Chronic Post-thoracotomy Pain Syndrome Research Articles

New Thoracotomy Closure, a Simple Way to Decrease Chronic Post-Operative Pain in Selected Patients-Blinded Prospective Study.

Background and Objectives: Chronic post-thoracotomy pain syndrome (PTPS) is a very common and uncomfortable complication, occurring frequently after thoracic operations, leading to the necessity of further medication and hospitalizations. One important risk factor in developing chronic pain is the chest closure technique, which can lead to chronic intercostal nerve damage. This study proposes an alternative nerve-sparring closure technique to standard peri-costal sutures, aimed toward minimizing the risk of chronic pain in selected patients. Materials and Methods: We performed a prospective randomized study on 311 patients operated for various thoracic pathology over a period of 12 months, evaluating incision types, chest closure technique, and number of drains with drainage duration. The patients were divided into three groups: peri-costal (PC), proposed extra-costal (EC), and simple (SC) suture, respectively. Pain was measured on day 1, 2, 5, 7, and at 6 months post-operatively using the Visual Analogic Scale. Results: No significant differences in pain level were recorded in the first two post-operative days between the PC and EC groups. However, a significant decrease in pain level was observed on day 5 and at 6 months post-operatively, with a mean level of 3.5 ± 1.8, 1.2 ± 1 for the EC group compared to a mean value of 5.3 ± 1.6, 3.2 ± 1.5, respectively. No significant differences were observed regarding other evaluated variables. Conclusions: The lower recorded pain scores in patients with extra-costal chest closure are a strong argument to use this technique. Its ease of use is similar to the classic peri-costal closure, and the time needed to perform it is not significantly increased. The association of this technique with less invasive procedures and short drainage duration limits chronic post-operative pain. This procedure may represent an option for decreasing healthcare costs associated with the management of PTPS.

Serratus Anterior Plane Block as a Regional Analgesia Technique for Post Thoracotomy and Thoracoscopy Pain: Review Article

Background: Chest wall surgeries are accompanied by severe postoperative pain. Inadequate relief of this pain may lead to both pulmonary complications as lung atelectasis and infection and chronic post thoracotomy pain syndrome. Regional analgesic modalities are important portion of the multimodal therapeutic approach suggested for the management of post thoracotomy pain. Objective: To evaluate serratus anterior plane block as a regional analgesia technique for post thoracotomy and thoracoscopy pain. Recent Findings: Serratus anterior plane block (SAPB), a regional analgesic modality developed by Blanco et al. in 2013, has shown good analgesic effect after thoracotomy and thoracoscopy in many case reports and clinical trials. In such block, a local anesthetic is injected in the fascial plane deep or superficial to the serratus anterior muscle leading to block of lateral cutaneous branches of the intercostal nerves. This provides a sensory block of T2–T9 dermatomes. Conclusion:Serratus anterior plane block as a fascial plane block can be a preferred regional analgesia technique for both post-operative pain management with procedures involving anterolateral chest wall as thoracotomy, thoracoscopy and breast surgery and in cases of multiple rib fractures. This is owing to its easy technique, effective pain relief and potentially better side effects profile compared to other regional modalities and systemic opioids.

Incidence of Acute and Chronic Post-Thoracotomy Pain in Pediatric Patients

We studied acute and chronic pain in pediatric patients who underwent thoracotomy for benign disease with a follow-up of at least three months. A telephone interview investigated about the presence of pain and the analgesic therapy in progress. The results were compared with the anesthetic technique, postoperative pain and the adequacy of pain therapy, both during the first week after surgery and at the time of interview. Fifty-six families consented to the study. The mean age of the children at surgery was 2.9 ± 4.5 years, while at the time of the interview was 6.5 ± 4.4 years. We performed different anesthetic strategies: Group A: general anesthesia (36 pts); Group B: general anesthesia and thoracic epidural (10 pts); Group C: general anesthesia and intercostal nerve block (10 pts). During the immediate postoperative period, 21 patients (37.5%) had at least one painful episode. At the time of interview, 3 children (5.3%) had moderate chronic neuropathic (burning) pain on surgical scar. There was no statistically significant difference between the type of anesthesia and the incidence and severity of acute post-operative pain. Despite its limitations, this study confirms the low incidence of chronic post-thoracotomy pain syndrome in children.

