Society for Pediatric Pain Medicine
Better Care for Children in Pain

Mo Esfahanian, MD
Clinical Instructor, Pediatric Anesthesiology

                                                   
Your patient is an 8-year-old girl presenting with Ewing's sarcoma of the left scapula (Figure 1). She is scheduled for left chest wall wide resection, left scapula wide resection, multiple muscle transfers and muscle-skin flaps involving the shoulder and arm, along with neurolysis and vessel mobilization. The surgical team is unsure how far they will need to extend the chest wall wide resection. She has a history of severe nausea with opioids. You plan to use a regional anesthetic technique for post-operative pain control as part of your multi-modal regimen.

What is the sensory innervation of the scapula bone (i.e. osteotome)?

Written by: Tommy Spain, MD, MPH
Associate Professor UT Southwestern
Children’s Medical Center Dallas

You are a pediatric pain management physician at a tertiary care pediatric hospital. Due to the overwhelming number of pediatric patients presenting to your hospital system complaining of headaches, you and your team have been asked to help the neurologists with the patient load. You have been seeing a 17 y/o female patient for the last three years for migraine headaches. She has been treated with numerous different preventives including topiramate, zonisamide, and nortriptyline with limited efficacy. She is interested in trying Aimovig (erenumab).

Which of the following is NOT true:

Written by; Zvonimir Bebic, MD
Fellow in Adult/Pediatric Chronic Pain program
University of Colorado

A 14 year old female presents to the multidisciplinary chronic pain clinic for evaluation of widespread myalgias and symmetrical polyarthralgias that are worst in her bilateral hips, knees, ankles, and wrists. She also suffers from recurrent abdominal pain which has improved since starting oral Cromolyn Sodium. She also takes fluoxetine for anxiety which has been helping. Her mother notes that she has always been flexible and was very active in sports until she injured her knee playing volleyball one year ago and has had significant pain ever since.

During the interview she tells you that she often gets “subluxations and dislocations of both shoulders.” Which of the following physical exam maneuvers would not be useful in diagnosing shoulder instability or subluxation?

Amber Borucki, MD
Assistant Professor, Anesthesiology
UCSF Benioff Children’s Hospital

You are the sole pediatric pain physician who is part of a small multidisciplinary clinic that includes a part time pain psychologist, physical therapist, and a nurse. You see patients on a thrice weekly regular basis. Your clinic provides the sole pain care to pediatric patients in a 100 mile radius for pain conditions ranging from musculoskeletal pain to oncologic pain. Your clinic is going well and your patients are expertly taken care of using a multidisciplinary approach with local medical community support to provide physical therapy, psychological therapy, procedural intervention (when necessary), integrative medicine, and social work. Your clinic has a stable patient list consisting of around 150 patients that you see in your clinic office, and you do about 5 interventional pain procedures per month.

Unexpectedly, a novel coronavirus begins to infect thousands of people in a foreign country and creates a public health crisis. Eventually the virus spreads to your country, state, and finally your city. Due to concern for infection containment and to “flatten the curve”, your clinic must be closed to physical visits for an uncertain amount of time. You have been informed by your health administrators that your staff will now be advised to work remotely. Your patients are very concerned about how they will continue to receive care during your office closure and look to you for reassurance that you will continue to see them. You would like to continue to provide high level outpatient care to your patients to prevent acute pain exacerbations and emergency room visits, especially as you are the sole pediatric pain physician in your area. You begin to research your options regarding how to proceed with pediatric chronic pain care during the COVID-19 public health crisis.

Which of the following statements is TRUE?

Jared RE Hylton, MD, MS Assistant Professor
American Family Children’s Hospital, Madison, Wisconsin

An 11 year-female is referred to your chronic pain clinic with complaints of a one month history of intermittent right lower quadrant (RLQ) pain. The pain is located at a fixed position, does not radiate, and is described as sharp and stabbing with occasional burning quality. Activity and upright positioning are aggravating factors. Her pain is not associated with food and she denies diarrhea, blood in her stool, or changes in her bowel habits. Her pain at its worst is rated as a 8/10 on the Visual Analogue Scale and 2/10 at its best. She has experienced intermittent nausea associated with severe pain but no vomiting. She denies fevers, chills, changes or abnormalities with urination, or vaginal bleeding.

She has been followed by her pediatrician, gynecologist and gastroenterologist with extensive workup that has shown no evidence of abdominal or pelvic pathology including imaging, blood, urine, and fecal tests. She has tried acetaminophen, ibuprofen, amitriptyline and lidocaine patches, all without significant relief.

Upon examination, skin overlying the abdomen appears normal. Upon palpation, she has significant tenderness of the right lower quadrant (RLQ) with rebound, with localization of pain to one specific point in RLQ. She also reports decreased cold sensation in RLQ. From a supine position, you ask the patient to lift her head and shoulders off of the bed and she reports triggering of abdominal pain with this motion. In addition to enrolling this patient in the interdisciplinary pediatric chronic pain clinic, what else would be considered as a next appropriate step?