Post Thoracotomy Pain

Postthoracotomy Pain
Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist
Relevant Clinical Anatomy

& acupuncturist
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

& acupuncturist
Clinical Presentation

& acupuncturist
During the Acute postoperative phase, patients

experience
sharp pain that increases with breathing and coughing.
The pain is also associated with numbness, especially
along the scar
site

& acupuncturist
Chronic pain after thoracotomy is typically a combination

of neuropathic and nociceptive pain
Burning pain and allodynia
Aching chest or back pain
Myofascial pain
(referred shoulder pain may occur, especially after procedures that cause injury
to the diaphragm or the phrenic nerve)

& acupuncturist
Differential Diagnosis

& acupuncturist
Herniated disc
Neuroforaminal stenosis
Rib pathology
Postherpetic neuralgia
Slipping rib syndrome
Costochondritis
Tietze's syndrome
Myofascial pain syndrome
& acupuncturist

& acupuncturist
Acute Pain Management for Patients

Undergoing
Thoracotomy

& acupuncturist
Management of thoracotomy pain can be difficult, but the

benefits of effective pain control are significant
Systemic opiates
Regional analgesics
New oral and parenteral agents

& acupuncturist
Pain is a key component in the alteration of lung function

after thoracic surgery
Postoperative analgesia to reduce pulmonary
complications and
attenuate the stress response

& acupuncturist
Almost 200,000 patients a year are diagnosed with

bronchogenic
carcinoma, and nearly one-quarter of these patients will
undergo surgical resection

& acupuncturist
Ineffective chest expansion due to pain may predispose

to
Atelectasis
Ventilation/ perfusion mismatching
Hypoxemia
Infection

& acupuncturist
Thus, the goal of the clinician is to develop an analgesic

regimen that provides effective pain relief to allow
postoperative
thoracotomy patients the ability to maintain
their functional residual capacity by deep breathing

& acupuncturist
Effective clearing of secretions with cough and early

mobilization can lead to quicker recovery and shorter
length of hospital stay

& acupuncturist
Inadequate acute postoperative pain management may contribute to

the development of a chronic postthoracotomy pain syndrome
(52%)
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

& acupuncturist
The pain associated with thoracotomy incisions can be

difficult to target and quantify, and prior studies have
evaluated :
Chest tube pain
Incisional pain
Visceral pain
Coughing or movement
& acupuncturist
Systemic administration of opioids is the simplest and

most common method to provide analgesia for
postoperative pain
Unfortunately systemic opioid administration may not be
adequate
for treating the intense postoperative pain associated
with thoracotomy
& acupuncturist

& acupuncturist
Ketorolac, tramadol, COX-2 inhibitors, and ketamine are

other potentially useful analgesic agents as alternatives
or adjuncts to opioids

& acupuncturist
To improve the quality of analgesia, two classes of drugs

can
be administered concurrently to obtain a synergistic
analgesic effect while minimizing the side effects of each
drug
Surgical technique itself can be modified in an attempt to
reduce the impact of postoperative pain
& acupuncturist

& acupuncturist
Concepts in Postoperative Pain

& acupuncturist
Pain can be defined as an unpleasant sensory and

emotional
experience associated with actual or potential tissue
damage

& acupuncturist
Local tissue damage results in inflammation and

propagation
of stimuli to the central nervous system
These stimuli are modulated by
Excitatory [NMDA])
Inhibitory (opiate) pathways
& acupuncturist
Animal data have shown that administration of low doses

of systemic morphine before noxious stimulation
suppresses spinal cord hyperexcitability, whereas
administration of doses after noxious
stimulation does not completely blunt it

& acupuncturist
Because the NMDA receptor has been implicated in the

generation
and maintenance of spinal cord wind-up, NMDA
antagonists
(eg, ketamine and dextromethorphan) are logical
candidates for preemptive analgesia

