Society for Pediatric Pain Medicine
Better Care for Children in Pain

May's Question Submitted By:

Carole Lin, MD
Clinical Assistant Professor
Stanford University

Patient is a 11-year-old child presenting to the operating room for right thoracotomy with pleural fluid drainage and middle lobe mass resection. Past medical history is complicated with current ongoing chemotherapy-induced low platelets (below 40 platelets per microliter), CNS and spinal metastases, scoliosis, and chronic headaches. Port placement and open thoracotomy is planned due to mass size. Chest tube drainage is planned the end.

April's question submitted by:


Caitlin Thompson, PhD
Pediatric Psychology Consultation Program
Kennedy Krieger Institute


Chris Joseph, DPT
Pediatric Chronic Pain and Connective Tissue Disorders Clinic
Kennedy Krieger Institute

A 15-year-old female presents to the multidisciplinary chronic pain clinic for evaluation of widespread body pain, primarily in the back and knees.  Her rheumatological testing and imaging were normal.  During the physical exam, all orthopedic testing indicated no acute injury.  She reports that she has more pain when sitting for a long period of time and after doing a lot of activity. She feels her sleep is nonrestorative and has difficulty initiating sleep. She has little to no pain during an activity she really enjoys, but pays for it the next day.  She scores a 9/9 on the Beighton scale for hypermobility and shows mild proximal weakness in the core and hip extensors.  Her numeric self-rating of pain is 9/10 at the worst, with an average of 6-7/10.  She previously participated in field hockey and volleyball, but discontinued due to pain. She is typically very social but has avoided doing activities with friends because she worries that doing so will lead to increased pain.  Psychologically, she describes anxiety about schoolwork, worries that her pain will not get better, and feelings of hopelessness.  Standardized measures showed clinical elevation of anxiety and depression. 

What course of treatment should be recommended?

March's question is written by:


Clarice Nguyen, MD
Combined Pediatrics and Anesthesiology Resident
Department of Anesthesiology
Department of Pediatrics
Stanford University

AND


Viviana F. Ruiz, MD
Pediatric Anesthesiology Fellow
Lucile Packard Children's Hospital
Stanford University

An 11-year-old female with a history of precursor B cell acute lymphoblastic leukemia (ALL) is admitted to your pediatric hospital after she was found to have a medullary relapse. The patient has already undergone two rounds of chemotherapy and is now undergoing Chimeric Antigen Receptor (CAR) T-cell therapy.  The patient also has a history of chronic peripheral neuropathy and low back pain and is on scheduled hydromorphone. Four days after starting CAR T-cell therapy the patient develops flu-like symptoms, including fever, headache, and severe muscle and joint pain. Blood cultures have been negative to date. You are consulted to help manage the patient’s acute on chronic pain during CAR T-Cell treatment. Which of the following would BEST address this patient’s current pain symptoms?

February's Question is written by:

Elisha Peterson, MD, FAAP
Director of Chronic Pain, Division of Anesthesiology, Pain and Perioperative Medicine
Children's National Hospital

A 17-year-old young woman presented to the chronic pain clinic complaining of left buttock pain that radiated down to her left knee.  She described her left leg as aching and feeling heavy.  Other than taking an oral contraceptive for dysmenorrhea, she was otherwise healthy.

Her physical exam was notable for positive faber and fair maneuvers.  No allodynia, tender points, trigger points, or trochanteric bursitis were appreciated.  Her left leg had venous varicosities and appeared dusky with coolness to the touch compared to the right.  Images revealed no neuroforaminal narrowing, normal piriformis and sciatic nerve and no sacroiliitis noted but an abnormality in venous drainage was noted, that would be better correlated with a pelvic CT. 

Which of the following syndromes is most suggested by the presentation outlined above?

January's Question of the Month is written by:    

Elizabeth O'Brien, MD
Pediatric Anesthesiology Fellow
Department of Anesthesiology and Critical Care
Children’s Hospital of Philadelphia


An 8-year-old female with a history of a cleft lip and palate status post staged primary repairs of both defects presents for an alveolar cleft graft. The surgical team intends to use a pyramidal bone block from the anterior iliac crest for the graft site. The patient reports hives with morphine and a history of postoperative nausea/vomiting. As part of an opioid-sparing multimodal analgesic plan, you offer to place a transversalis fascia plane block for post-op pain control. Identify the location for local anesthetic deposition for a successful block:

Figure 1