Post-thoracotomy pain syndrome: assessment and intervention

Incidence and risk factors of chronic post-thoracic surgery pain: A retrospective study

BACKGROUND

Chronic post-thoracic surgery pain (CPTSP) is a common complication that affects a patient's quality of life. Thoracotomy is associated with a high risk of chronic pain. Video-assisted thoracoscopy surgery (VATS) is a less traumatic option, but its role in the development of CPTSP is unclear. Regardless of the approach, there is evidence that demographic, psychosocial, or clinical factors also contribute to pain. The primary objective of this study is to determine the incidence of CPTSP in our hospital. The secondary objective is to identify possible risk factors related to CPTSP.

METHOD

Retrospective, single-centre observational study. The medical records of patients that underwent thoracic surgery between January 2016 and January 2020 were reviewed. The diagnosis of CPTSP was made by reviewing the postoperative visits 6 months after surgery. We analysed the relationship between CPTSP and a series of variables, and then constructed a multivariate binary logistic regression model with a significance level of p < 0.05.

RESULTS

A total of 259 patients were analysed, 46.7% underwent VATS and 53.3% underwent thoracotomy. The overall incidence of CPTSP was 12%; 4.1% in VATS and 18.8% in thoracotomies. The multivariate model revealed that moderate-to-severe acute postoperative pain and a greater number of chest tubes were risk factors for CPTSP.

CONCLUSION

The incidence of CPTSP was 12% in our hospital. Patients with higher acute postoperative pain severity and several chest tubes were more likely to develop CPTSP.

Adding Dexmedetomidine to Methylene Blue in Thoracic Paravertebral Block for Video-Assisted Lobectomy: A Case Series Study

PURPOSE

Thoracic surgery often results in severe chronic postoperative pain. Current evidence favors two locoregional techniques. Thoracic Epidural Anesthesia (TEA), the gold standard, and Thoracic Paravertebral Block (TPVB), which is associated with fewer side effects but is limited by short duration of action of local anesthetics (LA) and potential failure due to improper drug distribution. This study investigates the use of dexmedetomidine (DEX) as adjuvant to prolong the effects of LA in TPVB, with methylene blue used for visual confirmation of accurate injectate spread.

PATIENTS AND METHODS

We observed 6 patients undergoing Video-Assisted Thoracoscopy (VATS) lobectomy who received TPVB with ropivacaine, DEX and methylene blue. The primary endpoint was postoperative pain recorded at 1, 12, 24, 48 hours using Numeric Rating Scale (NRS); the secondary endpoints were cumulative opioid consumption in the first 24 hours in Milligram Morphine Equivalents (MME); adverse events: occurrence of bradycardia, hypotension, Postoperative Nausea and Vomiting (PONV); length of hospital stay. All patients completed the study.

RESULTS

Our results showed optimal pain scores, with NRS scores always below 4, decreased need for opioids, and prolonged analgesia. None of the patients had bradycardia nor PONV, but two patients experienced acute and self-limited hypotension following TPVB.

CONCLUSION

Thoracic Paravertebral Block with Dexmedetomidine and methylene blue was effective and safe in controlling postoperative pain. Methylene blue could help improving knowledge on anesthetics distribution to reduce failure rates.

Validation of the tablet-based Turkish-PAINReportIt® for lung cancer patients after thoracotomy in Turkey

BACKGROUND

Digital pain assessment is advantageous and timely for healthcare priorities in Turkey. However, a multi-dimensional, tablet-based pain assessment tool is not available in the Turkish language.

PURPOSE

To validate the Turkish-PAINReportIt® as a multi-dimensional measure of post-thoracotomy pain.

METHODS

In the first of a two-phased study, 32 Turkish patients (mean age 47.8 ± 15.6 years, 72 % male) participated in individual cognitive interviews as they completed the tablet-based Turkish-PAINReportIt® once during the first four days post-thoracotomy, and 8 clinicians participated in a focus group discussion of implementation barriers. In the second phase, 80 Turkish patients (mean age 59.0 ± 12.7 years, 80 % male) completed the Turkish-PAINReportIt® preoperatively, on postoperative days 1-4, and at the two-week post-operative follow-up visit.

