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Post-Thoracotomy Pain Syndrome Justin Wilson, M.D.

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Presentation on theme: "Post-Thoracotomy Pain Syndrome Justin Wilson, M.D."— Presentation transcript:

1 Post-Thoracotomy Pain Syndrome Justin Wilson, M.D.

2 Disclaimer: The available studies have major inconsistencies in collection of data thus hindering conclusive methods for prevention and treatment.

3 Post-Thoracotomy Pain Syndrome (PTPS): Pain that recurs or persist along a thoracotomy scar at least 2 months following the surgery.

4 Variable, but high, roughly >50%, the majority experiencing mild pain, and 3-16% experience moderate-severe pain 82-90% report it is most profound around scar/surgical site Incidence

5 Pain: myofascial vs neuropathic allodynia- sensation of pain to a non-painful stimulus majority report aching dysthetic burning lancinating combination of above

6 Preoperative Risk risk of chronification decreased in elderly risk is increased in females existence of chronic pain elsewhere (hysterectomy and hernia surgery data) no relation to anxiety/depression

7 Intraoperative Risk surgical technique posterolateral vs muscle sparing posterolateral muscle sparing less pain at 1 month axillary vs anterior approach anterior reduced incidence PTPS Video assisted thoracic surgery (VATS) no difference, although decreased early pain

8 Intraoperative Risk surgical technique rib retractors causing nerve damage, confirmed by evoked motor potentials suture technique, 78% damage to inferior and 40% damage to nerve superior to incision due to pericostal suture

9 PTPS 60yo female with acute/chronic chest pain localized at 10yo thoracotomy scar

10 Intraoperative Risk analgesia Intrapleural analgesia: inferior to cryoanalgesia and opioids (23.4%) Thoracic epidural analgesia (TEA): variable (14.8%) TEA + NSAID (9.9%) Cryoanalgesia: no decrease in PTPS (31.6%) Pre-emptive analgesia: inconclusive, although TEA had less postop pain

11 Postoperatively Several studies from other procedures indicate the intensity of acute postop pain to be a risk factor for persistent post surgical pain. (data from hip arthroplasty, hernia, and c-section)

12 Management Acute TEA gold standard multimodal drug therapy (NSAID, IVPCA)

13 Management Chronic First rule out tumor recurrence First line: PT, NSAIDS, TENS, TCA, anti-epileptics, sodium channel blockers, and opioids 2nd: ISB (phrenic-shoulder), intercostal nerve block, PVB, SNRB, sympathetic nerve blocks, TPI, SCS

14 In conclusion, there is a need for large, prospective, randomized trials evaluating PTPS.

15 Perkins FM, Kehlet H: Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000 Oct;93(4):1123-33 Wildgaard K, Ravn J, Kehlet H: Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg. 2009 Jul;36(1):170-80 Karmakar MK, Ho AM. Postthoracotomy pain syndrome. Thorac Surg Clin. 2004 Aug;14(3):345-52 Strebel BM, Ross S. Chronic post-thoracotomy pain syndrome. CMAJ. 2007 Oct 23;177(9):1027 Koehler RP, Keenan RJ. Management of postthoracotomy pain: acute and chronic. Thorac Surg Clin. 2006 Aug;16(3):287-97 Gerner P. Postthoracotomy pain management problems. Anesthesiology Clinics. 2008 June;26(2) Gerner P. Postthoracotomy pain management problems. Anesthesiology Clinics. 2008 June;26(2):355-67

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