Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment
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REVIEW ARTICLE
Post‑Thoracotomy Pain: Current Strategies for Prevention and Treatment Ruchir Gupta1 · Thomas Van de Ven2 · Srinivas Pyati2
© Springer Nature Switzerland AG 2020
Abstract Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.
Key Points
1 Background
Post-thoracotomy pain syndrome is extremely difficult to treat, so the focus should be on prevention.
Both management of acute pain following thoracic surgery and prevention of chronic pain after thoracic surgery remains a significant challenge. Chronic post-thoracotomy pain syndrome (PTPS) occurs with a prevalence ranging from 25 to 57%, with severe debilitation in less than 10% of this cohort [1–3]. PTPS is defined by the International Association for the Study of Pain as “pain that recurs or persists along a thoracotomy incision [for] at least 2 months following the surgical procedure” [4] and has typical features of neuropathic pain such as burning and dysesthesia [5]. In the last few years investigators have sought clarity on definitions of post-surgical chronic pain that are applicable clinically and for research purposes. Most observe that pain that develops 3–6 months following surgery (after exclusion of other causes) affects quality of life, and pain that is either localized or referred to a dermatome should be included in the diagnostic criteria [6, 7]. While acute pain is primarily a mixed bag of nocipetive, visceral, and neuropathic components, chronic post-thoracotomy pain is predominantly neuropathic in nature, and in the case of thoracotomy the etiology may be related to nerve damage [8]. In this review we briefly discuss acute pain management, and risk factors and strategies to prevent PTPS.
Successful management of acute post-surgical thoracotomy pain is effective at preventing the development of post-thoracotomy pain syndrome. Preoperative testing such as Quantitative Sensory Testing (QST) and Diffuse Noxious Inhibitory
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