiety, excessive perioperative opioid exposure, and high postsurgical pain intensity[9,30,44]. Most perioperative analgesic studies in children have been conducted in heterogeneous populations and rarely assess pain outcomes beyond the immediate postsurgical period, thereby limiting the understanding of their efficacy in preventing chronic pain[44-48]. Given the current lack of sufficient evidence, a multimodal perioperative therapeutic approach is considered the most effective strategy for preventing and managing chronic pain. Consideration of patient-specific factors, including genetic predisposition, psychological vulnerability, and previous pain experiences, is essential. Anesthetists should therefore adopt a patient-centered approach that includes assessment of baseline factors such as pre-existing pain conditions, anxiety, and pain catastrophizing, to individualize analgesic strategies, particularly for children at high risk of severe or prolonged postsurgical pain. Multimodal analgesia is the preferred approach and should ideally be supplemented with neuraxial or regional anesthesia when anatomically and clinically feasible (Figure 3)[49]. Preventive analgesia aims to block noxious afferent signals from the surgical incision and throughout the postsurgical period to prevent peripheral and central sensitization[50].
Figure 3 Proposed perioperative management approach for the prevention and mitigation of chronic postsurgical pain in children.
NMDA: N-methyl-D-aspartate; NSAID: Non-steroidal anti-inflammatory drug; POD1: Postoperative day 1; SNRI: Serotonin-norepinephrine reuptake inhibitor; TCA: Tricyclic antidepressant.
REGIONAL ANALGESIA AND LOCAL ANAESTHETICS
Neuraxial techniques, including epidural and spinal anesthesia, as well as peripheral nerve blocks, should be considered before surgical incision to provide adequate intraoperative and postsurgical analgesia and reduce opioid requirements. The choice between neuraxial and peripheral techniques should be guided by factors such as the surgical field, the need for bilateral analgesia, and patient safety. The use of extended-release formulations (e.g., liposomal bupivacaine) can provide analgesia for up to 72 hours, eliminating the need for indwelling catheters[50].
The Pediatric Regional Anesthesia Network has highlighted the safety of regional and neuraxial techniques; however, their role in the prevention of CPSP remains unclear, and evidence is insufficient to draw definitive conclusions regarding the efficacy of regional techniques as an adjunct for limiting CPSP[51]. The use of ultrasound guidance has further enhanced the safety profile of regional anesthesia in children and is also associated with a reduction in opioid use and consequent opioid-induced hyperalgesia. Semkovych[52] reported reduced chronic pain intensity in patients undergoing anterior abdominal wall surgery when quadratus lumborum and transversus fascia plane blocks were incorporated into general anesthesia. Linares and Barroso[53] described the prevention of phantom limb pain in a child undergoing knee disarticulation using combined femoral and sciatic nerve blocks, emphasizing the potential benefit of peripheral nerve blocks in altering long-term pain trajectories.
GABAPENTINOIDS
Gabapentin is an extensively studied drug that has been shown to reduce immediate postsurgical pain and opioid use after pediatric procedures such as amputations and limb-sparing surgeries. For example, the use of a preoperative and postsurgical gabapentin regimen in patients with osteosarcoma significantly lowered the incidence of phantom limb pain 60 days after amputation. Gabapentinoids can therefore be integrated into practice as a favorable strategy to modify the transition from acute postoperative pain to chronic pain[47,54].
LOW-DOSE KETAMINE INFUSIONS
Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, represents a promising strategy for CPSP as it addresses key mechanisms in CPSP pathogenesis, including central sensitization and opioid-induced hyperalgesia. Its adjuvant role in high-risk populations such as pediatric hematology and oncology patients has been studied retrospectively, emphasizing its capacity to reduce opioid requirements[55]. Esketamine (S-enantiomer of ketamine) is a potent NMDA receptor antagonist that also interacts with opioid, monoaminergic, and muscarinic receptors, as well as voltage-gated ion channels. It has been used in non-intubated video-assisted thoracic surgery for its analgesic action, immunomodulatory effects, ability to prolong the duration of local anesthetic blocks, reduction of rebound pain, and attenuation of central sensitization. Patients with CPSP may benefit from its neuroprotective and antidepressant effects, which further improve functional recovery. Additionally, it stabilizes nociceptive membranes and inhibits leukocyte activation, counteracting the central sensitization exacerbated by inflammation[56].
LIDOCAINE INFUSIONS
Intravenous lidocaine infusions may modulate the postoperative inflammatory response by decreasing cytokine levels and reducing opioid consumption. This approach is most commonly used in pediatric spinal surgery. A possible role in mitigating central sensitization has been proposed based on its anti-inflammatory and analgesic properties; however, data in pediatric oncosurgical populations remain limited[57,58].
DEXMEDETOMIDINE
Dexmedetomidine is an alpha-2 agonist that can be used as an adjunct to neuraxial or peripheral local anesthetics to prolong the intensity and duration of analgesia, along with providing sedation, improved sleep quality, and anxiolysis. It is a flexible and valuable component of multimodal analgesia owing to its opioid-sparing properties[35,45].
METHADONE
Methadone is a long-acting opioid with additional NMDA receptor antagonist activity and monoamine reuptake inhibition properties. It provides sustained analgesia following complex surgeries, reduces opioid consumption requirements, and potentially attenuates central sensitization. Regular monitoring for corrected QT interval prolongation is recommended during methadone therapy[49,59].
ANTIDEPRESSANTS
Anxiety and depression are well-established risk factors for CPSP and may be targeted by antidepressants, including tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors, which modulate the descending inhibitory pain pathways. Further studies are required to clarify their role in perioperative pediatric pain prophylaxis and comprehensive care[60].
NON-PHARMACOLOGICAL INTERVENTIONS
Guided imagery, therapeutic play, and music-based interventions can effectively reduce perioperative anxiety and contribute to a holistic, multidisciplinary approach to pain management[61].
CHALLENGES IN THE DIAGNOSIS AND MANAGEMENT OF PAEDIATRIC CPSP
The effective diagnosis and management of pediatric CPSP remain challenging owing to barriers such as limited preoperative risk screening, poor communication among perioperative teams, delayed recognition of CPSP, insufficient evidence to guide long-term analgesic strategies, limited specialized pain services, and stigma related to pre-existing mental health conditions. These barriers result in delayed intervention and suboptimal outcomes, especially in children at high risk of developing prolonged or severe pain.
CONCLUSION
Early identification of CPSP by anesthetists, surgeons, and healthcare systems through routine preoperative screening and targeted prevention strategies such as interdisciplinary communication and shared education can improve early recognition and coordinated management. Evidence-based guidelines should be developed and implemented for perioperative analgesia to prevent CPSP in children, alongside ongoing research into long-term pain outcomes. In addition, specialized pediatric pain services should be readily accessible, and early referral may reduce delays in care. Integrating psychological assessment and support into routine perioperative care can ensure equitable, patient- and family-centered management for children at increased risk of developing CPSP.
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