A Guide to Diagnoses, Indications,

and Contraindications for

Interventions in Pediatric
Chronic Pain

Alexandra Szabova, MD
John Rose, MD
Kenneth Goldschneider, MD
Chronic Pain Center, Division of Pain Management, Department of Anesthesia,
Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio

Objectives

1. Emphasize importance of multidisciplinary team in the care

of pediatric patients with chronic pain.
2. Discuss barriers to pediatric interventional pain management.
3. List a limited number of diagnoses that benefit from interventions.
4. Review diagnoses NOT suitable for interventional pain management.

The Role of Multidisciplinary Teams in the Care of

Pediatric Patients With Chronic Pain: Barriers to
Pediatric interventional Pain Management

Chronic pain in children is more common than once believed. An

epidemiologic study of pain in Dutch children revealed that 25% of
those surveyed reported recurrent or continuous pain of 3-month
duration. The incidence was even higher, about 43%, in adolescent girls
12 years of age and older.1 The most commonly reported types of pain
included limb pain, headache, and abdominal pain. There is a growing
body of literature demonstrating that chronic pain adversely impacts
children.25 School attendance, school performance, mood, sleep, and
REPRINTS: ALEXANDRA SZABOVA, MD, CHRONIC PAIN CENTER, DIVISION OF PAIN MANAGEMENT, DEPARTMENT OF
ANESTHESIA, CINCINNATI CHILDRENS HOSPITAL MEDICAL CENTER, MLC 2001, 3333 BURNET AVENUE, CINCINNATI,
OH 45229. E-MAIL: ALEXANDRA.SZABOVA@CCHMC.ORG
INTERNATIONAL ANESTHESIOLOGY CLINICS
Volume 50, Number 4, 109119
r 2012, Lippincott Williams & Wilkins

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social interaction can all deteriorate. Family life can be disrupted as

parents struggle to remain employed while attending to their childs
needs. There may also be increased utilization of health services placing
a financial strain on the family. Combination of these factors makes the
management of children with chronic pain complex and challenging,
further complicated by the lack of evidence supporting the use of a
variety of treatments (pharmacologic or interventional) for managing
chronic pain in children. Nevertheless, the practicing anesthesiologist,
whether pediatric or adult, may be asked as a consultant for assistance
in managing chronic painful conditions in children and young adults.
The conservative treatment of children and young adults with chronic
pain utilizing a multidisciplinary approach to care has been considered
the gold standard.
Apart from the physicians and nurses, physical therapists and
psychologists (specializing in pain management) are essential members
of the treatment team. When needed, consultations by neurologist,
physical medicine and rehabilitation specialist, or psychiatrist may be
requested. Close communication between the team memberspreferably
on a daily (multidisciplinary rounds) or weekly basis assures that the team
members send consistent messages to the patient and family.
Physical therapy (PT) and cognitive-behavioral therapy with
emphasis on pain coping, stress management, and relaxation training
have proven essential and effective in management of chronic painful
conditions in children and young adults.69 Compared to adult pain
medicine, interventional approaches to treatment of chronic pain in
children and young adults reveal limited utility and have required
specific considerations. The barriers to interventional treatments are not
only restricted to simple needle phobias many young patients demonstrate, but also to the lack of solid evidence-based practice guidelines. Although paucity of evidence for the use of many interventions is
also true for pain medicine in general, indications for interventional
therapies remain less well studied in pediatric pain medicine. There are
few well-designed, prospective, placebo-controlled, and double-blinded
studies on the use of interventions in pediatric chronic pain, because
many chronic pediatric pain conditions that might be amendable for
injection therapies are relatively rare, and historically there were only
a few centers treating children with chronic pain. Other issues involve
consent and use of placebo-controlled trials for pain treatment in
minors.
We attempt to answer some basic questions that arise when
designing a plan of care for a pediatric or young adult patient with
chronic pain: Which diagnoses are or are not suitable for an
intervention? At what point of treatment does one proceed with an
intervention? We will attempt to establish a context in which the
interventions should be considered.
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Diagnoses Suitable for Intervention and Timing

