Management of postthoracotomy pain: acute and chronic

The effect of continuous intercostal nerve block vs. single shot on analgesic outcomes and hospital stays in minimally invasive direct coronary artery bypass surgery: a retrospective cohort study

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) grafting surgery is accompanied by severe pain. Although continuous intercostal nerve block (CINB) has become one of the multimodal analgesic techniques in single port thoracoscopic surgery, its effects on MIDCAB are unclear. The purpose of this study was to compare the effects of CINB and single shot on analgesic outcomes and hospital stays in patients undergoing MIDCAB in a real-world setting.

METHODS

A retrospective cohort study was carried out at Peking University Third Hospital, China. Two hundred and sixteen patients undergoing MIDCAB were divided into two groups: a CINB group and a single block (SI) group. The primary outcome was postoperative maximal visual analog scale (VAS); secondary outcomes included the number of patients with maximal VAS ≤ 3, the demand for and consumed doses of pethidine and tramadol, and the length of intensive care unit (ICU) and hospital stays. The above data and the area under the VAS curve in the 70 h after extubation for the two subgroups (No. of grafts = 1) were also compared.

RESULTS

The maximum VAS was lower in the CINB group, and there were more cases with maximum VAS ≤ 3 in the CINB group: CINB 52 (40%) vs. SI 17 (20%), P = 0.002. The percentage of cases requiring tramadol and pethidine was less in CINB, P = 0.001. Among all patients, drug doses were significantly lower in the CINB group [tramadol: CINB 0 (0-100) mg vs. SI 100 (0-225) mg, P = 0.0001; pethidine: CINB 0 (0-25) mg vs. SI 25 (0-50) mg, P = 0.0004]. Further subgroup analysis showed that the area under the VAS curve in CINB was smaller: 28.05 in CINB vs. 30.41 in SI, P = 0.002. Finally, the length of ICU stay was shorter in CINB than in SI: 20.5 (11.3-26.0) h vs. 22.0 (19.0-45.0) h, P = 0.011.

CONCLUSIONS

CINB is associated with decreased demand for rescue analgesics and shorter length of ICU stay when compared to single shot intercostal nerve block. Additional randomized controlled trial (RCT) is needed to support these findings.

Patient-reported outcomes 6 to 12 months after isolated rib fractures: A nontrivial injury pattern

BACKGROUND

Despite the ubiquity of rib fractures in patients with blunt chest trauma, long-term outcomes for patients with this injury pattern are not well described.

METHODS

The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project has established a multicenter prospective registry with 6- to 12-month follow-up for trauma patients treated at participating centers. We combined the FORTE registry with a detailed retrospective chart review investigating admission variables and injury characteristics. All trauma survivors with complete FORTE data and isolated chest trauma (Abbreviated Injury Scale score of ≤1 in all other regions) with rib fractures were included. Outcomes included chronic pain, limitation in activities of daily living, physical limitations, exercise limitations, return to work, and both inpatient and discharge pain control modalities. Multivariable logistic regression models were built for each outcome using clinically relevant demographic and injury characteristic univariate predictors.

RESULTS

We identified 279 patients with isolated rib fractures. The median age of the cohort was 68 years (interquartile range, 56-78 years), 59% were male, and 84% were White. Functional and quality of life limitations were common among survivors of isolated rib fractures even 6 to 12 months after injury. Forty-three percent of patients without a preexisting pain disorder reported new daily pain, and new chronic pain was associated with low resilience. Limitations in physical functioning and exercise capacity were reported in 56% and 51% of patients, respectively. Of those working preinjury, 28% had not returned to work. New limitations in activities of daily living were reported in 29% of patients older than 65 years. Older age, higher number of rib fractures, and intensive care unit admission were independently associated with higher odds of receiving regional anesthesia. Receiving a regional nerve block did not have a statistically significant association with any patient-reported outcome measures.

CONCLUSION

Isolated rib fractures are a nontrivial trauma burden associated with functional impairment and chronic pain even 6 to 12 months after injury.

