Neurosurgical management for chronic and end-of-life pain in children: A systematic review

Chronic and end-of-life pain in children is underreported and undermanaged. Current guidelines for pediatric chronic pain include medical and interventional modalities; however, the inclusion of neurosurgical treatments is uncommon and inconsistent. This systematic review presents the literature, and we provide recommendations for the role of neurosurgical procedures in treating chronic and end-of-life pain in children.

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines using three databases: PubMed, Embase, and Scopus. We included 40 studies presenting neurosurgical procedures for the treatment of chronic and end-of-life pain in children.

Thirty-one (77.5%) manuscripts focused on the treatment of neuropathic pain, five (12.5%) focused on nociceptive pain, and four (10%) treated mixed pain conditions. The most common neurosurgical procedure was intrathecal opioid therapy via pump placement (29.3%), followed by spinal cord stimulation (26.8%). Neuropathic pain syndromes were primarily treated with neurostimulation (58%), demonstrating good efficacy. Ablative procedures (40%) were most effective for nociceptive pain syndromes. Both chordotomy and intrathecal pumps provided subjective pain relief for mixed pain syndromes. The quantification of procedural efficacy, including pain outcomes and grading scales, varied significantly across studies.

Neurosurgical treatments for chronic pediatric pain are safe, although broad efficacy cannot be determined due to sparse literature and inadequately quantified pain responses. Guidelines for escalating chronic and end-of-life pain management in pediatric patients should be updated to include neurosurgical treatments and appropriate outcome scales. Focused research on appropriate patients, available neurosurgical therapies, and pediatric outcomes is warranted.