of Interventions

Complex regional pain syndrome (CRPS) has been considered a

prototype of neuropathic pain. As defined by the International Association
for Study of Pain,10,11 CRPS represents an array of painful conditions that
are characterized by a continuing spontaneous and/or evoked regional
pain that is seemingly disproportionate in time or degree to the usual
course of any known trauma or other lesion (see Table 1 for the
International Association for Study of Pain diagnostic criteria).12 The pain
is regional (not in a specific nerve territory or dermatome) and usually
displays a distal predominance of abnormal sensory, motor, sudomotor,
vasomotor, and/or trophic findings. The syndrome shows variable
progression over time.13 Affected patients, most often adolescent white
females, high achieving, from successful families, active in sports, present
with lower extremity pain (Fig. 1). The disease often affects children and
young adults with high level of anxiety and/or stress (eg, school, family
problems, illness, peer problems, etc.).14,15
The initial thinking regarding causes of CRPS focused on the role of
sympathetic nervous system. The temperature differences, sudomotor
and trophic changes were thought to be mediated by the overreactive
sympathetic nervous system. Pain resulted from poor perfusion and
ischemia. And so, historically, blocking the sympathetic nervous system
was frequently utilized for diagnostic and therapeutic purposes. Low
concentration of local anesthetics with or without glucocorticoids has
been used to block sympathetic ganglia. The often dramatic response to
the block with a several degree temperature raise in affected extremity
and subjective pain relief reinforced the use of blocks for CRPS. So,
although sympathetic nerve blocks once were considered a gold
standard for treatment, it is not the case nowadays for 2 reasons. First,
long-term efficacy proven by randomized-controlled trials remains
lacking. Second, there is mounting evidence of a more complex systemic
involvement, beyond the sympathetic nervous system (see Marinus and
colleagues10,11 for excellent reviews).
This diagnosis, best addressed by a multidisciplinary team, involves
at least a pain medicine specialist, physical therapist, and a psychologist.
The goal of the treatment of this painful condition is to maintain normal
function of the affected extremity. The mainstay of care becomes
aggressive daily PTstrengthening, range of motion, desensitization,
which challenges a hurting young individual. To facilitate compliance
with the PT, the anesthesiologist/pain physician prescribes adjuncts from
several drug groups: tricyclic antidepressants, anticonvulsants, and
nonsteroidal antiinflammatory drugs (NSAIDs) for pain relief. A brief
course of opioids may be considered (usually 2 wk, in certain situations
up to 4 wk, but very rarely beyond 6 wk), accompanied by a clear
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Szabova et al

Table 1. Budapest Clinical Diagnostic Criteria for CRPS

1. Continuing pain, disproportionate to inciting event
2. Report of at least 1 symptom in 3 of the 4 following categories:
Sensory: hyperesthesia and/or allodynia
Vasomotor: temperature asymmetry and/or skin color changes and/or skin color
asymmetry
Sudomotor/edema: edema and/or sweating changes and/or sweating asymmetry
Motor/trophic: decreased range of motion and/or motor dysfunction (weakness,
tremor, dystonia) and/or trophic changes (hair, nail, skin)
3. Display of at least 1 sign at time of evaluation in Z2 of the following categories:
Sensory: hyperalgesia (pinprick) and/or allodynia (light touch and/or deep
somatic pressure and/or joint movement)
Vasomotor: temperature asymmetry and/or skin color changes and/or asymmetry
Sudomotor/edema: edema and/or sweating changes and/or sweating asymmetry
Motor/trophic: decreased range of motion and/or motor dysfunction (weakness,
tremor, dystonia) and/or trophic changes (hair, nail, skin)
4. There is no other diagnosis that better explains the signs and symptoms
For research purposes, the presence of at least 1 symptom in all the 4 symptoms categories and
at least 1 sign (observed at evaluation) in Z2 sign categories is required.
Adapted from Harden et al.12

message to the patient and the family emphasizing the temporary nature
of the opioids and PT goals to be achieved while prescribing the
medication. Also, the anesthesiologist/pain physician needs to emphasize
the role of psychological services in pain coping, stress management,
and/or relaxation techniques training. Addressing sleep disturbances
forms an essential part of initial assessment. A prevalent philosophy in
the management of pediatric patients with CRPS (or any chronic painful
condition) is to optimize conservative measures prior to considering
interventional techniques. We view interventions as a double-edge