& acupuncturist
Chronic Postthoracotomy Pain

& acupuncturist
Up to 50% of patients undergoing thoracotomy will

develop chronic pain related to the surgical site
Chronic postthoracotomy pain has been defined as a
continuous
dysesthetic burning and aching in the general area of the
incision that persists at least 2 months after thoracotomy
Surgical aspects of chronic postthoracotomy pain. Eur J Cardiothorac Surg 2000;18:7116
& acupuncturist
Although no one surgical technique has been proven to

decrease the incidence of chronic pain, intercostal nerve
damage due to rib retraction seems to be involved in the
development of the neuralgia
Preliminary findings in the neurophysicological assessment of intercostal nerve injury

during thoracotomy.
Eur J Cardiothorac Surg 2002;21:298301
& acupuncturist
Initiation of epidural bupivacaine/ morphine before

surgical incision reduced the incidence of long-term pain
[The effects of three different analgesia techniques on long-term postthoracotomy pain. Anesth Analg 2002;94:11
5]
Patients with increased postoperative pain had an

increased incidence of chronic postoperative pain
[Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 1996;12:505]

& acupuncturist
Epidural Analgesia as the Mainstay of

Postoperative Pain Management

& acupuncturist
Epidural analgesia has emerged as the analgesic technique of

choice for postoperative thoracotomy pain management
Provide excellent pain control
Avoids much of the sedation associated with systemic opiates
Epidural Catheter allows for continued dosing postoperatively
Avoids much of the motor blockade associated with
intrathecal drug administration

& acupuncturist
Much lower doses of drug administered in the epidural space

are
needed ( in compare with systemic administration )
Postoperative patients can consume on the order of 50 to
100 mg of intravenous morphine during the first 24 hours
postoperatively when administered by a PCA device
In comparison, epidural doses of 5 mg of morphine can
provide postoperative analgesia for 12 to 24 hours
& acupuncturist
Commonly used opioidlocal anesthetic mixtures :

Fentanyl-bupivacaine
Morphine-bupivacaine
Fentanyl-ropivacaine

& acupuncturist
Epidural fentanyl 5 g/mL combined with bupivacaine

0.1% provided
an optimal balance between pain relief and side effects
WALDMAN 2011
& acupuncturist
TEA was effective in control of the incision pain but not

effective in
alleviation of postthoracotomy shoulder pain, which is
most
likely related to irritation of the pericardium or the pleura.

& acupuncturist
Patients receiving thoracic epidural analgesia for

postthoracotomy pain, phrenic nerve infiltration with 10
mL of ropivacaine just before lung expansion and chest
closure reduced the incidence and delayed the onset of
ipsilateral shoulder pain by about 50% during the first 24
hours after open lung resection

& acupuncturist
Hypotension and urinary retention are common side

effects related to TEA
Paravertebral block was found to be as effective as
epidural block with local anesthetic
However, paravertebral block had a better side effect
profile.

& acupuncturist
In many clinical settings, epidural analgesia is used as

often as possible, whereas systemic analgesia is reserved
for situations in which epidural analgesia is unsuccessful
or contraindicated :
Coagulopathy
Infection
Neurologic disease

& acupuncturist
A meta-analysis of pre-emptive use of thoracic epidural

analgesia concluded that it offered improved postoperative
analgesia in the first 48 hours after surgery, but had no
impact on chronic post-thoracotomy pain
Other techniques such as intrapleural analgesia,
paravertebral block, cryoanalgesia, and infiltration at the
incision site did not effect the incidence of postthoracotomy pain syndrome
& acupuncturist
Postoperative epidural pain control may significantly

decrease pulmonary morbidity
The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative

meta-analyses of randomized, clinical trials. Anesth Analg 1998;86:598612

& acupuncturist
Thoracic Versus Lumbar

Catheters

& acupuncturist
Both lumbar and thoracic epidural catheters can be used

for postoperative thoracotomy pain management
In majority of studies, no significant differences in
analgesia and
pulmonary function were seen; however, less opioid was
required in patients receiving thoracic epidural analgesia

& acupuncturist
In one study, thoracic epidural analgesia was associated

with an increased incidence of ventilatory depression
Adverse effects of extradural and intrathecal opiates: report of a nationwide survey in Sweden. Br J
Anaesth 1982;54:47986

& acupuncturist
With thoracic epidural placement, the risk of injuring

spinal cord tissue if the dura is inadvertently punctured is
theoretically greater, and placement of a thoracic
epidural catheter can be technically more
difficult due to the greater caudad angulation of the
spinous processes

& acupuncturist
Patients who received epidural bupivacaine had a

reduced incidence of supraventricular tachyarrhythmias
when compared with patients who
only received epidural opiates
Thoracic epidural bupivacaine attenuates supraventricular tachyarrhythmias after pulmonary
resection.
Anesth Analg 2001;93:2539

