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Pain impulses
from the skin, ribs, and parietal pleura are transmitted
through the intercostal nerves
from the visceral pleura through autonomic nerves
from the lung through the vagus nerve
from the mediastinum, pericardial pleura, and diaphragm
through the pherenic nerves
Clinical Presentation
Differential Diagnosis
Herniated disc
Neuroforaminal stenosis
Rib pathology
Postherpetic neuralgia
Slipping rib syndrome
Costochondritis
Tietze's syndrome
Myofascial pain syndrome
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 1996;12:505
Pathogenesis and management of persistent postthoracotomy pain. Chest Surg Clin N Am 1998;8:70322
WALDMAN 2011
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Adverse effects of extradural and intrathecal opiates: report of a nationwide survey in Sweden. Br J
Anaesth 1982;54:47986
WALDMAN 2011
In one study:
Patients in the intercostal group required more supplemental
morphine
Comparative study of continuous extrapleural intercostal nerve block and lumbar epidural morphine in postthoracotomy pain. Can J Surg 1997;40:4316
In another study:
With similar analgesia Vomiting, pruritus, and urinary retention
occurring only in the epidural group
Continuous intercostal nerve block versus epidural morphine for postthoracotomy analgesia. Ann
Thorac Surg 1993;55:37780.
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
In one study:
Both thoracic epidural analgesia and extrapleural intercostal
analgesia were safe and effective
Intercostal analgesia should be instituted in patients who do
not qualify for thoracic epidural analgesia
Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.
Ann Thorac Surg 1998;66:36772
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Intrapleural Analgesia
Tramadol
Ketamine
In one study
in comparison analgesia through a thoracic epidural
catheter,
patients in the thoracic paravertebral group had lower
pain scores, less postoperative morphine consumption,
and better preservation of pulmonary function
In addition,
Side effects such as nausea, vomiting, urinary retention
and hypotension were more problematic in the epidural
group
Cryoablation
Others factors
Neuroma formation
Healing rib fracture
Frozen shoulder
Local infection/pleurisy
Costochondritis/costochondral dislocation
Local tumor recurrence
Psychological overlay
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Pathology
Preventing and treating pain after thoracic surgery. Anesthesiology 104: 594600
Initial Hx & PE
At risk for recurrence
or
YES
Anatomic
Abnormality
NO
Physical therapy/
Relaxation/
Psychological
fellowship anesthesiologist
evaluation Dr Mehran Rezvani& pain
acupuncturist
CXR & CT
SCAN
Hypertrophic scar
Trigger point,neuroma
NO
NSAIDS
(SYSTEMIC OR TOPICAL)
/ Tramadol
/Topical caspaicine
Local
anesthetic /+
steroid
Symptoms consistent
With neuropathic pain
NO
Persistent pain
YES
Tactile
allodynia
N
O
TCA or Anticonvulsants
/consider
NMDA Antagonists or
calcitonin
Continue therapy,
weaning as indicated
YES
Consider TENS
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Topical lidocaine
patch
Candidate for
opioid
trial or nerve
blocks?
yes
Trial of
opioid
therapy
NO
Acupuncture /
Alternative
therapies
YES
Sympathetic
component?
Intercostal cryo /
pulse RF
Intercostal Nerve Block
Paravertebral Nerve block
Thoracic Epidural Steroid
Injection
Sympathetic
Block
Persistent pain?
NO
YES
Neuromodulation