LEVEL OF EVIDENCE

Prognostic/epidemiologic, level III.

A Review of Techniques of Intercostal Nerve Blocks

PURPOSE OF REVIEW

Intercostal nerve blocks are indicated for multiple chronic pain and acute pain conditions including rib fractures, herpes zoster, post-thoracotomy pain syndrome, and intercostal neuralgia. Intercostal neuralgia is a type of neuropathic pain that is in the distribution of intercostal nerves. The purpose of this review is to evaluate the different techniques used to perform intercostal nerve blocks and review their efficacy and safety including blind technique using anatomical landmarks, and fluoroscopically guided and ultrasound-guided intercostal nerve blocks.

RECENT FINDINGS

Literature search was performed with the keywords including intercostal neuralgia, treatment, intercostal nerve blocks, and radiofrequency ablation on PubMed and Google Scholar. Three studies and one case report were identified. Literature review revealed that ultrasound-guided techniques and fluoroscopically guided techniques are superior to landmark-based technique in terms of efficacy. There was no difference in efficacy and complication rates between ultrasound and fluoroscopic guidance. Ultrasound-guided techniques and fluoroscopically guided techniques can both be performed safely and effectively for various chronic pain conditions. Ultrasound guidance has its advantages of direct visualization of nerves, vessels, muscles, and the lung. It is potentially a superior technique in terms of improving accuracy and decreasing complications. Further large population randomized control studies should be conducted to compare the efficacy of intercostal nerve blocks performed under ultrasound and fluoroscopy.

Remote monitoring of patient recovery following lung cancer surgery: a messenger application approach

Background

Repeated assessment of patient recovery after discharge is challenging. This study used a popular messenger application to remotely collect patient self-reported symptoms and their severity so as to monitor patient recovery and identify the factors affecting the recovery of symptoms following lung cancer surgery.

Methods

This prospective observational study was conducted at a single tertiary lung cancer center in China between November 2018 and June 2019. Participants received demonstration videos and repeated symptom surveys regarding pain and cough severity (assessed using numeric rating scores of 0–10 for pain and 0–6 for cough) at 2, 4, 6, 8, and 12 weeks after discharge via a smartphone program bound to the WeChat application. Patients who responded to at least 3 of the 5 post-discharge surveys were included in this study. The data were analyzed to investigate the symptom recovery and its related factors.

Results

Of the 826 patients enrolled, 589 (71.3%) responded to at least three surveys. The average pain score reduced from 4.1±2.5 at 2 weeks to 2.2±2.0 at 12 weeks (P<0.001). Factors associated with higher pain severity included the female gender, age over 60 years, thoracotomy, longer operation time (>90 minutes), and prolonged chest tube drainage (>7 days). The average cough score decreased from 2.34±1.30 at 2 weeks to 1.93±1.26 at 12 weeks (P<0.001). Being female and a prolonged operation time (>90 min) were related to increased cough severity. Sublobar resection and limited lymphadenectomy may contribute to lower cough severity post-surgery.

Conclusions

The messenger application-based remote monitoring successfully collected post-discharge symptom information and identified factors associated with recovery following lung surgery.

Risk of Urinary Recatheterization for Thoracic Surgical Patients with Epidural Anesthesia

Background:

Current quality guidelines recommend the removal of urinary catheters on or before postoperative day two, to prevent catheter-associated urinary tract infections (CAUTI). The goal of this study was to evaluate the impact urinary catheter removal on the need for urinary recatheterization (UR) of patients with epidural anesthesia undergoing thoracic surgery.

Materials and Methods:

All patients undergoing thoracic surgery between November 4^th, 2017 and January 9^th, 2018 who had a urinary catheter placed at the time of intervention were prospectively evaluated. Patient characteristics including: history of benign prostatic hyperplasia (BPH), catheter related variables and rates of UR were collected through chart review and daily visits to the wards. BPH was defined as history of transurethral resection of the prostate or treatment with selective α₁-adrenergic receptor antagonists.