Figure 1. Adolescent female with complex regional pain syndrome of the right foot, note mottled
and bluish discoloration compared to left foot.
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swordthey may provide quicker pain relief, but if the patients do not
rehabilitate the extremity well enough before returning to normal
activities (which tend to be of high intensity), a pain-free extremity with
residual weakness or limited range of motion may predispose to injuries.
Pediatric patients with CRPS usually undergo 6 to 8 weeks of initial
conservative treatment consisting of medications and PT before
considering intervention. If the initial conservative approach
successful in majority of casesfails, then moving forward with an
intervention becomes reasonable. Patient selection is a key to good
outcomecompliant patients do better than those neglecting certain
aspects of the therapies.
Myofascial pain, pain originating from muscle and fascia layers, is
frequently overlooked by practitioners, although it can be a source of
severe pain and disability. Myofascial pain can be primary, resulting
from direct muscle injury, or secondary, a reflex protective response of
the body to an underlying problem. One symptom patients consistently
describe when asked about their pain is either sensation of tightness in
particular muscle group, or intermittent muscle spasms. An example of
primary myofascial pain is upper back pain that usually occurs from
trapezius muscle spasms in patients with anxiety coupled with high
levels of stress. Temporomandibular joint dysfunction can be associated
with myofascial pain in children.16 Children with chronic tension-type
headache reveal discrete trigger points in head, neck, and shoulder
muscles.17 Lower back paravertebral myofascial pain can start primarily
after direct injury (sprain), or secondarily because of underlying spinal
pathology (facet arthropathy, discogenic pain) in reflexive attempt to
protect the affected structure. Patients with kidney stones may present
with flank pain that is not only caused by pain from the kidneys or the
ureters, but also by reflex muscle spasm, persistent, and quite disabling.
Another frequently seen, overlooked area of myofascial pain, is
abdominal wall pain. Isolated somatic abdominal pain, relatively rare
compared to its visceral or functional counterparts, is usually a
secondary symptom associated with primary visceral problem (see
belowinflammatory bowel disease or a type of functional gastrointestinal disorder, eg, irritable bowel syndrome, visceral hyperalgesia,
abdominal migraine, functional abdominal pain). Severe vomiting or
crampy abdominal pain may be associated with abdominal wall muscle
tightness resulting in severe pain.
Good physical examination remains the key to successful treatment,
and patients need to be educated about the slower nature of recovery
(several weeks to months). The pain can be either diffuse, or
concentrated to discrete trigger points. The diagnostic criteria for a
trigger point have not been unified and many definitions are available,
we tend to use those defined by Simons et al18 (Table 2). Symptomatic
treatment of primary and secondary myofascial pain (as part of the
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Table 2. Definition of Trigger Point

The term trigger point was coined in 1942 by Dr Janet Travell to describe a clinical
finding with the following characteristics:
Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by
acute local trauma, inflammation, degeneration, neoplasm, or infection
The painful point can be felt as a nodule or band in the muscle, and a twitch
response
Palpation of the trigger point reproduces the patients complaint of pain, and the
pain radiates in a distribution typical of the specific muscle harboring the trigger
point
The pain cannot be explained by findings on neurological examination
Adapted from Chou.19

