Chronic postsurgical pain in children: Current evidence and clinical perspectives

Table 1 Studies demonstrating the prevalence of chronic postsurgical pain associated with pediatric surgeries

Ref.	Design and setting	Surgery type(s)	Follow-up time(s)	CPSP prevalence/incidence
Rosenbloom et al[2], United States	Prospective cohort, tertiary children’s hospital	Mixed major surgeries (orthopedic, thoracic, abdominal)	6 and 12 months	35% at 6 months; 38% at 12 months (moderate to severe CPSP)
Dugan et al[16], United States	Single-center cross-sectional online survey, tertiary pediatric hospital	Surgeries across multiple specialties	Median of several years after surgery	30% of respondents reported CPSP
Rabbitts et al[11]	Systematic review + meta-analysis (4 cohorts)	Mostly major surgeries, mixed type	12 months (most studies)	Median prevalence of 20% at 12 months (IQR 14.5%-38%)
Sim et al[17]	Systematic review of prevalence (20 studies, n approximately 3742)	Wide range, mostly major surgery (orthopedic, spine, thoracic)	≥ 3 months; subgroup analyses at 3-5 and 6-12 months	Individual study prevalence ranged 10%-63%
Rosenbloom et al[5]	Systematic review + meta-analysis (20 studies, n = 3742)	Mostly major surgeries; spinal fusion subgroup analysis	3-5 months and 6-12 months	Overall pooled prevalence 282% (95% confidence interval: 21.4%-36.1%); 27% at 3-5 months; 29% at 6-12 months; spinal fusion subgroup 31% (95% confidence interval: 21.4%-43.5%)

CPSP: Chronic postsurgical pain; IQR: Interquartile range.

Table 2 Factors that increase the likelihood of developing chronic postsurgical pain

Risk category	Specific risk factors in children
Premorbid factors
Demographic factors	Age at surgery
	Female sex
	Lower socioeconomic status
Genetic factors	Family history of chronic pain (e.g., recurrent abdominal pain, headaches, musculoskeletal pain)
Medical factors	Pre-existing chronic or recurrent pain conditions (e.g., recurrent abdominal pain, headaches, musculoskeletal pain)
	History of prior surgery with persistent pain
	Chronic medical conditions (e.g., sickle cell disease, inflammatory bowel disease, cerebral palsy, obesity)
Injury and recovery factors	Surgery related and early postoperative course
Type, extent, and duration of surgery	High-risk surgeries
	Nerve injury, or re-operation
Acute postsurgical pain	High pain scores in the first 3-7 days postoperatively (e.g., NRS > 6-7)
	Persistent pain beyond expected recovery period
	Pain-related interference with sleep, eating, mobility, or school attendance
Acute pain	Inadequate or delayed analgesia
	Over-reliance on opioids
	Poorly controlled pain despite treatment
Biological factors	Physiological response to surgery
Inflammatory and endocrine response	Strong local/systemic inflammation (e.g., high CRP, IL-6, or TNF-α levels)
	Prolonged pro-inflammatory state after surgery
	Dysregulation of the hypothalamic-pituitary-adrenal axis
Epigenetic factors	Surgery-induced epigenetic changes in pain-related genes (e.g., opioid receptors, ion channels, inflammatory mediators, catechol-O-methyltransferase/opioid receptor mu 1)
Psychosocial factor	Child’s psychological and behavioral responses
Emotional and cognitive factors	General: High trait anxiety, fear of pain, fear of procedure, low self-efficacy
	Pain specific: Pain-related hypervigilance, fear of re-injury, and negative pain beliefs
Behavioral factors	Avoidance of activity, school, sports, or social interaction
	Poor sleep quality, poor adherence to physiotherapy
	Maladaptive coping strategies
Parental and family factors	Parental chronic pain, anxiety, or depression
	Overprotective parenting, illness reinforcement
	Excessive parental utilization of healthcare services
	Family stress or a history of adverse childhood experiences

CRP: C-reactive protein; IL-6: Interleukin-6; NRS: Numerical Rating Scale; TNF-α: Tumor necrosis factor-alpha.

Table 3 Modifiable and non-modifiable risk factors for chronic postsurgical pain

Modifiable risk factors	Non-modifiable risk factors
Psychosocial factors	Age (adolescents: 12-18 years)
Preoperative pain status	Sex (female > male)
Acute pain management	Surgery type (e.g., scoliosis/thoracic surgery)
Physical/lifestyle factors	Medical history
Surgery characteristics (e.g., prolonged surgical duration)	Genetic factors
Preoperative distress

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	Burning; shooting/electric; tingling/numbness; allodynia/hyperalgesia	Often immediate or early after surgery, can persist or worsen if untreated	Amputation; thoracotomy; spinal surgery; limb-sparing surgery
Nociceptive CPSP	Pain from ongoing tissue inflammation/damage. Movement-related	Aching; throbbing; sharp with movement	Correlates with tissue healing; may improve slowly or plateau	Orthopedic procedures; major abdomen and chest surgeries
Mixed CPSP	Combination of neuropathic + nociceptive features. Most common presentation	Variable: Aching + burning. Movement-induced shooting pain	Mixed timeline; inflammatory component may reduce, neuropathic may persist	Spinal fusion; major oncologic resection
Phantom limb pain	Pain perceived in absent limb. Often neuropathic mechanism	Cramping; twisting; burning in “phantom”	Within days to weeks after amputation; can become chronic	Amputation
Stump pain	Pain at amputation residual limb. Can be neuropathic or nociceptive	Tenderness; burning at incision/scar; shock-like jolts	Early postoperative; may evolve into neuroma pain	After amputation; following limb disarticulation
Central sensitization-mediated CPSP	Amplified pain due to CNS maladaptation. Widespread hyperalgesia	Diffuse sensitivity. Disproportionate to exam	Postoperative onset; associated with high acute pain	After major surgeries; preoperative anxiety/pain
Visceral CPSP	Poorly localized, deep pain. Often referred patterns	Cramping; pressure; deep aching	May appear after initial recovery; triggered by organ distension	Abdominal/pelvic surgery

CNS: Central nervous system; CPSP: Chronic postsurgical pain.