Chronic post-thoracotomy pain—What is new in pathogenic mechanisms and strategies for prevention?

Paravertebral Block versus Thoracic Epidural Analgesia for Postthoracotomy Pain Relief: A Meta-Analysis of Randomized Trials

OBJECTIVE

 Paravertebral block (PVB) and thoracic epidural analgesia (TEA) are commonly used for postthoracotomy pain management. The purpose of this research is to evaluate the effects of TEA versus PVB for postthoracotomy pain relief.

METHODS

 A systematic literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library (last performed on August 2020) to identify randomized controlled trials comparing PVB and TEA for thoracotomy. The rest and dynamic visual analog scale (VAS) scores, rescue analgesic consumption, the incidences of side effects were pooled.

RESULTS

 Sixteen trials involving 1,000 patients were included in this meta-analysis. The pooled results showed that the rest and dynamic VAS at 12, 24, and rest VAS at 48 hours were similar between PVB and TEA groups. The rescue analgesic consumption (weighted mean differences: 3.81; 95% confidence interval [CI]: 0.982-6.638, p < 0.01) and the incidence of rescue analgesia (relative risk [RR]: 1.963; 95% CI: 1.336-2.884, p < 0.01) were less in TEA group. However, the incidence of hypotension (RR: 0.228; 95% CI: 0.137-0.380, p < 0.001), urinary retention (RR: 0.392; 95% CI: 0.198-0.776, p < 0.01), and vomiting (RR: 0.665; 95% CI: 0.451-0.981, p < 0.05) was less in PVB group.

CONCLUSION

 For thoracotomy, PVB may provide no superior analgesia compared with TEA but PVB can reduce side effects. Thus, individualized treatment is recommended. Further study is still necessary to determine which concentration of local anesthetics can be used for PVB and can provide equal analgesic efficiency to TEA.

Trajectories of Pain in Patients Undergoing Lung Cancer Surgery: A Longitudinal Prospective Study

CONTEXT

Lung cancer surgery is among the surgical procedures associated with the highest prevalence of pain, but prospective longitudinal studies after the pain trajectory are scarce.

OBJECTIVES

We aimed to describe the pain trajectory in patients undergoing surgery for primary lung cancer and investigate whether distinct groups of patients could be identified based on different pain trajectories.

METHODS

Patients (n = 264; 95% thoracotomies) provided data on the average and worst pain intensity, pain location, and comorbidities before, and at one month and five, nine, and 12 months after surgery. Pain profiles were analyzed by latent class mixed models.

RESULTS

The occurrence of any pain increased from 40% before surgery to 69% after one month and decreased to 56%, 57%, and 55% at five, nine, and 12 months, respectively. Latent class mixed models identified two classes both for average and worst pain; one class started low with high ratings after one month, then returning to a level slightly higher than baseline. The other class started higher with similar scores through the trajectory. Patients reporting no pain (8%) were placed in a separate class. Higher comorbidity score, preoperative use of both pain and psychotropic medicine characterized the class with overall highest pain for average and/or worst pain.

CONCLUSION

Pain was highly prevalent after surgery, and subgroups could be identified based on different pain trajectories. Patients reported both postoperative pain and pain from chronic conditions. Knowledge about vulnerable patients and risk factors for pain is important to tailor interventions and information about pain.

If post-thoracotomy pain is the target, Integrated Thoracotomy is the choice

OBJECTIVES

Despite the overgrowth of procedures done by VATS, there are still needs for thoracotomy. Post-thoracotomy pain plays an important role in many post-operative morbidities. Surgeons should make efforts to evolve new techniques to reduce post-thoracotomy pain with its associated morbidities. This trial aimed to study the impact of combining lack of rib retraction with protection of both intercostal nerves on post-operative pain.

METHODS

This was a prospective study of 57 patients who had Integrated thoracotomy (I group) which consists of modified French window with Double-Edge closure. The results of I group were compared to our previous study that contained two groups 60 patients each, double edge (DE group) in which standard thoracotomy was closed using double-edge technique and (PC group) in which pericostal sutures was used for closure of thoracotomy. Outcomes assessed were operative time, time to ambulation, doses of analgesics injected in the epidural catheter, post-operative complications, chest tube drainage, hospital stay, and pain score and use of analgesics during the first post-operative year.

