OBJECTIVE: Chronic pain, including persistent postsurgical pain, reduces patients' quality of life, mood, and productivity. It presents a significant economic burden to society, yielding an estimated $600 billion annual cost due to health care and lost work productivity. Moderate to severe chronic pain affects 5% of children and adolescents. The current body of knowledge has demonstrated a consensus opinion that psychological factors and sensory factors are correlated with pain in the adult population. However, more research is necessary to determine what role depression and sensory function play in predicting severity of persistent postsurgical pain in children and adolescents. Thus, the present study seeks to explore how, if at all, post-operative pain and functional disability at 1 month postsurgery is correlated with pre-operative depression and sensory profile. METHODS: Eligible candidates were Adolescent Idiopathic Scoliosis (AIS) patients aged 10-17 who have been recommended to undergo spinal fusion surgery at Boston Children's Hospital (BCH). Fifteen participants were included in this study. Prior to surgery, all participants completed the Children's Depression Inventory: Short Form (CDI:S) via REDCap and underwent Quantitative Sensory Testing (QST) on their palmar thenar eminence (non-surgical site) and their lower back (surgical site). Participants' light touch detection thresholds and sharp prick pain threshold scores were determined using von Frey hairs. Participants' pressure-pain sensation threshold scores were determined using a pressure algometer. Warm and cool detection thresholds and hot and cold pain thresholds were measured using a thermode strapped to the skin. At 1 month postsurgery, participants completed the Functional Disability Inventory (FDI) and reported their pain scores, including their current pain, average and worst pain in the last week, average and worst pain in the last month, and average and worst pain in the last six months. Each presurgical variable was compared with each postsurgical variable using Pearson correlations at a significance level of p < 0.05. Additionally, postsurgical FDI scores were compared with postsurgical pain scores using Pearson correlations. RESULTS: Due to the small sample size (N = 15), the results should be considered preliminary. Preoperative CDI:S scores were not found to be correlated with postoperative pain and functional disability at 1 month postsurgery. Several preoperative QST variables were found to be correlated with postsurgical pain at 1 month. Namely, light touch detection threshold on the hand was negatively correlated with current pain (p < 0.05), average pain in the last week (p < 0.05), worst pain in the last week (p < 0.05), average pain in the last month (p < 0.05), and worst pain in the last month (p < 0.05). Warm detection threshold on the hand was negatively correlated with four different post-operative pain measures taken at one month post-surgery: worst pain in the last week (p < 0.05), worst pain in the last month (p < 0.05), average pain in the last six months (p < 0.05), and worst pain in the last six months (p < 0.05). Finally, heat pain threshold on the hand was negatively correlated with worst pain in the last 6 months at 1 month postsurgery (p < 0.05). Furthermore, postsurgical scores on the FDI were positively correlated with current pain at the 1-month post-surgical time point (p < 0.01), average pain in the last week at the 1-month post-surgical time point (p < 0.05), and worst pain in the last week at the 1-month post-surgical time point (p < 0.05). CONCLUSIONS: This study provides preliminary evidence of a correlation between heat sensitivity and poor postsurgical pain outcomes in the AIS population. Contrary to what was expected, hyposensitivity to light touch was correlated with worse pain outcomes. It is unclear why this is the case, and further research on the somatosensory profiles of pain patients is needed to examine this phenomenon. One of the most important findings in the present study is the correlation between post-operative pain and functional disability. The present study contributes to the small but growing body of knowledge surrounding the correlates of pediatric postsurgical pain. The use of QST provides an objective, quantifiable measure of patients' somatosensory profile. Furthermore, the present study contributes to the expansive research base that has shown the detrimental effects of chronic pain, highlighting the correlation between pain and functional disability in the AIS population following spinal fusion surgery.

