Postthoracotomy Pain Management Problems

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Pain after thoracotomy is very severe, probably the most severe pain experienced after surgery. Thoracic epidural analgesia has greatly improved the pain experience and its consequences and has been considered the standard for pain management after thoracotomy. This view has been challenged recently by the use of paravertebral nerve blocks. Nevertheless, severe ipsilateral shoulder pain and the prevention of the postthoracotomy pain syndrome remain the most important challenges for management of postthoracotomy pain.

Section snippets

Acute postthoracotomy pain

Severe acute pain after thoracotomy caused by retraction, resection, or fracture of ribs, dislocation of costovertebral joints, injury of intercostal nerves, and further irritation of the pleura by chest tubes is a normal response to all these insults [26]. Acute pain after video-assisted thoracoscopic surgery is considered less severe.

Suboptimal management of pain after thoracotomy (or after video-assisted thoracoscopic surgery in patients who have severely limited respiratory reserve) has

Chronic postthoracotomy pain

Postthoracotomy pain syndrome (chronic postthoracotomy pain or postthoracotomy neuralgia, PTPS) is defined by the International Association for the Study of Pain as “pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure.” In general, it is burning and stabbing pain with dysesthesia and thus shares many features of neuropathic pain [29]. PTPS is acknowledged increasingly by anesthesiologists and surgeons alike [30].

Prevalence of postthoracotomy pain

Chronic postthoracotomy pain was noted commonly by surgeons during the Second World War in men who had had a thoracotomy for chest trauma; it was called “chronic intercostal pain.” Unfortunately, not much has changed since then, because the majority of patients do not seek help for their pain but mention it only when specifically asked.

Furthermore, despite a commonly held belief that postthoracotomy pain is transient, there is no evidence that the pain experience decreases significantly over

Mechanism of postthoracotomy pain

There are several mechanisms for chronic pain after thoracotomy, and no consensus exists regarding causality.

Median or paramedian approach

Most practitioners prefer either the median or paramedian approach. There seems to be little difference in terms of patient safety. The paramedian approach makes it much easier to locate the epidural space when overlapping spinous processes might prevent the operator from reaching the epidural space in the median plane.

Asleep versus awake technique

The difference between an awake technique and an asleep technique should have a major impact on potential spinal cord cannulation. Surprisingly, a survey of the practice of

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