Impact of regional analgesia techniques on the long-term clinical outcomes following thoracic surgery.

Continuous monitoring of clinical outcomes after thoracotomy is very important to improve medical services and to reduce complications. The use of regional analgesia techniques for thoracotomy offers several advantages in the perioperative period including effective pain control, reduced opioid consumption and associated side effects, enhanced recovery, and improved patient satisfaction. Postthoracotomy complications, such as chronic postthoracotomy pain syndrome, postthoracotomy ipsilateral shoulder pain, pulmonary complications, recurrence, and unplanned admission to the intensive care unit are frequent and may be associated with poor outcomes and mortality. The role of regional techniques to reduce the incidence of these complications is questionable. This narrative review aims to investigate the impact of regional analgesia on the long-term clinical outcomes after thoracotomy.

Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment.

Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.

Pain Management Strategies for Thoracic Surgery

Improper management of postoperative pain following thoracic surgery can be quite debilitating and lead to a number of complications due to the multitude of comorbid conditions manifested by the population of patients undergoing these types of procedures. These can include advanced lung disease, advanced age, heart disease, renal insufficiency and obesity.¹ The source of this acute postsurgical pain is multifactorial and can include skin incisions, deep tissue injuries, thoracostomy tubes, costovertebral joint separation and rib or sternal fractures.² Benefits of effective analgesia include decreased risk of perioperative morbidity, decreased hospital stay, decreased cost and increased patient satisfaction.³ There have been numerous studies conducted to determine the best pain management regimen for control of postthoracotomy pain, however, no single technique has thus far proven to be superior. Instead, most clinicians would advocate for a multimodal approach combining regional techniques, such as thoracic epidural analgesia or paravertebral blocks, with systemic analgesic medications including a combination of cyclooxygenase (COX)-2 inhibitors, nonsteroidal anti-inflammatory drugs, opioids and other analgesic adjuncts. This chapter will examine the different analgesic options currently available and being utilized for various types of thoracic surgical procedures. This will include a review of the systemic analgesic and non-analgesic optiondis as well as regional anesthetic techniques. The chapter will conclude with a discussion of chronic post-thoracotomy pain syndrome and currently available treatments. This review contains 4 tables, and 87 references. Keywords: systemic analgesic therapy, opioid analgesic medications, regional anesthetic techniques, thoracic epidural analgesia, paravertebral analgesia, chronic post-thoracotomy pain management, Enhanced Recovery After Surgery (ERAS), intrathecal opioid analgesia, intercostal analgesia, intrapleural analgesia

Anesthetic considerations for lung resection: preoperative assessment, intraoperative challenges and postoperative analgesia.

This article is intended to provide a general overview of the anesthetic management for lung resection surgery including the preoperative evaluation of the patient, factors influencing the intraoperative anesthetic management and options for postoperative analgesia. Lung cancer is the leading cause of death among cancer patients in the United States. In patients undergoing lung resection, perioperative pulmonary complications are the major etiology of morbidity and mortality. Risk stratification of patients should be part of the preoperative assessment to predict their risk of short-term vs. long-term pulmonary complications. Improvements in surgical technique and equipment have made video assisted thoracoscopy and robotically assisted thoracoscopy the procedures of choice for thoracic surgeries. General anesthesia including lung isolation has become essential for optimizing visualization of the operative lung but may itself contribute to pulmonary complications. Protective lung ventilation strategies may not prevent acute lung injury from one-lung ventilation, but it may decrease the amount of overall lung injury by using small tidal volumes, positive end expiratory pressure, low peak and plateau airway pressures and low inspired oxygen fraction, as well as by keeping surgical time as short as possible. Because of the high incidence of chronic post-thoracotomy pain syndrome following thoracic surgery, which can impact a patient's normal daily activities for months to years after surgery, postoperative analgesia is a necessary part of the anesthetic plan. Multiple options such as thoracic epidural analgesia, intravenous narcotics and several nerve blocks can be considered in order to prevent or attenuate chronic pain syndromes. Enhanced recovery after thoracic surgery is a relatively new topic with many elements taken from the experience with colorectal surgery. The goal of enhanced recovery is to improve patient outcome by improving organ function and decreasing postoperative complications, and therefore decreasing length of hospital stay.