Foi estudado o efeito analgésico e anestésico adjuvante do cloridrato de tramadol aplicado localmente, após extração do terceiro molar inferior impactado. Um total de 52 pacientes foi submetido à exodontia sob anestesia local (mepivacaína 2% 1:20 000 corbadrina), em estudo duplo-cego, dose única, cruzado, controlado por placebo. Pacientes e os lados dos procedimentos foram distribuídos aleatoriamente para receberem 2 ml de tramadol (100%) (grupo T) ou 2 ml de solução salina 0,9% (grupo P). Ambas as soluções foram injetadas na submucosa gengival e alvéolo, imediatamente após as cirurgias realizadas por um mesmo cirurgião. Impacção dental e quantidade anestésica foram pareadas. Dados do consumo e a hora de uso de analgésico de resgate (dipirona 500 mg) foram utilizados para avaliar o efeito analgésico de tramadol. Uma Escala Analógica Visual (EAV) de dor foi aplicada após término da anestesia, 4, 8, 24, 48 e 72 horas após cirurgia, com os dados submetidos ao teste de Wilcoxon (p < 0,05). Não houve diferença no bloqueio anestésico e efeitos adversos entre os grupos. O grupo T requisitou um número significativamente menor (p = 0,008) de comprimidos de dipirona durante o período de avaliação (3,37 ± 4,65) do que o grupo P (4,4 ± 3,71). O grupo T levou mais minutos para usar a dipirona após a primeira cirurgia (303,72 ± 416,01) do que o grupo P (185,4 ± 59,4) (p = 0,006). O grupo T apresentou menor média de dor na EAV após término da anestesia (3,55 ± 2,27) do que no grupo P (5,26 ± 2,49) (p = 0,001). O tramadol administrado localmente após exodontia de terceiros molares inferiores melhora a qualidade da analgesia pós-operatória, porém não prolonga a duração da anestesia local com mepivacaína. / The present study sought to assess the analgesic and adjuvant anesthetic effects of surgical site administration of tramadol hydrochloride immediately after extraction of impacted mandibular third molars. In this double-blind, placebo-controlled, singledose, crossover investigation, 52 patients underwent bilateral extraction of impacted mandibular third molars under local anesthesia (mepivacaine 2% with levonordefrin 1:20 000). Patients and procedures, by side of intervention, were randomly assigned to receive either 2 mL of tramadol (100%) (Group T, n = 52) or 2 mL of normal saline, 0.9% (Group P, n = 52). Medications were administered by submucosal injection at the level of the third molar immediately after surgery. All patients were operated on by the same surgeon; patients were paired for technical difficulty and amount of anesthetic solution. Use of supplementary analgesics (500 mg metamizole) and time to first postoperative use of a rescue drug were used to assess the analgesic effect of tramadol. Pain level on both sides (Group T and P) was recorded on a visual analog scale (VAS 010 cm) immediately after cessation of anesthetic effect and at 4, 8, 24, 48, and 72 hours postoperatively. Data were compared using the Wilcoxon test (p < 0.05). There was no difference in anesthetic blockade between groups. There were no differences in reported adverse effects. In the 72 hours following surgery, patients in group T took significantly fewer (p = 0.008) metamizole tablets (3.37 ± 4.65) than did those in group P (4.4 ± 3.71). Time to first dose of a rescue drug (in minutes) was longer in Group T (303.72 ± 416.01) than in Group P (185.4 ± 59.4) (p = 0.006). Tramadol reduced pain intensity values (VAS) significantly in Group T (3.55 ± 2.27) as compared to Group P (5.26 ± 2.49) after anesthetic effect had worn off (p = 0.001). Local administration of tramadol after oral surgery improves the quality of postoperative analgesia, but does not extend the duration of anesthetic action.