& acupuncturist
Thoracic epidural anesthesia (TEA) is the gold standard

modality for pain control
WALDMAN 2011

& acupuncturist
Intercostal Nerve Block

& acupuncturist
Blockade of intercostal nerves interrupts C-fiber

afferent
transmission of impulses to the spinal cord

& acupuncturist
A single intercostal injection of a long-acting

local anesthetic can provide pain relief and
improve pulmonary function for up to 6
hours

& acupuncturist
To achieve longer durations of analgesia, a continuous

extrapleural intercostal nerve block technique has been
developed in which a catheter is placed percutaneously
into an extrapleural pocket by the thoracic surgeon

& acupuncturist
A continuous intercostal catheter allows frequent dosing

or infusions of local anesthetic agents and avoids
multiple needle injections

& acupuncturist
Shorter-acting local anesthetic, lidocaine, was just as

effective as the
longer-acting agent bupivacaine
Cardiotoxicity of bupivacaine is far more dangerous than
with lidocaine, especially in light of the fact that systemic
absorption is great with an intercostal block

& acupuncturist
However, the advent of newer long-acting local

anesthetic agents,
including ropivacaine and levo-bupivacaine, has
introduced new possibilities for prolonged analgesia with
minimal cardiotoxicity

& acupuncturist

& acupuncturist
Extrapleural intercostal analgesia

or
Epidural analgesia?

& acupuncturist
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.
& 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
& acupuncturist

& acupuncturist
Intrapleural Analgesia

& acupuncturist
Local anesthetic agents can also be administered through

a catheter positioned inside the pleural cavity as another
modality to anesthetize intercostal nerves
The mechanism of action appears to be diffusion
across the parietal
pleura

& acupuncturist
There are inconsistent results in Interpleural analgesia

studies:
Loss of local anesthetic through the chest tube
Dilution of local anesthetic with blood and exudative fluid
present in the pleural cavity
Binding of local anesthetic with proteins
Altered diffusion across the parietal pleural following surgical
manipulation and inflammation
& acupuncturist
Nonsteroidal Anti-Inflammatory Drugs

& acupuncturist
Ketorolac is an NSAID available in a parenteral form, and

it has been shown to be an effective adjunct agent to
improve the quality of intercostal and epidural analgesia

& acupuncturist

& acupuncturist
Nonsteroidal anti-inflammatory drugs, however, have

been associated with inhibition of platelet aggregation,
gastrointestinal bleeding,
and renal toxicity, limiting their usefulness in clinical
practice

& acupuncturist
Blocking COX-1 activity alters platelet function and

promotes gastrointestinal bleeding, whereas blocking
COX-2 inhibits production of prostaglandins that mediate
inflammation and pain-signaling
transmission

& acupuncturist
Oral celecoxib (Celebrex) and rofecoxib (Vioxx), and the

parenteral parecoxib have been developed to relieve pain
and lessen the risk of gastrointestinal bleeding

& acupuncturist

& acupuncturist

& acupuncturist
Tramadol

& acupuncturist
It binds to opiate receptors and inhibits epinephrine and

serotonin reuptake, but lacks many of the side effects
associated with other drugs with similar sites of action
Findings do provide an alternative to opiates

& acupuncturist
Ketamine

& acupuncturist
Ketamine confers analgesia by blocking the NMDA

receptor
Side effects, however, including catecholamine release
and significant cognitive impairment, limit the utility of
this agent
Several authors suggest that ketamine may be a useful
adjunct
& acupuncturist
Paravertebral Nerve Block

& acupuncturist

& acupuncturist
Paravertebral analgesia can be an effective alternative to

epidural
analgesia in thoracotomy patients

& acupuncturist
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

& acupuncturist
In addition,
Side effects such as nausea, vomiting, urinary retention
and hypotension were more problematic in the epidural
group

& acupuncturist

& acupuncturist
Video-Assisted Thoracic Surgery

& acupuncturist
When compared with standard thoracotomy incisions,

patients undergoing VATS had less postoperative pain
and narcotic consumption in multiple studies