Perioperative systemic magnesium sulphate to minimize acute and chronic post-thoracotomy pain: a prospective observational study.

Thoracotomy leads to acute and chronic post-thoracotomy pain (CPTP). The purpose of this study was to investigate the effect of magnesium sulphate (MgSO4) administered perioperatively on acute postoperative and CPTP syndrome. One hundred patients were enrolled in this prospective, observational study. Analgesic medication was provided according to the World Health Organization pain relief ladder (control group). The study group received additionally MgSO4 (40 mg/kg over 10 minutes) during induction of anesthesia followed by an infusion over 24 hours (10 mg/kg/h). The presence and severity of pain were assessed before surgery, on postsurgical days 1-8, 30 and 90, respectively. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) was used pre- and postoperatively for documentation of neuropathic pain. The incidence and severity of CPTP were assessed by a telephone survey 30 and 90 days after surgery. Numerical rating scale (NRS) pain scores at rest were significantly lower in the study group receiving MgSO4 at days 1 to 8 (P<0.05). Thirty days after surgery, 2.1% of the MgSO4-patients had a LANSS score ≥12 compared to 14.3% in the control group (P=0.031). No patient had a LANSS score ≥12 in the study group compared to the control group (0% vs. 12.2%, P<0.05) 90 days following surgery. MgSO4 administration reduces postoperative pain at rest according to the NRS pain scores and is effective in preventing chronic neuropathic post-thoracotomy pain measured by LANSS score. Prospective-randomized trials are needed to confirm the results of the present study.

Patient with Postthoracotomy Pain

Pain due to thoracotomy is among the most severe pain experienced after surgery. It has both neuropathic and myofascial components. About 50% of patients suffer from chronic postthoracotomy pain 1 year after surgery. Thoracic paravertebral block or thoracic epidural analgesia is recommended as the first-choice therapy for thoracotomy analgesia. Preoperatively initiated thoracic epidural analgesia is associated with better pain control and decreased incidence (and intensity) of chronic postthoracotomy pain compared with postoperative (epidural or intravenous) analgesia. Compared with inhalation anesthesia, total intravenous anesthesia significantly reduced the incidence of chronic postthoracotomy pain syndrome, which is notoriously challenging to treat. Gabapentinoids and antidepressants may be beneficial for the neuropathic component of chronic postthoracotomy pain syndrome. A pregabalin and methylcobalamin combination has been shown to be safe and effective in the treatment of chronic postthoracotomy pain, with minimal side effects. Interventional therapies such as intercostal nerve block or ablation, spinal cord stimulation, and targeted subcutaneous neuromodulation may be indicated in more refractory and debilitating cases. This review contains 1 table, and 57 references. Key words: chronic postthoracotomy pain, cryoneurolysis, intercostal nerve block, open thoracotomy surgery, paravertebral block, postthoracotomy pain, postthoracotomy pain syndrome, spinal cord stimulation, thoracic epidural analgesia, thoracotomy, total intravenous analgesia, video-assisted thoracoscopic surgery

Regional and peripheral blockades for prevention of chronic post-thoracotomy pain syndrome in oncosurgical practice

