Sex-specific pain management and outcomes in pediatric elective posterior spinal fusion: a database review

While sex-based differences in pain perception have been increasingly recognized, their reporting in adolescent patients undergoing spinal fusion (SF) remains inconsistent. This study examined the prevalence of sex-stratified outcomes in pain reporting following SF for adolescent idiopathic scoliosis (AIS).

A systematic database review was conducted in accordance with a pre-registered protocol to identify studies (January 2015-January 2025) evaluating pain management in pediatric posterior spinal fusion. Eligible studies reported sex-stratified outcomes related to pain scores, reporting frequency, or management modalities. Screening and data extraction were performed independently by two reviewers, with adjudication by a third.

Of 207 studies undergoing full text review, 43 (21%) met inclusion criteria, representing 27,691 patients (29.4% male; 70.6% female; mean age 15 years). Twenty studies disaggregated pain scores by sex, 23 reported sex-specific pain management, and only two reported both. Several studies identified greater pain burden and chronic postoperative pain in females, whereas others found no sex differences. Some studies reported higher opioid or benzodiazepine use among males, while others demonstrated prolonged postoperative opioid use in females. Eleven studies reported no differences. Heterogeneity in pain assessment tools and analgesic regimens limited comparability.

Sex-stratified outcomes remain under-reported and inconsistently analyzed in AIS patients undergoing SF. Only 20% of studies provided sex-specific outcomes, and fewer reported both pain score and pain management data. Standardized reporting using uniform pain metrics and stratified analyses is needed to clarify differential pain trajectories and guide equitable, individualized perioperative care.