Results:

Over a two-month period 267 patients were included, 124 (46%) were male. Epidural catheters were placed in 88 (33%) patients. Median duration of urinary catheters for the cohort was 1 day (0 days – 18 days), and it was significantly higher in patients with epidural anesthesia (Table 1). Overall 20 (7%) patients required UR. On initial analysis, there was no statistical difference in the rate of UR among patients with and without epidural catheters [9/88 (10%) vs 11/179 (6%), p=0.23). The rate of UR was higher in males than in females (14/124 (11%) vs 6/143 (4%), p=0.03). Fifteen (12%) patients had a diagnosis of BPH. The rate of UR was three-times higher in this group than in those without BPH [4/15 (27%) vs 10/109 (9%) p=0.05]. Four (1%) patients developed a CAUTI during follow-up, and the rate of CAUTI was not different between those with and without epidural catheters.

Conclusion:

Urinary catheters in patients with thoracic epidural anesthesia can be safely removed, as evidenced by low reinsertion and infection rates. Removal of urinary catheters in patients with a history of BPH should be carefully evaluated, as over 1/4 will require urinary recatheterization in this subgroup. Further study of this group is needed to avoid unnecessary patient discomfort associated with recatheterization.

The serratus anterior plane block for analgesia after thoracic surgery: A meta-analysis of randomized controlled trails

BACKGROUND

The serratus anterior plane (SAP) block is a newer method that can be used in patients undergoing thoracic surgeries. The postoperative analgesia efficacy of SAP blocks for thoracic surgery remains controversial. We conduct a meta-analysis to evaluate the analgesia of SAP blocks after thoracic surgery.

METHODS

We searched PubMed, Embase, EBSCO, the Cochrane Library, Web of Science, and CNKI for randomized controlled trials (RCTs) regarding the postoperative pain control of a SAP block on thoracic surgery. All of the dates were screened and evaluated by two researchers and meta-analysis was performed using RevMan5.3 software.

RESULTS

A total of 8 RCTs involving 542 patients were included. The meta-analysis showed statistically significant differences between the two groups with respect to postoperative pain scores at 2 h (standardized mean difference [Std.MD] = -1.26; 95% confidence interval [CI] = -1.66 to -0.86; P < .0001); 6 h (SMD = -0.50; 95%CI = -0.88 to -0.11; P = .01); 12 h (SMD = -0.63; 95%CI = -1.10 to -0.16; P = .009); 24 h (SMD = -0.99; 95%CI = -1.44 to -0.51; P < .0001); postoperative opioid consumption at 24 h (SMD = -0.83; 95%CI = -1.10 to -0.56; P < .00001); and postoperative nausea and vomiting (PONV) rates (RR = 0.39; 95% CI = 0.21-0.73; P = .003).

CONCLUSION

The SAP block can play an important role in the management of pain after thoracic surgery by reducing both pain scores and 24-h postoperative opioids consumption. In addition, there is fewer incidence of PONV in the SAP block group.

Neuromodulation of the Dorsal Root Ganglion for Chronic Postsurgical Pain

Objective

The objective of this study is to review the available evidence for dorsal root ganglion (DRG) stimulation for the treatment of complex regional pain syndrome type II (CRPS II; peripheral causalgia) associated with chronic neuropathic postsurgical pain (NPP).

Design

Available literature was identified through a search of the US National Library of Medicine’s Medline database, PubMed.gov. References from published articles also were reviewed for relevant citations.

Results

The data published to date support the use of DRG stimulation to treat chronic NPP of the groin, knee, and foot. NPP following procedures such as thoracotomy, hernia surgery, and knee replacement surgery were identified as some of the conditions for which DRG stimulation is likely to be effective.

Conclusion

DRG stimulation is known to be an effective treatment for focal neuropathic pain. Currently, NPP of the foot, groin, and knee all appear to be the conditions with the most clinical experience, backed by a limited but growing body of evidence. However, prospective studies lag behind real-world clinical experience and are needed to confirm these findings.