To compare an effectiveness of thoracic epidural anesthesia/analgesia, paravertebral and intercostal blockades in prevention of chronic post-thoracotomy pain syndrome (CPTPS) in oncosurgery. There were 300 patients who underwent open surgery including lobectomy or pneumonectomy. Patients were randomized into 3 groups depending on type of anesthesia: TEA (n=100) - combined general and epidural anesthesia; PVB (n=50) - combined general and paravertebral anesthesia; ICB (n=50) - general anesthesia was supplemented by intercostal blockade after removal of the drug. CPTPS incidence was 34 and 40% in 6 months postoperatively after PVB and ICB, respectively (p>0.05). In TEA group this value was significantly lower compared with ICB group (23%, p<0.05). TEA contributes to significant reduction of CPTPS incidence, while paravertebral blockade does not affect the frequency of this complication.

Prevention of chronic the postthoractomy pain syndrome in cancer surgery

The review is concerned the actual problem - the prevention of chronic postthoracotomy pain syndrome in cancer surgery. The analysis of modern investigations and trends dedicated this problem is presented. The advantages and controversies of each method of perioperative management of patients with malignant pulmonary neoplasms underwent lung resections via thoracotomy approach are reported. The authors also present their original method, which reduces two times the incidence of chronic postthoracotomy pain syndrome.

Image-guided Nerve Cryoablation for Post-thoracotomy Pain Syndrome

Chronic post-thoracotomy pain syndrome (PTPS) can cause significant patient distress and is frequently difficult to manage. Percutaneous intercostal nerve (ICN) cryoablation by palpation of surface landmarks can be risky, as inaccurate probe placement can lead to hemo- or pneumothorax. Experience with image-guided ICN cryoablation with treatment planning and device navigation is limited. A patient with intractable PTPS was treated with ICN cryoablation under cone-beam computed tomography guidance with software-assisted needle trajectory planning and ablation zone simulation. This procedure provided the patient ~8 weeks of relief. This case demonstrated that ICN cryoablation is feasible under image guidance with device navigation and ablation simulation and may result in a few months of pain relief in cases of intractable PTPS.

Reply to Chen et al.

We would like to thank Chen et al. for their careful reading of, and comments [1] regarding, our manuscript [2]. We completely agree that diagnostic pain is mainly dependent on the patient’s description and lacks an objective assessment. This is one of the limitations of our study that was mentioned in the discussion. We also agree that our results demonstrate that pain intensity, analgesic use and the incidences of the principal pain characteristics of the two groups were not significantly different during the early phase or at 3-months and 6-months after thoracic surgery. Our results do show, however, that the incidence of newly developed pain at 6 months was significantly less common in the TIVA (total intravenous anaesthesia) group, which is an important factor that can help understand the transition of pain to chronicity. In addition, although allodynia-like pain was not a main feature, it was significantly more common in the inhaled-anaesthesia group. However, we do not agree with the comments regarding the role TIVA plays in reducing the prevalence of CPTS (chronic postthoracotomy pain syndrome) because we compared the prevalence of CPTS in the TIVA group with the inhalation group, which demonstrated a statistically significant difference between the two groups. It would be of little significance or importance to compare it with the prevalence of CPTS reported in previous studies. We apologize for the error we made in Table 4 and thank Chen et al. for helping us to correct this mistake, as well as the editor for giving us the opportunity to do so. We have amended Table 4 as follows: in group II, burning has been changed from 5 (2.9%) to 15 (8.8%; P = 0.38), pins and needles have been changed from 17 (10%) to 27 (15.9%; P = 0.24) and aching has been changed from 19 (11.2%) to 29 (17.1; P = 0.35) at 6 months. We have also changed the percentage of aching in group I at 6 months from 1.2 to 12.7%. At our institution, the use of inhalation anaesthetics (such as sevoflurane) with the continuous infusion of thoracic epidural analgesia has been the routine anaesthetic technique for thoracic surgery. As mentioned in the methods section, we maintained sevoflurane with the continuous infusion of thoracic epidural patient controlled analgesia to a bispectal index (BIS, XP version 4.1; Aspect Medical Systems, Newton, MA, USA) level of 50 when performing on the inhalation group. Using this method, we performed anaesthesia for thoracic surgery without weak analgesic problems during the operation. Another major limitation of our study is that we did not include a sevoflurane and remifentanil group, which was also mentioned in the discussion. Further studies are needed to verify which drug may play pivotal roles in lowering the incidence of CPTS.