Foi estudado o efeito analgésico e anestésico adjuvante do cloridrato de tramadol aplicado localmente, após extração do terceiro molar inferior impactado. Um total de 52 pacientes foi submetido à exodontia sob anestesia local (mepivacaína 2% 1:20 000 corbadrina), em estudo duplo-cego, dose única, cruzado, controlado por placebo. Pacientes e os lados dos procedimentos foram distribuídos aleatoriamente para receberem 2 ml de tramadol (100%) (grupo T) ou 2 ml de solução salina 0,9% (grupo P). Ambas as soluções foram injetadas na submucosa gengival e alvéolo, imediatamente após as cirurgias realizadas por um mesmo cirurgião. Impacção dental e quantidade anestésica foram pareadas. Dados do consumo e a hora de uso de analgésico de resgate (dipirona 500 mg) foram utilizados para avaliar o efeito analgésico de tramadol. Uma Escala Analógica Visual (EAV) de dor foi aplicada após término da anestesia, 4, 8, 24, 48 e 72 horas após cirurgia, com os dados submetidos ao teste de Wilcoxon (p < 0,05). Não houve diferença no bloqueio anestésico e efeitos adversos entre os grupos. O grupo T requisitou um número significativamente menor (p = 0,008) de comprimidos de dipirona durante o período de avaliação (3,37 ± 4,65) do que o grupo P (4,4 ± 3,71). O grupo T levou mais minutos para usar a dipirona após a primeira cirurgia (303,72 ± 416,01) do que o grupo P (185,4 ± 59,4) (p = 0,006). O grupo T apresentou menor média de dor na EAV após término da anestesia (3,55 ± 2,27) do que no grupo P (5,26 ± 2,49) (p = 0,001). O tramadol administrado localmente após exodontia de terceiros molares inferiores melhora a qualidade da analgesia pós-operatória, porém não prolonga a duração da anestesia local com mepivacaína. / The present study sought to assess the analgesic and adjuvant anesthetic effects of surgical site administration of tramadol hydrochloride immediately after extraction of impacted mandibular third molars. In this double-blind, placebo-controlled, singledose, crossover investigation, 52 patients underwent bilateral extraction of impacted mandibular third molars under local anesthesia (mepivacaine 2% with levonordefrin 1:20 000). Patients and procedures, by side of intervention, were randomly assigned to receive either 2 mL of tramadol (100%) (Group T, n = 52) or 2 mL of normal saline, 0.9% (Group P, n = 52). Medications were administered by submucosal injection at the level of the third molar immediately after surgery. All patients were operated on by the same surgeon; patients were paired for technical difficulty and amount of anesthetic solution. Use of supplementary analgesics (500 mg metamizole) and time to first postoperative use of a rescue drug were used to assess the analgesic effect of tramadol. Pain level on both sides (Group T and P) was recorded on a visual analog scale (VAS 010 cm) immediately after cessation of anesthetic effect and at 4, 8, 24, 48, and 72 hours postoperatively. Data were compared using the Wilcoxon test (p < 0.05). There was no difference in anesthetic blockade between groups. There were no differences in reported adverse effects. In the 72 hours following surgery, patients in group T took significantly fewer (p = 0.008) metamizole tablets (3.37 ± 4.65) than did those in group P (4.4 ± 3.71). Time to first dose of a rescue drug (in minutes) was longer in Group T (303.72 ± 416.01) than in Group P (185.4 ± 59.4) (p = 0.006). Tramadol reduced pain intensity values (VAS) significantly in Group T (3.55 ± 2.27) as compared to Group P (5.26 ± 2.49) after anesthetic effect had worn off (p = 0.001). Local administration of tramadol after oral surgery improves the quality of postoperative analgesia, but does not extend the duration of anesthetic action.