multidisciplinary treatment) may include transcutaneous electrical nerve

stimulation (available through PT), muscle relaxants and NSAIDs, PT
stretching, strengthening, and addressing relevant underlying. As an
adjunct to these basic therapies, trigger-point injection may be useful in
the management of myofascial pain in children.
Postdural puncture headache (PDPH) is a well-described complication related to needle penetration of the dura mater. The incidence, not
well defined in pediatric patients, occurs more frequently than initially
thought (2% to 15%, not age dependent).16 The risk factors for PDPH
are thought to be similar for adults and children. Larger needle size,
cutting point design, and perpendicular orientation of the needle tip in
relation to the dural fibers during the puncture, large volume of
cerebrospinal fluid removed for diagnostic purposes, absence of stylet
before withdrawing the needle, multiple attempts, previous history of
PDPH, history of migraine headaches, and extremes of body mass index
can all predispose to PDPH.20 PDPH can develop in patients undergoing diagnostic lumbar puncture, as a complication while receiving
epidural or spinal anesthesia or analgesia by single-shot or catheter
technique, or in children undergoing intrathecal chemotherapy.21 The
prophylactic treatment has included bed rest, aggressive prehydration,
and administration of intravenous caffeine, although these lack
evidence. The onset of head pain occurs typically within 24 to 48 hours
after the procedure, but may occur up to a week later. The duration is
usually 5 to 10 days; the headaches tend to resolve spontaneously. We
recommend conservative treatment for the first 48 hours after onset and
reassess the patient. Pediatric patients and their parents usually prefer to
start with conservative approach and choose to proceed with interventional treatment after conservative options have become exhausted and
symptoms continue. Then the epidural blood patch (EBP) is offered.
Untreated severe PDPH can lead to subdural hematoma, intracerebral
hemorrhage, or cerebral nerve palsy.22 The reported success rate ranges
from 75% to 96% for the first EBP and approach 100% for second EBP.
For conservative treatment, a recent review demonstrated that caffeine
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administration significantly decreases the proportion of participants

with postdural puncture headache and in those needing supplementary
interventions, compared with placebo. Gabapentin, theophylline, and
hydrocortisone decrease pain severity compared with placebo or
conventional care. These conclusions should be interpreted with caution
as results come from studies with limited sample sizes (7 studies
involving a total of 200 participants). The other drugs assessed
(sumatriptan and adrenocorticotropic hormone) have not shown a
significant effect.23
Patients with posttraumatic and migraine headaches are often quite
disabled by pain. Posttraumatic headache (PTH) is a dominant symptom
of a controversial postconcussion syndrome (combination of headache,
dizziness, fatigue, irritability, anxiety, insomnia, loss of concentration and
memory, and noise sensitivity). Loss of consciousness does not have to
take place in order to develop postconcussion syndrome. Every year,
300,000 of the 1.5 million head injuries are associated with athletics,
majority striking high school level and younger athletes.24 Pathophysiology of PTH is poorly understood, it is considered multifactorial with
component of excitatory neurotransmitters activity, and delayed (within
24 h) secondary axotomy as proven by diffusion tensor imaging, more
sensitive than conventional imaging methods.25 According to International Headache Society diagnostic criteria, the onset of headache
should occur within 7 days of injury. Clinically, the presentation varies
from tension-type headache, occipital neuralgia, migraine headache,
cluster headache, low cerebrospinal fluid pressure headache, suprarbital
and infraorbital neuralgia, whiplash and cervicogenic headache. The
acute PTH lasts up to 3 months after the injury, the persistent PTH lasts
beyond that (in about 20% of patients). A total of 90% of athletes achieve
complete recovery within 1 month after the injury, minority progresses
to chronic process. Persistent PTH presents a complex psychosocial
disorder where psychiatric problems, social problems, compensation
and litigation issues, and malingering all play a role.26 Treatment of
PTH mirrors multidisciplinary treatment of migraine headaches.
Abortive therapy includes nonsteroidal anti-inflammatory drugs, and
triptans. Prophylactic therapy includes b-blockers, anticonvulsants,
antidepressants, and tricyclic antidepressants. Greater occipital nerve
block with or without trigger-point injection with local anesthetics or
botulinum toxin A has been used effectively.27 It can be offered in
addition to multidisciplinary care (cognitive-behavioral therapy, biofeedback, transcutaneous electrical stimulation, PT, and manipulation).
Pediatric and adolescent patients with lower back pain represent
some of the most challenging case in a pain clinic. More than 80%
of patients will not display an identifiable pathology, although they
exhibit severe disabling pain resulting in significant dysfunction. Only a
minority of patients will present with spondylolysis, spondylolisthesis, or
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discogenic pain with or without sciatica. Some will have muscle tightness
and spasms that limit their activity and affect the quality of their lives.
The first step in evaluation is to exclude serious structural causes of pain
(eg, tumor, osteomyelitis, discitis, abscess). The usual cause for nonspecific back pain is core muscle weakness and poor flexibility.28 Stress
often exacerbates lower back pain. A multidisciplinary approach is
indicated for both nonspecific and well-identified etiology of back pain
PT for strengthening and flexibility, and cognitive-behavioral therapy for
pain coping/stress management. The anesthesiologist may offer medications for symptomatic reliefmuscle relaxants, NSAIDs, acetaminophen, if needed and/or desired by the patient. Sleep disturbances
should be addressed. Tricyclic antidepressants and anticonvulsants can be
used as adjunct to treat discogenic back pain. Once again, the primary
approach is conservative for several weeks, then adding an intervention if
indicated and if the patient and family desire an interventional approach.
Detailed information about management of chronic back pain can be
found in the American Pain Society Practice Guidelines.19
Visceral abdominal painsuch as in chronic pancreatitis, or
pancreatic cancer (rare in children), occurs infrequently in pediatric
and young adult patients. Treatment is generally multidisciplinary. The
decision to perform an intervention for nonmalignant abdominal pain
always involves consultation among gastroenterologist, pain physician,
parent, and patient and is done more often for diagnostic purposes to
help guide pharmacologic treatment rather than therapeutic purposes.