Reducing the prevalence of chronic post-thoracotomy pain syndrome: is total intravenous anaesthesia superior to inhalation anaesthesia?

We read with great interest the article written by Song et al. [1]. The authors reported a prospectively randomized study, including 343 patients, regarding the effect of the type of anaesthesia on chronic post-thoracotomy pain syndrome (CPTS). They concluded that compared with inhalation anaesthesia, total intravenous anaethesia (TIVA) with propofol and remifentanil may reduce the incidence of CPTS. Their results are valuable, because the high incidence of CPTS after thoracic surgery is still a significant clinical problem. Although the pathophysiological mechanisms of CPTS after thoracic surgery remain unclear, neuropathic pain resulting from intercostal nerve injury seems to be the most important cause of CPTS. Patients with neuropathic pain, identified at 6 months postoperatively, have higher pain intensity and more analgesic consumption during the early postoperative period than other patients with pain [2]. The diagnosis of neuropathic pain depends on the combination of patients’ symptoms, intercostal nerve sensory testing and a DN4 neuropathic pain diagnostic questionnaire. In this study, however, the diagnostic pain is mainly dependent on patients’ oral description, lacking an objective assessment of neurophathic pain. At the early phase, 3 months and 6 months after thoracic surgery, both the pain intensity and the analgesic use did not show any difference between the TIVA group and the inhalation group, respectively. In addition, the incidence of the main pain characteristics between the two groups was not significantly different. Therefore, TIVA does not reduce the intensity of CPTS pain (including neuropathic pain), compared with inhalation anaesthesia. Moreover, TIVA plays a slight role in reducing the prevalence of CPTS (38.2% at 3 months and 33.5% at 6 months postoperatively), since the incidence of chronic pain complaints after thoracic surgery are reported as 25–60% previously [3]. More importantly, we find that the pain incidence at 6 months in the inhalation group (group II) in Table 3 (86/170) is inconsistent with the corresponding value in Table 4 (57/170). We do not know which is the correct figure regarding the number of patients with CPTS pain in the inhalation group. If the figures in Table 4 are correct, there would be a comparable incidence of the CPTS at 6 months postoperatively in both anaesthesia groups. Undoubtedly, multimodal analgesia during thoracic surgery can help prevent CPTS [4, 5]. As described in the article, pre-emptive analgesia, epidural analgesia combined with low-dose remifentanil and postoperative analgesic use in the TIVA group are all methods that have beneficial effects in preventing CPTS. In the inhalation group, however, only sevoflurane was used to maintain anaesthesia depth. In fact, due to its weak analgesic effect, we seldom use only inhale anaesthetics during thoracic surgery in clinical practice. And thus, the prevalence of CPTS (56.5% at 3 months and 50.6% at 6 months postoperatively) in the inhalation group is less significant clinically. If low-dose remifentanil is used in the inhalation group, as it is in the TIVA group, the incidence of CPTS in the inhalation group would probably decrease.