This thesis focuses on the psychological factors that play a role in the development and maintenance of chronic postsurgical pain in patients after cardiac surgery. The literature review deals with the mechanisms of chronic postsurgical pain, its risk factors, the process of the transformartion of acute pain into chronic pain, and the psychological management of chronic pain after surgery, specifically in the field of cardiosurgery. The thesis focuses in particular on patient-related factors in terms of anxiety or depression before or after the surgery, coping strategies, fear of pain, attachment styles, and how are these factors involved in the development nad maintenance of chronic pain. The empirical part consists of a research of quantitative design conducted at the Department of Cardiac Surgery of the 3rd Faculty of Medicine and FN KV in Prague, which monitors the development of pain in patients after cardiac surgery at the time of discharge, 3 months after the surgery and after 1 year after the surgery, and focuses on the assessment of preoperative and postoperative patient-related factors that contribute to the development and maintenance of chronic pain. The main aim of the research is to identify these psychological factors.

Chronic pain is a significant public health problem. A large portion of those with chronic pain have had their acute postsurgical pain transition into a chronic postsurgical pain state. The mechanisms contributing to pediatric persistent postsurgical pain is not well understood; however, there is empirical support in the adult literature to suggest that psychosocial factors play a significant role in the maintenance and exacerbation of post-surgical pain. Recent research by our group found high pain prevalence rates up to 5-years post-surgery among children undergoing spinal fusion surgery, particularly among those reporting poor pre-surgical mental health. The current study aims to extend this research by exploring psycho-social functioning and pain among children (10-21 years) who underwent major orthopedic surgery and their parents (n=21 dyads; data collection is ongoing). Measures administered 1-3 years post-surgery included pain ratings, the Bath Adolescent Pain Questionnaire (Child; Parental Impact), Fear of Pain Questionnaire, Functional Disability Inventory, and the Adult Responses to Child Symptoms. Preliminary results found that 52% of patients reported pain in the moderate-severe range in the past 6 months. Additionally, increased child pain was associated with greater child-reported functional disability (p<.01), pain-specific anxiety (p<.01), and fear of pain (p<.05), as well as worse overall emotional functioning (p<.05). Parents of children with increased pain reported worse parental strain (e.g., "found my relationship with my child difficult," p<.05). Identifying correlates of poor long-term outcomes in children with postsurgical pain may prevent the development of chronic pain into adulthood. With recent economic costs of adult chronic pain estimated to be between $560-$635 billion per year research on the role of persistent pain in children is of upmost importance in order to positively impact pre-surgical preparation, postsurgical care, and in potentially preventing disabling pain into adulthood for a population at considerable risk. This investigation was supported by the Boston Children's Hospital Career Development Fellowship Award (CS).

INTRODUÇÃO: O Brasil ocupa o primeiro lugar entre os países com maiores taxas de cesariana no mundo. Pouco se sabe a respeito das consequências futuras deste procedimento, sobre a saúde materna. Este estudo investigou a influência da técnica anestésico-cirúrgica e analgesia pós-operatória, no aparecimento de dor crônica após a cesariana. Procuramos também identificar os fatores de risco de dor crônica pós-cesariana. MÉTODO: Este estudo prospectivo com distribuição aleatória foi conduzido em 443 pacientes que foram submetidas à cesariana (eletivas e emergenciais), com diferentes doses de bupivacaína 0,5% hiperbárica e opioides na raquianestesia, bem como uso