Role of Perioperative Pregabalin in the Management of Acute and Chronic Post-Thoracotomy Pain

BACKGROUND:

Post-thoracotomy pain syndrome (PTPS) can be challenging to treat.

AIM:

This study aimed to evaluate the efficacy of perioperative pregabalin in the prevention of acute and chronic post-thoracotomy pain.

METHODS:

Sixty patients scheduled for thoracotomy for oncologic surgeries were randomly allocated to one of two groups; Pregabalin and Control. In the Pregabalin group, pregabalin 150 mg was administered one hour before thoracotomy and 12 hours later, then every 12 hours for five days. Pain intensity was assessed using the Visual Analogue Scale (VAS) at rest (VAS-R) and dynamic (VAS-D) in the ICU and during the next four days. Morphine consumption and the frequency of side effects were recorded. Assessment of PTPS was done using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale at 1, 2, and 3 months.

RESULTS:

The VAS-R and VAS-D scores and the total morphine consumption were significantly lower in Pregabalin group during days 0 through 4. Neuropathic pain, allodynia, and hyperalgesia were significantly lower in Pregabalin group after 1, 2, and 3 months.

CONCLUSION:

Pregabalin is effective in the reduction of chronic neuropathic pain at 1, 2, and 3 months after thoracotomy and it also reduces pain and opioid consumption during the acute postoperative period with few adverse effects.

Intercostal Neurolysis for The Treatment of Postsurgical Thoracic Pain: a Case Series

INTRODUCTION

We investigated the possible role of intercostal surgical neurolysis in relieving chronic neuropathic pain refractory to other nonsurgical treatments in patients with postsurgical thoracic pain.

METHODS

We retrospectively collected clinical data on patients referred to the Neurosurgery Unit of Policlinic Hospital of Milan. Ten patients (age range, 20-68 years) suffering from neuropathic pain for at least 2 months after thoracic surgery underwent intercostal neurolysis.

RESULTS

Compared with preneurolysis, pain intensity decreased 1 month postneurolysis and remained stable 2 months postneurolysis (median score [interquartile range]: 8 [6-9] preneurolysis, 4 [3-5] 1 month after, and 3 [2-5] 2 months after, P < 0.001). Antiepileptic drugs for pain control decreased after neurolysis.

DISCUSSION

Surgical intercostal neurolysis may be a promising therapeutic option in patients with chronic neuropathic pain associated with neurological deficits. Muscle Nerve 58: 671-675, 2018.

Pregabalin as an analgesic option for patients undergoing thoracotomy: cost analysis of pregabalin versus epidural analgesia for post-thoracotomy pain relief

Background

Our previous randomized controlled trial (RCT) to evaluate the effects of pregabalin on acute post-thoracotomy pain compared with epidural analgesia showed that pregabalin is a safe and effective treatment and that it may be an alternative to epidural analgesia for acute post-thoracotomy pain. In this analysis, to additionally analyze the economic aspects of pregabalin in patients undergoing thoracotomy, we compared the medical costs between pregabalin and epidural analgesia as an analgesic technique for post-thoracotomy pain.

Methods

Costs for patients undergoing thoracotomy and receiving either pregabalin or epidural analgesia for post-thoracotomy pain relief in the previous RCT were retrospectively collected from health insurance claims data. The following five cost categories were compared between the groups: (I) surgery costs; (II) costs for surgical materials and medications; (III) costs for anesthetic management; (IV) total hospitalization costs; and (V) costs for outpatient pain-relief medications (from hospital discharge to 6 months after thoracotomy).

Results

We analyzed data from 90 patients (45 patients for each group). Median costs for surgical materials and medications and those for anesthetic management were significantly lower in the pregabalin group than in the epidural analgesia group [(Japanese yen) ¥69,720 vs. ¥77,180, P=0.017; ¥161,000 vs. ¥195,500, P<0.001, respectively]. However, total hospitalization costs and costs for outpatient pain-relief medications were similar between the groups. Pregabalin was prescribed to more patients in the pregabalin group than those in the epidural analgesia group as outpatient treatment (75.0% vs. 37.5%), but median prescribed doses were much smaller in the pregabalin group.