RESULTS

All groups had similar demographics, operative time, and incisions length, but in I group, there were significantly a smaller number of lobectomies and pneumonectomies. Patients in I group had significantly lower time to ambulation, epidural doses and post-operative pain score throughout the first week. Patients in the (I group) had a significantly lower pain score throughout the first 9 months post-operatively. Up to 6 months post-operatively, there was significantly less use of analgesics among the I group.

CONCLUSION

The combination of retractor-free exposures and neurovascular exclusion sutures for thoracotomy is safe and effective in decreasing post-thoracotomy pain and use of analgesics.

Double edge closure: a novel technique for reducing post-thoracotomy pain. A randomized control study

OBJECTIVES

Thoracic surgeons being doctors, spend much effort not only to manage pathologies but also to make their procedures painless. Many surgical manoeuvres have been evolved to reduce post-thoracotomy pain with its associated morbidities. This trial aimed to study the impact of double edge closure technique on post-thoracotomy pain.

METHODS

This was a prospective pre-muted block randomized study of 120 patients who had posterolateral thoracotomy. They were equally divided into two groups, the first in which double edge closure technique was used (DE group), and the other group in which the usual pericostal sutures were used (PC group). Outcomes assessed were operative time, time to ambulation, doses of analgesics injected in the epidural catheter, postoperative complications, chest tube drainage, hospital stay and pain score by the numeric rating scale from 0 to 10 and use of analgesics during the first postoperative year.

RESULTS

Both groups had similar demographics, types of procedures, operative time and incisions length. Patients in DE group had significantly lower time to ambulation from 14.47 to 12.85 h, epidural doses from 3.65 to 1.87 and postoperative pain score throughout the first week. At 2 weeks, 1 and 3 months, there was significant reduction in pain and analgesics use in the DE group. At 6 months, analgesic use was not significantly different between both groups, but the pain score was significantly lower in the DE group (0.33 ± 0.51) than that in the PC group (0.63 ± 0.74). After 9 months, no significant difference was present between both groups with regard to pain score or the use of analgesics.

CONCLUSIONS

Double edge technique for thoracotomy closure is easy, rapid, safe and effective in decreasing post-thoracotomy pain with subsequent earlier ambulation and lesser use of analgesics.

A retrospective study of chronic post-surgical pain following thoracic surgery: prevalence, risk factors, incidence of neuropathic component, and impact on qualify of life

Background

Thoracic surgeries including thoracotomy and VATS are some of the highest risk procedures that often lead to CPSP, with or without a neuropathic component. This retrospective study aims to determine retrospectively the prevalence of CPSP following thoracic surgery, its predicting risk factors, the incidence of neuropathic component, and its impact on quality of life.

Methods

Patients who underwent thoracic surgeries including thoracotomy and VATS between 01/2010 and 12/2011 at the First Affiliated Hospital, School of Medicine, Zhejiang University were first contacted and screened for CPSP following thoracic surgery via phone interview. Patients who developed CPSP were then mailed with a battery of questionnaires, including a questionnaire referenced to Maguire's research, a validated Chinese version of the ID pain questionnaire, and a SF-36 Health Survey. Logistic regression analyses were subsequently performed to identify risk factors for CPSP following thoracic surgery and its neuropathic component.

Results

The point prevalence of CPSP following thoracic surgery was 24.9% (320/1284 patients), and the point prevalence of neuropathic component of CPSP was 32.5% (86/265 patients). CPSP following thoracic surgery did not improve significantly with time. Multiple predictive factors were identified for CPSP following thoracic surgery, including age<60 years old, female gender, prolonged duration of post-operative chest tube drainage (≥4 days), options of post-operative pain management, and pre-existing hypertension. Furthermore, patients who experienced CPSP following thoracic surgery were found to have significantly decreased physical function and worse quality of life, especially those with neuropathic component.

Conclusions

Our study demonstrated that nearly 1 out of 4 patients underwent thoracic surgery might develop CPSP, and one third of them accompanied with a neuropathic component. Early prevention as well as aggressive treatment is important for patients with CPSP following thoracic surgery to achieve a high quality of life.