de anti-inflamatórios não esteroidais peri-operatório. Os grupos foram: G8SMA- 8 mg bupivacaína hiperbárica + 2,5 mcg sufentanil + 100 mcg morfina; G10SMA- 10 mg bupivacaína hiperbárica + 2,5 mcg sufentanil + 100 mcg morfina; G12,5MA- 12,5 mg bupivacaína hiperbárica + 100 mcg morfina; G15MA- 15 mg bupivacaína hiperbárica + 100 mcg morfina; G12,5M - 12,5 mg bupivacaína hiperbárica + 100 mcg morfina. Somente as pacientes do grupo G12,5M não receberam AINE no peri-operatório. Dor em repouso e em movimento foram avaliadas no pós-operatório imediato. Fatores peri-operatórios, cirúrgicos e obstétricos foram investigados. Contato telefônico foi realizado, após três e seis meses do procedimento cirúrgico, para identificação das pacientes com dor crônica. RESULTADOS: A incidência de dor crônica nos grupos foi: G8SMA= 20%, G10SMA= 13%; G12,5MA= 7,1%; G15MA= 2,2% e G12,5M= 20,3%. Pacientes que apresentaram escores de dor mais elevados no período pós- operatório imediato, que referiram doenças crônicas em tratamento, que apresentaram maior tempo em trabalho de parto sem analgesia, tiveram maior incidência de dor crônica (p<0,05). CONCLUSÃO: A incidência de dor crônica diminui com emprego de doses maiores de anestésicos locais e uso de anti-inflamatórios não esteroidais. Escores mais elevados de dor no período pós-operatório imediato tiveram associação com aparecimento de dor crônica após a cesariana. Os fatores de risco encontrados foram: doença crônica em tratamento, maior tempo em trabalho de parto sem analgesia e escores de dor elevados no pós- operatório imediato / INTRODUCTION: Brazil holds first place in cesarean section rate in the world. Little is known about the consequences upon maternal health. This study investigated the influence of anesthetic, surgical techniques and postoperative analgesia on chronic pain after cesarean section. We also tried to identify risk factors for chronic pain after cesarean section. METHODS: A prospective randomized study was conducted among 443 patients who underwent elective or emergency cesarean section with different doses of hyperbaric bupivacaine 0.5% and opioids in spinal anesthesia, associated or not to non steroidal anti-inflamatory drugs. The groups were: G8SMA- 8mg hyperbaric bupivacaine + 2.5 mcg sufentanil + 100 mcg morphine; G10SMA- 10 mg hyperbaric bupivacaine + 2.5 mcg sufentanil + 100 mcg morphine; G12.5MA- 12.5 mg hyperbaric bupivacaine + 100 mcg morphine; G15MA- 15 mg hyperbaric bupivacaine + 100 mcg morphine; G12.5M- 12.5 mg hyperbaric bupivacaine + 100 mcg morphine (only in this group, non-steroidal anti-inflammatory drug was not used). Pain at rest and during movement were evaluated on the first two postoperative days using the verbal numerical rating scale. Perioperative, surgical and obstetric factors were investigated. Phone survey was conducted after three and six months to identify patients with chronic pain RESULTS: Incidences of chronic pain in groups were: G8SMA= 20%, G10SMA= 13%; G12.5MA= 7.1%; G15MA= 2.2% and G12.5M= 20.3 %. Patients with co-morbidities, and who had been more than 15 hours in labor before the cesarean (without analgesia) had more chance to have chronic pain than those who did not have pain. Patients who had higher pain scores on the two postoperative days were associated to chronic pain (p<0.05).!! CONCLUSION: The incidence of chronic pain decreases with higher doses of local anesthetic and the use of non-steroidal anti-inflammatory drugs. Patients who had higher pain scores in the immediate postoperative period were more likely to develop chronic pain. The only predictors of chronic pain were: previous history of disease, longer time in labor, intensity of postoperative pain and the use of lower doses of local anesthetic in spinal anesthesia

