The dual etiology of ipsilateral shoulder pain after thoracic surgery⋆

Influence of extent of surgical resection on post-hepatectomy shoulder pain: an observational study

Shoulder pain frequently follows hepatectomy. However, the influence of surgical procedures on shoulder pain is unclear. In this observational study, patients who underwent hepatectomy were enrolled in Shanghai Cancer Center. Shoulder pain and surgical pain were assessed using the numeric rating scale 2 days after surgery. The incidence of shoulder pain was the outcome of the cohort study. Nested case-control analyses were further applied. Three hundred and twelve patients were finally enrolled in this study. Nested case-control analysis showed that there were no significant differences in the number of surgical segments between the two groups (P = 0.09). In addition, minor hepatectomy did not reduce the incidence of shoulder pain compared with major hepatectomy (P = 0.37). The drainage volume within 2 days after surgery was significantly more in those patients with shoulder pain (P = 0.017). In open surgery, surgical sites involving the right anterior lobe (OR (95% CI) 2.021 (1.075, 3.802), P = 0.029) and right posterior lobe (OR (95% CI) 2.322 (1.193, 4.522), P = 0.013) were both independent risk factors for shoulder pain. Left shoulder pain also occurred in patients who did not receive left lateral hepatectomy. The preventive phrenic nerve block was not suitable for post-hepatectomy shoulder pain. Stronger preventative intervention should be used in those high-risk patients.

Efficacy of Phrenic Nerve Block and Suprascapular Nerve Block in Amelioration of Ipsilateral Shoulder Pain after Thoracic Surgery: A Systematic Review and Network Meta-Analysis

Background and Objectives: Ipsilateral shoulder pain (ISP) is a common complication after thoracic surgery. Severe ISP can cause ineffective breathing and impair shoulder mobilization. Both phrenic nerve block (PNB) and suprascapular nerve block (SNB) are anesthetic interventions; however, it remains unclear which intervention is most effective. The purpose of this study was to compare the efficacy and safety of PNB and SNB for the prevention and reduction of the severity of ISP following thoracotomy or video-assisted thoracoscopic surgery. Materials and methods: Studies published in PubMed, Embase, Scopus, Web of Science, Ovid Medline, Google Scholar and the Cochrane Library without language restriction were reviewed from the publication's inception through 30 September 2022. Randomized controlled trials evaluating the comparative efficacy of PNB and SNB on ISP management were selected. A network meta-analysis was applied to estimate pooled risk ratios (RRs) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Results: Of 381 records screened, eight studies were eligible. PNB was shown to significantly lower the risk of ISP during the 24 h period after surgery compared to placebo (RR 0.44, 95% CI 0.34 to 0.58) and SNB (RR 0.43, 95% CI 0.29 to 0.64). PNB significantly reduced the severity of ISP during the 24 h period after thoracic surgery (WMD -1.75, 95% CI -3.47 to -0.04), but these effects of PNB were not statistically significantly different from SNB. When compared to placebo, SNB did not significantly reduce the incidence or severity of ISP during the 24 h period after surgery. Conclusion: This study suggests that PNB ranks first for prevention and reduction of ISP severity during the first 24 h after thoracic surgery. SNB was considered the worst intervention for ISP management. No evidence indicated that PNB was associated with a significant impairment of postoperative ventilatory status.

Effect of Upper Arm Position Changes on the Occurrence of Ipsilateral Shoulder Pain After Single-Operator Port Thoracoscopy

Background

The aim of this study was to explore the factors associated with the occurrence of ISP after VATS to reduce the incidence of ISP and improve patients' quality of life.

Methods

The data of patients were collected between June 2020 and August 2020 in the Department of Lung Cancer Surgery, Tianjin Medical University General Hospital. The angle of upper arm was measured intraoperatively. The patient's postoperative shoulder function was quantified using the Constant-Murley shoulder function rating score. The proportional hazards model was applied to identify multiple influence factors.