Conclusions

Although the use of pregabalin did not result in lower total hospitalization costs, it may reduce fee-for-service surgery- and anesthesia-related costs. The economic benefits of pregabalin may reinforce its usefulness as an alternative to epidural analgesia, especially for patients who are unsuitable for epidural analgesia.

The Effect of Massage on Acute Postoperative Pain in Critically and Acutely Ill Adults Post-thoracic Surgery: Systematic Review and Meta-analysis of Randomized Controlled Trials

Critical care practice guidelines identify a lack of clear evidence on the effectiveness of massage for pain control. To assess the effect of massage on acute pain in critically and acutely ill adults post-thoracic surgery. Medline, Embase, CINAHL, PsychInfo, Web of Science, Scopus and Cochrane Library databases were searched. Eligible studies were randomized controlled trials (RCTs) evaluating the effect of massage compared to attention control/sham massage or standard care alone on acute pain intensity post-thoracic surgery. Twelve RCTs were included. Of these, nine evaluated massage in addition to standard analgesia, including 2 that compared massage to attention control/sham massage in the intensive care unit (ICU), 6 that compared massage to standard analgesia alone early post-ICU discharge, and 1 that compared massage to both attention control and standard care in the ICU. Patients receiving massage with analgesia reported less pain (0-10 scale) compared to attention control/sham massage (3 RCTs; N = 462; mean difference -0.80, 95% confidence interval [CI] -1.25 to -0.35; p < 0.001; I² = 13%) and standard care (7 RCTs; N = 1087; mean difference -0.85, 95% CI -1.28 to -0.42; p < 0.001; I² = 70%). Massage, in addition to pharmacological analgesia, reduces acute post-cardiac surgery pain intensity.

Postoperative Pain Management following Thoracic Outlet Decompression

BACKGROUND

Thoracic outlet decompression (TOD) is associated with significant postoperative pain often leading to hospital length of stay out of proportion to the risk profile of the operation. We seek to describe the improvement in hospital length of stay and patient pain control with an improved multiagent pain management regimen.

METHODS

We retrospectively reviewed the hospital length of stay, medication regimen/usage, operative details, and operative indications for all patients undergoing TOD from January 2012 through June 2015. During early experience, single-agent narcotic therapy was the mainstay of postoperatively pain control. Since 2014, we have adopted a regimen consisting of narcotic patient controlled analgesia, oral narcotics, and scheduled ibuprofen and valium, which is transitioned to oral narcotics/valium upon discharge. Operative approach (supraclavicular, infraclavicular, transaxial, or paraclavicular) was determined by patient anatomy and indication for procedure (neurogenic/arterial thoracic outlet syndrome or arteriovenous access dysfunction).

RESULTS

Seventy-four patients were treated with TOD over the study period: 36 (49.3%) for neurogenic thoracic outlet syndrome, 23 (31.5%) for venous thoracic outlet syndrome, and 15 (19.2%) for arteriovenous access dysfunction. Prior to 2014, the mean length of stay was 4 days with a median pain score of 6. Since 2014, the mean length of stay was 2.6 (P = 0.04) with a median pain score of 4 (P = 0.005). There was no statistically significant difference in the indication for operation or operative approach between the two periods.

CONCLUSIONS

Since adoption of a multiagent pain management regimen to include scheduled NSAIDs and benzodiazepines, we have reduced the mean pain score experienced by our patients as well as the hospital length of stay.

Comparison of early and late quality of life between left anterior thoracotomy and median sternotomy off-pump coronary artery bypass surgery

OBJECTIVE

Minimally invasive coronary artery bypass surgery performed through a left thoracotomy has potential benefits over conventional sternotomy, including reduced surgical trauma, faster recovery and potential improvement in quality of life. This study is a prospective assessment of quality of life in patients undergoing off-pump coronary bypass by median sternotomy and left anterior thoracotomy.