INTRODUÇÃO: O Brasil ocupa o primeiro lugar entre os países com maiores taxas de cesariana no mundo. Pouco se sabe a respeito das consequências futuras deste procedimento, sobre a saúde materna. Este estudo investigou a influência da técnica anestésico-cirúrgica e analgesia pós-operatória, no aparecimento de dor crônica após a cesariana. Procuramos também identificar os fatores de risco de dor crônica pós-cesariana. MÉTODO: Este estudo prospectivo com distribuição aleatória foi conduzido em 443 pacientes que foram submetidas à cesariana (eletivas e emergenciais), com diferentes doses de bupivacaína 0,5% hiperbárica e opioides na raquianestesia, bem como uso de anti-inflamatórios não esteroidais peri-operatório. Os grupos foram: G8SMA- 8 mg bupivacaína hiperbárica + 2,5 mcg sufentanil + 100 mcg morfina; G10SMA- 10 mg bupivacaína hiperbárica + 2,5 mcg sufentanil + 100 mcg morfina; G12,5MA- 12,5 mg bupivacaína hiperbárica + 100 mcg morfina; G15MA- 15 mg bupivacaína hiperbárica + 100 mcg morfina; G12,5M - 12,5 mg bupivacaína hiperbárica + 100 mcg morfina. Somente as pacientes do grupo G12,5M não receberam AINE no peri-operatório. Dor em repouso e em movimento foram avaliadas no pós-operatório imediato. Fatores peri-operatórios, cirúrgicos e obstétricos foram investigados. Contato telefônico foi realizado, após três e seis meses do procedimento cirúrgico, para identificação das pacientes com dor crônica. RESULTADOS: A incidência de dor crônica nos grupos foi: G8SMA= 20%, G10SMA= 13%; G12,5MA= 7,1%; G15MA= 2,2% e G12,5M= 20,3%. Pacientes que apresentaram escores de dor mais elevados no período pós- operatório imediato, que referiram doenças crônicas em tratamento, que apresentaram maior tempo em trabalho de parto sem analgesia, tiveram maior incidência de dor crônica (p<0,05). CONCLUSÃO: A incidência de dor crônica diminui com emprego de doses maiores de anestésicos locais e uso de anti-inflamatórios não esteroidais. Escores mais elevados de dor no período pós-operatório imediato tiveram associação com aparecimento de dor crônica após a cesariana. Os fatores de risco encontrados foram: doença crônica em tratamento, maior tempo em trabalho de parto sem analgesia e escores de dor elevados no pós- operatório imediato / INTRODUCTION: Brazil holds first place in cesarean section rate in the world. Little is known about the consequences upon maternal health. This study investigated the influence of anesthetic, surgical techniques and postoperative analgesia on chronic pain after cesarean section. We also tried to identify risk factors for chronic pain after cesarean section. METHODS: A prospective randomized study was conducted among 443 patients who underwent elective or emergency cesarean section with different doses of hyperbaric bupivacaine 0.5% and opioids in spinal anesthesia, associated or not to non steroidal anti-inflamatory drugs. The groups were: G8SMA- 8mg hyperbaric bupivacaine + 2.5 mcg sufentanil + 100 mcg morphine; G10SMA- 10 mg hyperbaric bupivacaine + 2.5 mcg sufentanil + 100 mcg morphine; G12.5MA- 12.5 mg hyperbaric bupivacaine + 100 mcg morphine; G15MA- 15 mg hyperbaric bupivacaine + 100 mcg morphine; G12.5M- 12.5 mg hyperbaric bupivacaine + 100 mcg morphine (only in this group, non-steroidal anti-inflammatory drug was not used). Pain at rest and during movement were evaluated on the first two postoperative days using the verbal numerical rating scale. Perioperative, surgical and obstetric factors were investigated. Phone survey was conducted after three and six months to identify patients with chronic pain RESULTS: Incidences of chronic pain in groups were: G8SMA= 20%, G10SMA= 13%; G12.5MA= 7.1%; G15MA= 2.2% and G12.5M= 20.3 %. Patients with co-morbidities, and who had been more than 15 hours in labor before the cesarean (without analgesia) had more chance to have chronic pain than those who did not have pain. Patients who had higher pain scores on the two postoperative days were associated to chronic pain (p<0.05).!! CONCLUSION: The incidence of chronic pain decreases with higher doses of local anesthetic and the use of non-steroidal anti-inflammatory drugs. Patients who had higher pain scores in the immediate postoperative period were more likely to develop chronic pain. The only predictors of chronic pain were: previous history of disease, longer time in labor, intensity of postoperative pain and the use of lower doses of local anesthetic in spinal anesthesia