& acupuncturist
Phrenic Nerve Infiltration

& acupuncturist
Patients undergoing thoracic surgery frequently complain

of ipsilateral shoulder pain due to diaphragmatic irritation
Infiltration of 10 mL of 1% lidocaine into the periphrenic fat
pad at
conclusion of surgery at the level of the diaphragm in patients
undergoing thoracotomy significantly decreased incidence of
ipsilateral shoulder pain and an overall reduction in pain score
when compared with placebo infiltration
& acupuncturist

& acupuncturist
Cryoablation

& acupuncturist
Much of the pain associated with thoracotomy is

mediated
through the intercostal nerves
Patients undergoing minithoracotomy for minimally
invasive cardiac surgery benefited from cryoablation of
the intercostal nerve at the completion of surgery

& acupuncturist
Chronic Post-thoracotomy Pain

& acupuncturist
The first reference to chronic post-thoracotomy pain was

in 1944 by United States Army surgeons who noted
chronic intercostal pain in men who had thoracotomy
for chest trauma during the Second World War

& acupuncturist
Chronic post-thoracotomy pain is defined by the

International Association for the Study of Pain as pain
that recurs or persists along a thoracotomy incision at
least 2 months following the surgical procedure

& acupuncturist
It is typically burning and dysesthetic in nature and has

many features of neuropathic pain
Post-thoracotomy pain also may result, at least in part,
from a non-neuropathic origin (myofascial pain)

& acupuncturist
Incidence of post-thoracotomy pain as ranging from 25

60 % which makes postthoracotomy pain the commonest
complication of thoracotomy
The majority of patients experience only mild pain, but 3
16 % experience moderate to severe pain

& acupuncturist
The risk of chronic pain following certain types of surgical

procedures is increased in women and decreased in the
elderly
Persistent postsurgical pain: risk factors and prevention.Lancet , 2006 367: 16181625

& acupuncturist

& acupuncturist
Two studies explored the role of preoperative

anxiety/depression in relation to development of postthoracotomy pain, both showing no relationship
A study exploring the role of intercostal nerve damage in chronic pain after thoracic
surgery. Eur J Cardiothorac Surg 2006 29: 873879
Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. 1997, Clin J
Pain 12: 5055

& acupuncturist
Thoracotomy, along with limb amputation, is considered

to be the procedure that elicits the highest risk of severe
chronic postoperative pain
Pain has been reported more profoundly around the
surgical site or scar

& acupuncturist
Others factors
Neuroma formation
Healing rib fracture
Frozen shoulder
Local infection/pleurisy
Costochondritis/costochondral dislocation
Local tumor recurrence
Psychological overlay
& acupuncturist
Injury of intercostal muscles, the serratus anterior, the

latissimus dorsi, and the shoulder girdle muscles may
cause significant myofascial pain
that may even results in frozen shoulder

& acupuncturist
Pleurectomy is a strong risk factor

Sternal osteomyelitis Sternal fracture
Incomplete healing
Sternocostal chondritis
Brachial plexus injury
Entrapment of nerves from sternal wires

& acupuncturist
Even hypersensitivity reaction against the metal wires

were
found to be other possible factors for development of
PTPS
after thymectomy and coronary artery bypass surgery

& acupuncturist
Pathology

& acupuncturist
Tissue injury results in the release of local inflammatory

mediators
Peripheral sensitization
These actions activate intracellular signalling pathways
on nociceptive terminal membranes reducing threshold
and increasing excitability

& acupuncturist
This hypersensitivity reduces the intensity of the

peripheral stimulus needed to activate nociceptors at the
site of inflammation (primary hyperalgesia)

& acupuncturist
The hyperexcitable state of the spinal cord dorsal horn

that follows release of humoral signals from noxious
peripheral stimuli is referred to as central sensitization
Prolonged central sensitization can lead to longlasting alterations in the central nervous system (CNS)
and can contribute to chronic pain long after withdrawal
of the acute painful stimulus
& acupuncturist
Thoracotomy is associated with surgical trauma to the

intercostal nerves
Injured primary sensory neurons begin to fire action
potentials spontaneously as a result of increased or novel
expression and altered trafficking of sodium channels

& acupuncturist
This altered activity contributes to spontaneous pain,

heightens pain sensitivity, and produces tactile allodynia

& acupuncturist
When a nerve is damaged, it heals by fibrosis and

neuroma formation, which can lead to abnormal signal
transduction and transmission to the CNS, generating
both neuronal and glial responses, including the elevation
of spinal prostaglandin (PGE2) concentrations