Incidence of post-thoracotomy pain: a comparison between total intravenous anaesthesia and inhalation anaesthesia

Thoracotomy is one of the most painful surgical incisions. Little is known, however, about the effect of type of anaesthesia on chronic post-thoracotomy pain syndrome (CPTS). We therefore compared the incidence of CPTS after total intravenous anaesthesia (TIVA) and inhalation anaesthesia. Patients (n = 366) were prospectively randomized into two groups: Group I (n = 173) received TIVA (propofol + remifentanil) and Group II (n = 170) received inhalation anaesthesia with sevoflurane. We assessed acute pain on postoperative days 1, 3 and 5, and the prevalence of CPTS at 3 and 6 months using a numerical rating scale (NRS). The prevalence of CPTS was significantly lower in patients receiving TIVA than in those receiving inhalation anaesthesia at 3 months (38.2% versus 56.5%, P = 0.001) and at 6 months (33.5% versus 50.6%, P = 0.002), respectively. Moreover, allodynia-like pain was significantly less common in the TIVA group at 3 (P = 0.021) and 6 months (P = 0.032). NRS score of acute pain, however, did not differ significantly between the two groups. TIVA with propofol and remifentanil may reduce the incidence of CPTS at 3 and 6 months.

Postoperative pain experience and barriers to pain management in Chinese adult patients undergoing thoracic surgery

The purpose of this study was (1) to explore postoperative pain experience among Chinese thoracotomy patients during hospitalisation; (2) to identify patient-related barriers to pain management; and (3) to explore how these barriers were related to patients' pain experience. Major thoracotomy causes severe pain and extreme stress for patients. Unrelieved postoperative pain leads to high risks of postoperative complications and chronic post-thoracotomy pain syndrome, compromising the quality of life for those patients. Cross-sectional design. A tertiary general hospital in mainland China was selected for this study. A total of 94 patients undergoing scheduled major thoracotomy operations participated in the study. All patients completed Brief Pain Inventory-Chinese version, the Barrier Questionnaire-Taiwan Form Surgical version and a demographic questionnaire. Patients suffered moderate to severe pain and experienced extremely high interferences with daily activities after major thoracotomy operation. Patients reported the four highest barrier scores in the subscale of Barrier Questionnaire-Taiwan Form Surgical version were fear of tolerance, inhibition of wound healing, time intervals and distracting the physician from treating the disease. Patient's demographic data had no significant impact on their concerns about communicating pain and using of analgesics with exception of the subscale 'fatalism' of the Barrier Questionnaire-Taiwan Form Surgical version in patients with higher education levels or patients with 'non-farmer' occupation. However, there were no significant correlations indicated either between Barrier Questionnaire-Taiwan Form Surgical version score and pain severity or pain interference. Patients were underexposure of pain treatment after thoracotomy operation in the study, while patients' concerns about reporting pain and using analgesics had minimal impacts on their pain experience. Education approach for patients is inadequate to improve the status of unrelieved postoperative pain. Appropriate pain management regime together with attentive nursing care should be provided to achieve better pain relief for Chinese patients.

Chronic post-thoracotomy pain syndrome

What's your call? ![Figure][1] Three-dimensional reconstruction of a chest computed tomography scan of a 60-year-old woman with acute and chronic chest pain localized to the region of a 10-year-old thoracotomy scar. The 3-dimensional reconstruction of the computed tomography scan was

Comparing efficacy of thoracic transforaminal injection of magnesium versus intercostal nerve block with methylprednisolone for chronic post thoracotomy pain syndrome

Comparing efficacy of thoracic transforaminal injection of magnesium versus intercostal nerve block with methylprednisolone for chronic post thoracotomy pain syndrome

39: Comparing efficacy of thoracic transforaminal injection of magnesium versus intercostal nerve block with methylprednisolone for chronic post thoracotomy pain syndrome

39: Comparing efficacy of thoracic transforaminal injection of magnesium versus intercostal nerve block with methylprednisolone for chronic post thoracotomy pain syndrome

441 Comparing the efficacy of thoracic transforaminal injection of magnesium versus intercostal nerve block with methylprednisolone for chronic post thoracotomy pain syndrome

441 Comparing the efficacy of thoracic transforaminal injection of magnesium versus intercostal nerve block with methylprednisolone for chronic post thoracotomy pain syndrome