Results

A total of 140 eligible patients met criteria. At postoperative day 3, only the age influenced patients' shoulder pain. At postoperative day 14, univariate and multivariate logistic regression analyses showed that age (odds ratio [OR]: 1.098 [1.046-1.152]; P < 0.001) and upper arm Angle A (OR: 1.064 [1.011-1.121]; P = 0.018) were independent risk factors for low shoulder function scores. However, height was its protective factor (OR: 0.923 [0.871-0.977]; P = 0.006). At postoperative day 42, univariate and multivariate logistic regression analyses showed that age (OR: 1.079 [1.036-1.124]; P < 0.001) was a risk factor for low shoulder function scores, and height (OR: 0.933 [0.886-0.983]; P = 0.009) was its protective factor. In contrast, upper arm Angle B was not statistically associated with low shoulder function scores (P>0.05). In addition, the reduction in ipsilateral Shoulder scores after surgery was higher in patients with more than 113° of angle A (P = 0.025).

Conclusion

ISP was closely related to the angle of anterior flexion of the upper arm on the patient's operative side intraoperatively. The increase in the degree of postoperative shoulder injury is more pronounced for an anterior flexion angle of >113°. Therefore, we recommend that the angle of anterior flexion of the upper extremity should be <113° intraoperatively.

Efficacy of Phrenic Nerve Catheter in Ipsilateral Shoulder Pain After Thoracic Surgery

The mechanism of ipsilateral shoulder pain (ISP) after thoracic surgery remains unexplained definitively in the literature. Regional techniques targeting specific nerves more precisely will provide practitioners with a better understanding of the pain source. We report the case of a 51-year-old woman who underwent robotic-assisted plication of the right hemidiaphragm. ISP was adequately managed using a low-volume infusion through a continuous phrenic nerve block in addition to a thoracic epidural for her chest pain. ISP after thoracic surgery likely originates from diaphragm manipulation. Phrenic nerve blockade is a successful strategy that does not worsen subjective dyspnea in this setting.

Postoperative Pain Management and the Incidence of Ipsilateral Shoulder Pain After Thoracic Surgery at an Australian Tertiary-Care Hospital: A Prospective Audit

OBJECTIVES

Ipsilateral shoulder pain (ISP) is a common but variably occurring (42%-85%) complication after thoracic surgery. Multiple potential treatments, including upper limb blocks, intrapleural local anaesthetic infiltration, and systemic opioids, have undergone trials, with limited efficacy. Phrenic nerve infiltration is a potential intervention that may prevent ISP. The aim of this study was to assess the incidence and severity of ISP after thoracic surgery at the authors' institution, where phrenic nerve infiltration is commonly used.

DESIGN

Observational cohort study.

SETTING

A single- center study in a tertiary referral center in Brisbane, Australia.

PARTICIPANTS

This study comprised all adult patients undergoing thoracic surgery at a tertiary- care referral center from May to July 2018.

MEASUREMENTS AND MAIN RESULTS

Surgical procedures were divided into open thoracotomy, video-assisted thoracic surgery (VATS) and VATS-guided mini-thoracotomy. The primary outcome was a comparison of incidence of ISP among the 3 types of surgical procedures. Data were analyzed using Stata (StataCorp), with significance testing by Kruskal-Wallis equality of populations rank test. A p value of < 0.05 was deemed significant. Sixty thoracic surgeries were performed during the audit period. Nineteen patients had thoracotomies performed for lobectomy or pneumonectomy, all of whom received phrenic nerve infiltration. The incidence of moderate-to-severe ipsilateral shoulder pain among the thoracoctomy cohort was 15.8% (3/19). Of the 36 VATS procedures audited, 7 patients (19.4%) received infiltration of their phrenic nerve, none of whom reported postoperative ISP. Of the remaining twenty-nine patients who did not receive phrenic nerve infiltration, there were 4 cases of moderate-to-severe ipsilateral shoulder pain (11.1%). Four of the 5 patients (80%) who underwent VATS-guided mini-thoracotomies received phrenic nerve infiltration intraoperatively. Three patients reported moderate-to-severe ISP and of these 3 patients, 2 patients had phrenic nerve infiltration, and 1 patient did not receive infiltration. Overall, there were no statistically significant differences in rest or dynamic pain scores across the surgical groups at any time point. Mann-Whitney test revealed that the participants with ISP were significantly older than those without ISP (p = 0.006). However, there were no significant differences in sex or body mass index between those with and without ISP.

CONCLUSION

The authors observed a lower (15.8%) incidence of moderate-to-severe ISP among their thoracotomy patients than reported in prior literature. Injection of local anesthetic into the phrenic nerve fat pad at the level of the diaphragm appeared to be an effective and safe surgical intervention that may eliminate a significant cause of ISP. None of the VATS patients who received phrenic nerve infiltration experienced ISP. Postoperative pain in VATS is expected to be reduced by avoiding the use of a rib spreader, severing of the intercostal nerves, and division of muscle tissue, which may account for the lower observed rates of ISP in the VATS cohort who did not receive phrenic nerve infiltration. Further randomized controlled trials are warranted to establish if patients undergoing various VATS procedures benefit from this intervention.