METHODS

Quality of life was assessed by the EuroQoL questionnaire, with additional questions on dyspnoea, angina, wound pain and scar aesthetics. Outcomes were compared across the data sets at pre-operation, three weeks and three months post-operation.

RESULTS

Sixty-six (17 minimally invasive and 49 off-pump) patients (mean age 65±12, 7 females and 59 males) were included. Significant differences in mean EuroQol outcomes were observed for activities, F(1,64) = 5.86, (p<0.05), pain scores, F(1,64) = 4.658 (p=0.035) and scar aesthetics, F(1,64) = 16.83 (p<0.05). There was an additional significant interaction, F(1.898, 121.49) = 3.282, (p<0.05), between time and group for activity levels; exploring this further indicated no significant difference at baseline, but significantly greater improvement observed in the minimally invasive group over time. At 3 weeks, 50% of minimally invasive patients compared to 82% of sternotomy patients (p<0.001) required oral analgesia. At 3 months, 8% of minimally invasive patients and 21% of sternotomy patients (p<0.001) required oral analgesia.

CONCLUSIONS

Off-pump coronary artery bypass performed with a minimally invasive approach through a left thoracotomy appears to result in earlier improvement in quality of life outcomes compared to conventional sternotomy. These results are important when counselling patients regarding the benefits and difference between a left anterior thoractomy MIDCABG and conventional OPCAB and can be used as pilot data for a larger trial examining differences in the MIDCABG and conventional full sternotomy OPCAB procedures.

Reprogramming of in situ spinal cord stimulator for covering newly developed postthoracotomy pain

The objective of this case report is to describe the use of in situ spinal cord stimulator (SCS) for postthoracotomy pain syndrome (PTPS). We report a 39-year-old woman with complex regional pain syndrome type I of the left lower extremity. The patient's pain was relieved by a SCS for 1 month before the patient developed slipping rib syndrome at her T12 rib from an unrelated trauma. After failed conservative treatments and undergoing a thoracotomy procedure, the patient developed PTPS. Conservative management with medications and intercostal nerve blocks provided short-term relief. An already implanted single Octrode with Eon Mini generator (St Jude Neuromodulator, Plano, TX) at the T7 level was reprogrammed in attempt to recruit peripheral fibers to target the patient's additional areas of chest discomfort. This adjustment improved the pain at the left lateral rib area as well as her left leg. The patient was followed for 1 year, and her quality of life improved since her initial presenting symptoms. The use of the SCS in this patient provided significant lasting pain relief for both complex regional pain syndrome and PTPS. We believe that the use of SCS should be considered as a treatment option for patients with PTPS to avoid side effects associated with medications and to provide long-term pain relief.

Introduction to neuropathic pain syndromes

Chronic pain impairs the quality of life for millions of individuals and therefore presents a serious ongoing challenge to clinicians and researchers. Debilitating chronic pain syndromes cost the US economy more than $600 billion per year. This article provides an overview of the epidemiology, clinical presentation, and treatment outcomes for craniofacial, spinal, and peripheral neurologic pain syndromes. Although the authors recognize that the diagnosis and treatment of the chronic forms of neuropathic pain syndromes represent a clinical challenge, there is an urgent need for standardized classification systems, improved epidemiologic data, and reliable treatment outcomes data.

Use of ketorolac is associated with decreased pneumonia following rib fractures

BACKGROUND

The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown.

METHODS

A retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac <4 days after injury compared with a random sample of those who did not.

RESULTS

Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia (odds ratio, .14; 95% confidence interval, .04 to .46) and increased ventilator-free days (difference, 1.8 days; 95% confidence interval, 1.1 to 2.5) and intensive care unit-free days (difference, 2.1 days; 95% confidence interval, 1.3 to 3.0) within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture nonunion were not different.

CONCLUSIONS

Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks.

