Post-Thoracotomy Pain Post-Thoracotomy Pain SyndromeSyndrome

Justin Wilson, M.D.Justin Wilson, M.D.

Disclaimer: The available studies have major Disclaimer: The available studies have major inconsistencies in collection of data thus inconsistencies in collection of data thus hindering conclusive methods for prevention hindering conclusive methods for prevention and treatment.and treatment.

Post-Thoracotomy Pain Syndrome (PTPS): Pain Post-Thoracotomy Pain Syndrome (PTPS): Pain that recurs or persist along a thoracotomy scar that recurs or persist along a thoracotomy scar at least 2 months following the surgery.at least 2 months following the surgery.

Variable, but high, roughly >50%, the majority Variable, but high, roughly >50%, the majority experiencing mild pain, and 3-16% experience experiencing mild pain, and 3-16% experience moderate-severe painmoderate-severe pain

82-90% report it is most profound around 82-90% report it is most profound around scar/surgical sitescar/surgical site

IncidenceIncidence

Pain: myofascial vs Pain: myofascial vs neuropathicneuropathic

allodynia- sensation of pain to a non-painful allodynia- sensation of pain to a non-painful stimulusstimulus

majority report achingmajority report aching

dysthetic burningdysthetic burning

lancinatinglancinating

combination of abovecombination of above

Preoperative RiskPreoperative Risk

risk of chronification decreased in elderlyrisk of chronification decreased in elderly

risk is increased in femalesrisk is increased in females

existence of chronic pain elsewhere existence of chronic pain elsewhere (hysterectomy and hernia surgery data)(hysterectomy and hernia surgery data)

no relation to anxiety/depressionno relation to anxiety/depression

Intraoperative RiskIntraoperative Risksurgical techniquesurgical technique

posterolateral vs muscle sparing posterolateralposterolateral vs muscle sparing posterolateral

muscle sparing less pain at muscle sparing less pain at 1 month1 month

axillary vs anterior approachaxillary vs anterior approach

anterior reduced incidence PTPSanterior reduced incidence PTPS

Video assisted thoracic surgery (VATS)Video assisted thoracic surgery (VATS)

no difference, although decreased early painno difference, although decreased early pain

Intraoperative RiskIntraoperative Risksurgical techniquesurgical technique

rib retractors causing nerve damage, rib retractors causing nerve damage, confirmed by evoked motor potentialsconfirmed by evoked motor potentials

suture technique, 78% damage to inferior and suture technique, 78% damage to inferior and 40% damage to nerve superior to incision due 40% damage to nerve superior to incision due to pericostal sutureto pericostal suture

PTPSPTPS60yo female with 60yo female with acute/chronic chest acute/chronic chest pain localized at pain localized at 10yo thoracotomy 10yo thoracotomy scarscar

Intraoperative RiskIntraoperative Riskanalgesiaanalgesia

Intrapleural analgesia: inferior to cryoanalgesia Intrapleural analgesia: inferior to cryoanalgesia and opioids (23.4%)and opioids (23.4%)

Thoracic epidural analgesia (TEA): variable Thoracic epidural analgesia (TEA): variable (14.8%)(14.8%)

TEA + NSAID (9.9%)TEA + NSAID (9.9%)

Cryoanalgesia: no decrease in PTPS (31.6%)Cryoanalgesia: no decrease in PTPS (31.6%)

Pre-emptive analgesia: inconclusive, although Pre-emptive analgesia: inconclusive, although TEA had less postop painTEA had less postop pain

PostoperativelyPostoperatively

Several studies from other procedures indicate Several studies from other procedures indicate the intensity of acute postop pain to be a risk the intensity of acute postop pain to be a risk factor for persistent post surgical pain. (data factor for persistent post surgical pain. (data from hip arthroplasty, hernia, and c-section)from hip arthroplasty, hernia, and c-section)

ManagementManagementAcuteAcute

TEA gold standardTEA gold standard

multimodal drug therapy (NSAID, IVPCA)multimodal drug therapy (NSAID, IVPCA)

ManagementManagementChronicChronic

First rule out tumor recurrenceFirst rule out tumor recurrence

First line: PT, NSAIDS, TENS, TCA, anti-First line: PT, NSAIDS, TENS, TCA, anti-epileptics, sodium channel blockers, and epileptics, sodium channel blockers, and opioidsopioids

2nd: ISB (phrenic-shoulder), intercostal nerve 2nd: ISB (phrenic-shoulder), intercostal nerve block, PVB, SNRB, sympathetic nerve blocks, block, PVB, SNRB, sympathetic nerve blocks, TPI, SCSTPI, SCS

In conclusion, there is a In conclusion, there is a need for large, need for large, prospective, prospective, randomized trials randomized trials evaluating PTPS.evaluating PTPS.

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Wildgaard K, Ravn J, Kehlet H: Chronic post-thoracotomy pain: a critical review of pathogenic Wildgaard K, Ravn J, Kehlet H: Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg. 2009 Jul;36(1):170-80mechanisms and strategies for prevention. Eur J Cardiothorac Surg. 2009 Jul;36(1):170-80

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