Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention☆

Abstract

Chronic pain complaints after thoracic surgery represent a significant clinical problem in 25-60% of patients. Results from thoracic and other surgical procedures suggest multiple pathogenic mechanisms that include pre-, intra-, and postoperative factors. This review attempts to analyse the methodology and systematics of the studies on the post-thoracotomy pain syndrome (PTPS) after lung cancer surgery in adults, in order to clarify the relative role of possible pathogenic factors and to define future strategies for prevention. Literature published from 2000 to 2008 together with studies included in previous systematic reviews was searched recursively using PubMed and OVID by combining three categories of search terms. The available data have major inconsistencies in collection of pre-, intra- and postoperative data that may influence PTPS, thereby hindering precise conclusions as well as preventive and treatment strategies. However, intercostal nerve injury seems to be the most important pathogenic factor. Since there is a general agreement on the clinical relevance of PTPS, a proposal for design of future trials is presented.

Preventing Post‐Thoracotomy Pain Syndrome

“…For example, some studies considered subjects to have PTPS based upon whether pain was present or absent, whereas others required a certain level of pain intensity in order to designate a subject as having PTPS. 9 Many of these investigations involved questionnaires and thus may have been significantly impacted by recall bias. Results from a fairly representative study indicated an overall incidence of 52% (32% mild, 16% moderate, and 3% severe chronic postoperative pain).…”

“…The degree to which genetics, preoperative pain, and psychosocial factors impact the risk of PTPS is unknown, and more studies are needed to clarify what role, if any, these factors play in the development of PTPS. 9 …”

“…18,19 However, because of a lack of prospective studies designed to specifically address the question of whether the type of surgical incision impacts the development of PTPS, no conclusions can be made about the potential benefit of one approach over others in reducing PTPS. 9 Video-assisted thoracic surgery (VATS) was expected to reduce the incidence of PTPS; however, studies have yielded conflicting results. Two prospective trials found no differences in the incidence of PTPS when VATS was used compared with the classic posterolateral approach or the muscle-sparing posterolateral approach.…”

“…22 Other intraoperative surgical techniques that have been associated with reduced incidence of PTPS are harvesting an intercostal muscle flap, free dissection of intercostal nerves, and the use of intracostal sutures for closing the incision. 9 A study by Cerfolio et al revealed that harvesting an intercostal muscle flap before rib spreading reduces PTPS. 23 In a prior study, Cerfolio et al also demonstrated that the use of intracostal sutures (made by drilling holes in the rib) was superior to pericostal sutures (placing sutures around the rib) in reducing PTPS.…”

Chest tube insertion is one important factor leading to intercostal nerve impairment in thoracic surgery

“…Post-thoracotomy pain syndrome (PTPS) is well established as a clinically important entity after thoracotomy, with persistent pain reported in 30-40% of patients [1]. PTPS is defined by the International Association for Study of Pain (IASP) as 'Pain that recurs or persists along a thoracotomy scar at least 2 months following a surgical procedure' [2].…”