& acupuncturist
Although pre-emptive effects of gabapentinoids in

reduction of postoperative morphine usage and opioid
related adverse effects such as nausea, vomiting, and
urinary retention have been established, their role in the
prevention of long term pain has not been fully explored

& acupuncturist
Strategies for Treating Long Term Pain
Preventing and treating pain after thoracic surgery. Anesthesiology 104: 594600

& acupuncturist
Study between radiofrequency of the dorsal

root ganglia, pulsed radiofrequency ablation of
intercostals
nerves, and pharmacotherapy:
Radiofrequency ablation (RFA) of the DRG is superior
to pulsed radiofrequency ablation of intercostal nerves
and
to pharmacotherapy
& acupuncturist
Because of the risk of RFA on the dorsal root ganglia,

they recommended that such procedure be reserved for
patients with intractable pain with failure of other
conservative pain management approaches

& acupuncturist
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

& acupuncturist
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
& 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

& acupuncturist
Sympathetic
Block
Persistent pain?
NO
YES
Neuromodulation

& acupuncturist

& acupuncturist

Post Thoracotomy Pain

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Post Thoracotomy Pain

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Postthoracotomy Pain

Dr Mehran Rezvani pain fellowship anesthesiologist

Relevant Clinical Anatomy

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

During the Acute postoperative phase, patients

Dr Mehran Rezvani pain fellowship anesthesiologist

Chronic pain after thoracotomy is typically a combination

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

Acute Pain Management for Patients

Dr Mehran Rezvani pain fellowship anesthesiologist

Management of thoracotomy pain can be difficult, but the

Dr Mehran Rezvani pain fellowship anesthesiologist

Pain is a key component in the alteration of lung function

Dr Mehran Rezvani pain fellowship anesthesiologist

Almost 200,000 patients a year are diagnosed with

Dr Mehran Rezvani pain fellowship anesthesiologist

Ineffective chest expansion due to pain may predispose

Dr Mehran Rezvani pain fellowship anesthesiologist

Thus, the goal of the clinician is to develop an analgesic

Dr Mehran Rezvani pain fellowship anesthesiologist

Effective clearing of secretions with cough and early

Dr Mehran Rezvani pain fellowship anesthesiologist

Inadequate acute postoperative pain management may contribute to

Dr Mehran Rezvani pain fellowship anesthesiologist

The pain associated with thoracotomy incisions can be

Systemic administration of opioids is the simplest and

Dr Mehran Rezvani pain fellowship anesthesiologist

Ketorolac, tramadol, COX-2 inhibitors, and ketamine are

Dr Mehran Rezvani pain fellowship anesthesiologist

To improve the quality of analgesia, two classes of drugs

Dr Mehran Rezvani pain fellowship anesthesiologist

Concepts in Postoperative Pain

Dr Mehran Rezvani pain fellowship anesthesiologist

Pain can be defined as an unpleasant sensory and

Dr Mehran Rezvani pain fellowship anesthesiologist

Local tissue damage results in inflammation and

Animal data have shown that administration of low doses

Dr Mehran Rezvani pain fellowship anesthesiologist

Because the NMDA receptor has been implicated in the

Dr Mehran Rezvani pain fellowship anesthesiologist

Chronic Postthoracotomy Pain

Dr Mehran Rezvani pain fellowship anesthesiologist

Up to 50% of patients undergoing thoracotomy will

Although no one surgical technique has been proven to

Preliminary findings in the neurophysicological assessment of intercostal nerve injury

Initiation of epidural bupivacaine/ morphine before

Patients with increased postoperative pain had an

Dr Mehran Rezvani pain fellowship anesthesiologist

Epidural Analgesia as the Mainstay of

Dr Mehran Rezvani pain fellowship anesthesiologist

Epidural analgesia has emerged as the analgesic technique of

Dr Mehran Rezvani pain fellowship anesthesiologist

Much lower doses of drug administered in the epidural space

Commonly used opioidlocal anesthetic mixtures :

Dr Mehran Rezvani pain fellowship anesthesiologist

Epidural fentanyl 5 g/mL combined with bupivacaine

TEA was effective in control of the incision pain but not

Dr Mehran Rezvani pain fellowship anesthesiologist

Patients receiving thoracic epidural analgesia for