Diagnoses not Suitable for Interventional Pain

Management

Visceral hyperalgesia or functional abdominal pain is the second

most common complaint bringing pediatric patients in our office.
The etiology of functional gastrointestinal disorders is multifactorial
and includes abnormal gut reactivity to physiological stimuli (meal,
distension, hormonal changes), noxious stressful stimuli (inflammation),
psychological stress (parental separation, anxiety). Functional abdominal
pain manifests as visceral hyperalgesiadecreased threshold for pain in
response to changes in intraluminal pressure. It is thought to be a result
of abnormal interactions between the enteric nervous system and central
nervous system, peripheral sensitization and abnormal central processing of afferent signals at the level of the central nervous system with
significant serotonin involvement (of note, 90% of body serotonin is
released in the gut).29 Treatment is always multidisciplinary, with
emphasis on cognitive-behavioral therapy. Pharmacologic therapy with
selective serotonin reuptake inhibitors/selective norepinephrine reuptake inhibitors, tricyclic antidepressants, and/or anticonvulsants may be
utilized not only to address pain, but also underlying depression or
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anxiety. Most importantlythe clinician needs to set realistic goals

with restoring function first, many times, weeks before eliminating pain.
These patients are NOT candidates for interventions.

Summary

Although the painful conditions in children and young adults do not

involve a broad spectrum of disorders, the treatment itself may pose a

CRPS
Myofascial pain

Functional Abdominal Pain

PDPH, PTH, migraine

Non-specific Back Pain

Discogenic/Facetogenic
Back pain
Somatic/Visceral
Abdominal pain

Diagnoses for which

injection therapy MAY be
indicated

Diagnoses for which

injections therapy is NOT
indicated

Multidisciplinary Treatment:
Cognitive-behavioral Therapy
Core approach to
pediatric chronic
pain

Physical/occupational therapy
Biofeedback
TENS
pharmacotherapy

Failure to progress in 4-8 weeks

Injection therapy

Figure 2. Summary of decision making algorithm when approaching pediatric patient with
chronic pain. CRPS indicates complex regional pain syndrome; PDPH, postdural puncture
headache; PTH, posttraumatic headache.
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Szabova et al

challenge. Taking care of psychosocial factors is equally important as

taking care of physical aspects. Our simple suggestion is to start with
basics and advance to more complex treatments if needed. Please
review Figure 2 for suggested treatment algorithms.

The authors have no conflicts of interest to disclose.

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