Musculoskeletal Signs Associated with Shoulder Pain in Patients Undergoing Video-Assisted Thoracoscopic Surgery

BACKGROUND

Lung cancer is the leading cause of cancer death worldwide, and lung resection still represents the main curative treatment modality. Although video-assisted thoracoscopic surgery has emerged as a minimally invasive alternative, its relationship with shoulder musculoskeletal signs remains unclear.

OBJECTIVE

To characterize shoulder dysfunction in patients after video-assisted thoracoscopic surgery and to analyze its influence on quality of life.

DESIGN AND SETTING

A longitudinal observational prospective cohort study has been carried out in the Thoracic Surgery Service of the Hospital Virgen de las Nieves (Granada).

SUBJECTS

Fifty-nine patients undergoing video-assisted thoracoscopic surgery were included.

METHODS

Patients were assessed before surgery, at discharge, and one month after discharge. Musculoskeletal disturbances, pain severity, and health status were assessed. Musculoskeletal outcomes measured were range of movement and trigger points, both bilaterally. Additionally, pain severity and health status were measured with Brief Pain Inventory and Euroqol-5 dimensions.

RESULTS

Significant differences were found at discharge in trigger points of ipsilateral and contralateral upper limbs. One month after surgery, no muscle returned to baseline measures, and ipsilateral and contralateral shoulders presented a decreased range of motion, as well as poor quality of life and high severity and interference of pain.

CONCLUSIONS

Video-assissted thoracoscopic surgery was associated with musculoskeletal shoulder dysfunction, which remained one month after the intervention. This musculoskeletal dysfunction included significant dysfunction in both shoulders with a decreased range of movement, an increase in trigger points, poor quality of life, and high severity and interference of pain.

The effect of interscalene block on ipsilateral shoulder pain and pulmonary function in patients undergoing lung lobectomy: A randomized controlled trial

BACKGROUND

Postoperative ipsilateral shoulder pain occurs in 37% to 68% of patients undergoing a thoracotomy. We examined whether interscalene brachial plexus block using a lower concentration of local anesthetic would reduce the incidence of post-thoracotomy ipsilateral shoulder pain with assessment of pulmonary function in patients who underwent a lung lobectomy.

METHODS

Forty-four patients who underwent a lung lobectomy were randomly assigned to either the control or the interscalene block group. Single-shot interscalene block on the surgical site side was performed using ropivacaine 0.25% 10 mL including dexamethasone 5 mg under ultrasound guidance in the interscalene block group. Lobectomy and continuous paravertebral block were performed under general anesthesia. The presence of ipsilateral shoulder pain and postoperative adverse events were assessed. Pulmonary function tests were performed preoperatively, the day after surgery, and the day after removing the chest tube.

RESULTS

The incidence of ipsilateral shoulder pain was significantly lower in the interscalene block group than in the control group (54.5% vs 14.3%, P = .006) with an overall incidence of 34.9%. Postoperative adverse events were similar between the groups, with no patients presenting symptoms of respiratory difficulty. Significant reductions in pulmonary function were observed in all patients after lobectomy; however, no significant difference in any of the pulmonary function test variables was observed postoperatively between the groups.

CONCLUSIONS

Interscalene block using 10 mL of 0.25% ropivacaine including dexamethasone 5 mg reduced the incidence of post-thoracotomy ipsilateral shoulder pain and did not result in additional impairment of pulmonary function.

Magnesium interscalene nerve block for the management of painful shoulder disorders

Shoulder pain is a common and distressing disorder. Systemic multimodal analgesia may be ineffective, but interscalene nerve block provides effective therapy. Magnesium may increase the efficacy and duration of systemic or regional analgesia. This case series examines the utility of magnesium interscalene nerve block for the management of painful shoulder disorders. Six elderly patients with shoulder pain and dysfunction received interscalene nerve block with injection of bupivacaine and magnesium. The patients subsequently reported significant improvement in sleep, shoulder pain, and physical function for 16 weeks. This report highlights that magnesium interscalene nerve block provides safe, effective, and prolonged shoulder analgesia.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.