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Cited by 355Anesthesia and Pain ManagementPain Management and Opioid UsePediatric Pain Management Techniques

Preventing and Treating Pain after Thoracic Surgery

Gottschalk, Allan, Cohen, Steven P., Yang, Stephen, Ochroch, E Andrew, Warltier, David C.·2006·Anesthesiology
DOI 10.1097/00000542-200603000-00027
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Abstract

THE pain that accompanies thoracic surgery is notable for its intensity and duration. Acutely, moderate to severe levels of pain may not decrease substantially over the course of hospitalization and the first postoperative month.1Chronically, pain can last for months to years, and even low levels of pain can decrease function.1,2Other than pain syndromes associated with limb amputation, pain after thoracic surgery may be the most recognized pain syndrome associated with a specific surgery. Although used with increasing frequency, thoracoscopic approaches have not had the favorable impact on pain that many had anticipated.3,4Given that the adverse effects of thoracic surgery on pulmonary function can be mitigated by effective perioperative analgesia,5–7it is not surprising that thoracic surgeons have joined anesthesiologists in becoming strong advocates of analgesic interventions known to limit the pain accompanying thoracic surgery. Here, we review evidence-based strategies for preventing and treating this type of pain.Noxious input associated with thoracic surgery is conveyed to the central nervous system along the intercostal, vagus, and phrenic nerves. Afferent phrenic activity is believed to be the source of the shoulder pain that frequently accompanies thoracic procedures because this is curtailed by phrenic8but not suprascapular or epidural blockade.9Intercostal nerve dysfunction resulting from incision, retraction, trocar placement, or suture is common10and likely plays a significant role in the pain accompanying thoracic surgery. In addition, the need for constant respiratory effort and enhanced pulmonary toilet produces an intense and relentless barrage of noxious input to the central nervous system.Initial reports indicated that 50% of patients describe pain 1 yr after thoracotomy, with many continuing to report pain even years later.2Fortunately, the prevalence of postthoracotomy pain may be modifiable, with rates as low as 21% one year after surgery when perioperative pain is managed aggressively.1Surprisingly, video-assisted thoracic surgery (VATS) is associated with a prevalence of chronic pain comparable to that of open procedures,3,4with rates of pain ranging from 22%3to 63%,4which is probably due to intercostal nerve and muscle damage from trocar insertion. In contrast, residual pain 1 yr after surgery is reported to be 25% after median sternotomy,11emphasizing the role that reduced intercostal nerve disruption and improved stability of the closure may play in reducing chronic pain. Several demographic and clinical factors help to identify patients predisposed to development of chronic postsurgical pain. These include anxiety, depression, previous surgery, concurrent pain, lesions of the chest wall, youth, female sex, and increased levels of pain and analgesic use in the perioperative period.1,12–19Lung volumes after thoracic surgery may be reduced by up to 50%, and aggressive analgesic therapy leads to improvements in pulmonary function not observed with standard therapy.5–7Supraventricular tachydysrhythmias are commonly observed after thoracic surgery20and may be less likely in conjunction with certain thoracic epidural analgesic regimens,21although this is more likely due to modification of sympathetic outflow than the associated analgesia. When pain persists, physical activity is reduced,1and even low levels of pain have been associated with reduced physical and social activity as well as global perceptions of decreased health.1,12The optimal perioperative analgesic strategy (fig. 1) is preemptive and multimodal. Although the definition22and efficacy23of preemptive analgesia are debated, several studies strongly suggest that preemptive approaches lead to reductions in pain and/or analgesic use after thoracic surgery.1,7,24–27However, it is equally clear that intraoperative nociception represents only a small portion of the noxious activity encountered during the entire perioperative period that could ultimately sensitize the central nervous system, exacerbating acute pain and initiating chronic pain. A multimodal approach takes into account the multiple pathways by which nociceptive input is conveyed to the central nervous system, the number of pharmacologically distinct mechanisms of modulating this input, the need for effective analgesia throughout the perioperative period and after discharge, and the importance of minimizing side effects, particularly respiratory depression. Although many aspects of analgesic management focus on specific analgesic interventions by the anesthesiologist and surgeon, other features of the surgical management may also impact on the intensity and duration of pain experienced by the patient.Thoracic epidural analgesia is currently the standard for analgesia for thoracic surgery and, in the absence of contraindications, all patients undergoing major open thoracic surgical procedures should have a thoracic epidural catheter placed preoperatively.28,29Epidura

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Authors
Gottschalk, A., Cohen, S. P., Yang, S., Ochroch, E. A., & Warltier, D. C.
Affiliations
  • Johns Hopkins University (US)
  • Associate Professor of Anesthesiology and Critical Care Medicine.
  • University of Pennsylvania (US)
ORCID
Venue
Anesthesiology
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2006-03-01
Volume
104
Issue
3
Pages
594-600
ISSN
0003-3022 (ISSN-L)
DOI
10.1097/00000542-200603000-00027
OpenAlex
W2111928590
Cited by
355
References
66
Citations by year
2026: 9 · 2025: 13 · 2024: 25 · 2023: 26 · 2022: 22 · 2021: 26 · 2020: 27 · 2019: 22 · 2018: 22 · 2017: 21 · 2016: 14 · 2015: 12 · 2014: 16 · 2013: 11 · 2012: 10
FWCI
2.74
Type
journal article
Language
en
Open access
closed
Locations
  • Anesthesiology (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institute of Neurological Disorders and Stroke (R01NS041865)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23HD040914)
Topics
  • Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
Keywords
post-thoracotomy pain, chronic postoperative pain, thoracic surgery, perioperative analgesia, intercostal nerve injury, phrenic nerve, video-assisted thoracoscopic surgery, thoracotomy, shoulder pain, pain prevention, pain management, postoperative pain duration, risk factors for chronic pain, thoracic nerve block, thoracic epidural analgesia
MeSH terms
Analgesics, Opioid, Chronic Disease, Humans, Postoperative Pain, Thoracic Vertebrae, Analgesia, Epidural, Thoracic Surgical Procedures

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