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Study Design: Retrospective review of a prospectively collected multicenter database.Objective: The aim of this study was to investigate factors associated with low preoperative SRS pain scores.Summary Of Background Data: The prevalence of preoperative pain in patients with adolescent idiopathic scoliosis (AIS) has become increasingly evident and is a primary concern for patients and families. Greater preoperative pain is associated with more postoperative pain; however, less is understood about what contributes to preoperative pain.Methods: A prospectively collected, multicenter database was queried for patients with AIS. Patients were divided into 2 cohorts based on preoperative SRS pain scores: ≤ 3 (Pain cohort), 4 to 5 (No Pain cohort). Univariate analysis was performed identifying which factors were associated with a low preoperative SRS score and used for a CART analysis.Results: Of 2585 patients total, 2141 (83%) patients had SRS pain scores of 4 to 5 (No Pain) and 444 (17%) had SRS pain scores ≤3 (Pain). Female sex, older age, greater % body mass index, larger lumbar curves, greater T5-12 kyphosis, and lower mental health scores were associated with greater preoperative pain. In multivariate CART analysis, lower mental health SRS scores (P = 0.04) and older age (P = 0.003) remained significant, with mental health scores having the greatest contribution. In subdividing the mental health component questions, anxiety-related questions appeared to have the greatest effect followed by mood/depression (SRS Question 13: OR 2.04; Q16: OR 1.35; Q7: OR 1.31; Q3: OR 1.20).Conclusion: Anxiety and mood are potentially modifiable risk factors that have the greatest impact on pre- and postoperative pain. These results can be used to identify higher-risk patients and develop preoperative therapeutic protocols to improve postoperative outcomes.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]