Preoperative education and use of analgesic before onset of pain routinely for post-thoracotomy pain control can reduce pain effect and total amount of analgesics administered postoperatively

The purpose of this study was to investigate the efficiency of preoperative pain management education and the role of analgesics administration before the onset of pain postoperatively. The study was a prospective, randomized, and single-blind clinical trial, which was conducted January 1, 2008 through October 1, 2008 in the Thoracic Surgery Unit of Akdeniz University Hospital. A total of 70 patients who underwent thoracotomy (35 in the control group and 35 in the study group) were included in the study. Of the patients, 70% (n = 49) were male and 30% (n = 21) were female. Mean age was 51 ± 10 years (range = 25-65). The same analgesia method was used for all patients; the same surgical team performed each operation. Methods, including preemptive analgesia and placement of pleural or thoracic catheter for using analgesics, that were likely to affect pain level, were not used. The same analgesia medication was used for both patient groups. But the study group, additionally, was educated on how to deal with pain preoperatively and on the pharmacological methods to be used after surgery. An intramuscular diclofenac Na 75 mg was administered to the study group regardless of whether or not they reported pain in the first two postoperative hours. The control group did not receive preoperative education, and analgesics were not administered to them unless they reported pain in the postoperative period. The routine analgesics protocol was as follows: diclofenac Na 75 mg (once a day) intramuscular administered upon the complaint of pain following extubation in the postoperative period and 20 mg mepederin intravenously (maximum dose, 100 mg/day), in addition, when the patient expressed pain. Pain severity was assessed during the second, fourth, eighth, 16th, 24th, and 48th hours, and marked using the Verbal Category Scale and the Behavioral Pain Assessment Scale. Additionally, the total dose of daily analgesics was calculated. The demographic characteristics showed a homogeneous distribution in both patient groups. The rate of pain, which was defined as sharp, stabbing, and exhausting, was higher in the control group than in the study group, and the difference between the two groups was statistically significant (p < .05). As the doses of analgesics used for pain management in both groups were compared, it was determined that analgesic consumption was lower in the study group than in the control group, and the difference was statistically significant (p < .05). As a result, it was determined that preoperative thoracic pain management education and analgesics administered postoperatively, before the onset of pain, reduced the amount of analgesics used in the first postoperative 48 hours.

An innovative case report detailing the successful treatment of post-thoracotomy syndrome with peripheral nerve field stimulation

INTRODUCTION

The detrimental effects of post-thoracotomy pain syndrome is experienced worldwide; however, an effective treatment regimen remains elusive.

METHODS

We report a case of post-thoracotomy pain syndrome effectively treated with peripheral nerve field stimulation (PNfS).

RESULTS

In the presented case, the patient underwent permanent placement of the PSfS device after a successful trial period. Upon follow-up the patient has reported even better coverage over her painful areas and admits to 80% and higher reductions in her painful symptoms.

CONCLUSION

Although the data are limited, in the aforesaid case report, post-thoracotomy syndrome was effectively treated with the use of PNfS. This resulted in a significant pain perception reduction, increased quality of life and mobility, as well as decreased usage of oral pain medications. This adds to the accumulating case report and case series data that suggest PNfS is showing great promise as a pain reduction modality. Further, it is minimally invasive, can be trialled prior to implantation, and is reversible. Large prospective studies will be required in the future to further evaluate its efficacy before it can be widely accepted and adopted.

Effects of gabapentin on brain hyperactivity related to pain and sleep disturbance under a neuropathic pain-like state using fMRI and brain wave analysis

Neuropathic pain is the most difficult pain to manage in the pain clinic, and sleep problems are common among patients with chronic pain including neuropathic pain. In the present study, we tried to visualize the intensity of pain by assessing neuronal activity and investigated sleep disturbance under a neuropathic pain-like state in mice using functional magnetic resonance imaging (fMRI) and electroencephalogram (EEG)/electromyogram (EMG), respectively. Furthermore, we investigated the effect of gabapentin (GBP) on these phenomena. In a model of neuropathic pain, sciatic nerve ligation caused a marked decrease in the latency of paw withdrawal in response to a thermal stimulus only on the ipsilateral side. Under this condition, fMRI showed that sciatic nerve ligation produced a significant increase in the blood oxygenation level-dependent (BOLD) signal intensity in the pain matrix, which was significantly decreased 2 h after the i.p. injection of GBP. Based on the results of an EEG/EMG analysis, sciatic nerve-ligated animals showed a statistically significant increase in wakefulness and a decrease in non-rapid eye movement (NREM) sleep during the light phase, and the sleep disturbance was almost completely alleviated by a higher dose of GBP in nerve-ligated mice. These findings suggest that neuropathic pain associated with sleep disturbance can be objectively assessed by fMRI and EEG/EMG analysis in animal models. Furthermore, GBP may improve the quality of sleep as well as control pain in patients with neuropathic pain.

Randomized controlled trial of a special acupuncture technique for pain after thoracotomy

OBJECTIVE

We sought to determine whether an acupuncture technique specially developed for a surgical oncology population (intervention) reduces pain or analgesic use after thoracotomy compared with a sham acupuncture technique (control).

METHODS

One hundred sixty-two patients with cancer undergoing thoracotomy were randomized to group A (preoperative implantation of small intradermal needles that were retained for 4 weeks) or group B (preoperative placement of sham needles at the same schedule). The numeric rating scale of pain and total opioid use was evaluated during the in-patient stay, and the Brief Pain Inventory and Medication Quantification Scale were evaluated after discharge up to 3 months after the operation.

RESULTS

The principal analysis, a comparison of Brief Pain Inventory pain intensity scores at the 30-day follow-up, showed no significant difference between the intervention and control groups. Pain scores were marginally higher in the intervention group (0.05; 95% confidence interval, 0.74 to -0.64; P = .9). There were also no statistically significant differences between groups for secondary end points, including chronic pain assessments at 60 and 90 days, in-patient pain, and medication use in the hospital and after discharge.

CONCLUSION

A special acupuncture technique, as provided in this study, did not reduce pain or use of pain medication after thoracotomy more than a sham technique.

A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia

BACKGROUND

Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the "gold standard" in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research.

METHODS

In this systematic review of randomized trials we evaluated thoracic epidural, paravertebral, intrathecal, intercostal, and interpleural analgesic techniques, compared to each other and to systemic opioid analgesia, in adult thoracotomy. Postoperative pain, analgesic use, and complications were analyzed.

RESULTS

Continuous paravertebral block was as effective as thoracic epidural analgesia with local anesthetic (LA) but was associated with a reduced incidence of hypotension. Paravertebral block reduced the incidence of pulmonary complications compared with systemic analgesia, whereas thoracic epidural analgesia did not. Thoracic epidural analgesia was superior to intrathecal and intercostal techniques, although these were superior to systemic analgesia; interpleural analgesia was inadequate.

CONCLUSIONS

Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.

Postthoracotomy pain management problems

Pain after thoracotomy is very severe, probably the most severe pain experienced after surgery. Thoracic epidural analgesia has greatly improved the pain experience and its consequences and has been considered the standard for pain management after thoracotomy. This view has been challenged recently by the use of paravertebral nerve blocks. Nevertheless, severe ipsilateral shoulder pain and the prevention of the postthoracotomy pain syndrome remain the most important challenges for management of postthoracotomy pain.

Perspective on pain management in the 21st century

Pain is a predictable consequence of surgery or trauma. Untreated, it is associated with significant physiologic, emotional, mental, and economic consequences. Despite the vast amount of current knowledge, uncontrolled postoperative pain is reported by approximately 50% of patients. Thus, techniques for effective acute pain management (APM) represent unmet educational needs. The significance of this unmet need is reflected in the number of journal and textbook publications dedicated to disseminating research, evidence-based guidelines, and clinical information. Acknowledging the importance of APM, health care accrediting agencies and professional societies have become increasingly focused on ensuring that patients receive prompt and acceptable pain relief.