RESULTS

Patients generally interpreted accurately the Turkish-PAINReportIt® instructions and items. We eliminated some items unnecessary for daily assessment based on focus-group suggestions. In the second study phase, pain scores (intensity, quality, pattern) were low pre-thoracotomy for lung cancer and high postoperatively high on day 1, decreasing on days 2, 3 and 4, and back down to pre-surgical levels at 2-weeks. Over time, pain intensity decreased from post-operative day 1 to post-operative day 4 (p < .001) and from post-operative day 1 to post-operative week 2 (p < .001).

CONCLUSIONS

The formative research supported proof of concept and informed the longitudinal study. Findings showed strong validity of the Turkish-PAINReportIt® to detect reduced pain over time as healing occurs after thoracotomy.

Trajectories of Pain in Patients Undergoing Lung Cancer Surgery: A Longitudinal Prospective Study

CONTEXT

Lung cancer surgery is among the surgical procedures associated with the highest prevalence of pain, but prospective longitudinal studies after the pain trajectory are scarce.

OBJECTIVES

We aimed to describe the pain trajectory in patients undergoing surgery for primary lung cancer and investigate whether distinct groups of patients could be identified based on different pain trajectories.

METHODS

Patients (n = 264; 95% thoracotomies) provided data on the average and worst pain intensity, pain location, and comorbidities before, and at one month and five, nine, and 12 months after surgery. Pain profiles were analyzed by latent class mixed models.

RESULTS

The occurrence of any pain increased from 40% before surgery to 69% after one month and decreased to 56%, 57%, and 55% at five, nine, and 12 months, respectively. Latent class mixed models identified two classes both for average and worst pain; one class started low with high ratings after one month, then returning to a level slightly higher than baseline. The other class started higher with similar scores through the trajectory. Patients reporting no pain (8%) were placed in a separate class. Higher comorbidity score, preoperative use of both pain and psychotropic medicine characterized the class with overall highest pain for average and/or worst pain.

CONCLUSION

Pain was highly prevalent after surgery, and subgroups could be identified based on different pain trajectories. Patients reported both postoperative pain and pain from chronic conditions. Knowledge about vulnerable patients and risk factors for pain is important to tailor interventions and information about pain.

Factors Associated With Opioid Use in Long-term Cancer Survivors

PURPOSE

To evaluate factors associated with opioid use in patients with cancer surviving more than five years without recurrence. We evaluated exposures of opioid use before cancer diagnosis, opioid use between cancer diagnosis and five-year anniversary, surgeries, and chemotherapy.

METHODS

We conducted a retrospective cohort study using linked provincial administrative data. Patients were aged 24-70 years and eligible for government-funded pharmacare. The index date was the five-year anniversary from diagnosis. Patients were accrued between 2010 and 2015. The main outcome was opioid prescription rate after index date. The main exposures were opioid use before diagnosis, opioid use between diagnosis and index, surgeries, and chemotherapy. A negative binomial regression model was used to estimate relative rates (RR) of opioid use after index date.

RESULTS

Our cohort included 7431 individuals. The overall crude prescription rate after the index date was 2 per person-year. The factor most strongly associated with a higher rate of opioid use after index was continuous opioid use between diagnosis and index (RR 46.1, 95% confidence interval 34.8-61.2). Opioid use before diagnosis was also a factor (RR = 1.8, 95% confidence interval 1.44-2.19). A history of depression, comorbidity, and more than two years of diabetes were also associated with higher risk of post-index date opioid use. Significant interactions were identified between prior opioid use and opioid use between diagnosis and index. Most prescriptions are from family physicians.

CONCLUSION

Patients who use opioids continuously between diagnosis and index date are at increased risk of continued use after five years of survival. Safe and appropriate pain management is an important survivorship issue.

Ropivacaine for Intercostal Nerve Block Improves Early Postoperative Cognitive Dysfunction in Patients Following Thoracotomy for Esophageal Cancer

BACKGROUND Ropivacaine is commonly used as an intercostal nerve block, but its effects on postoperative cognitive dysfunction (POCD) have not previously been investigated. This study aimed to examine the effects of the use of ropivacaine as an intercostal nerve block on early POCD, postoperative analgesia, and inflammation in patients following thoracotomy for esophageal cancer. MATERIAL AND METHODS One hundred patients with esophageal cancer undergoing thoracotomy were randomly divided into a group with intercostal nerve block (group A) (n=50) and a control group (group B) (n=50). The cognitive function score and visual analog scale (VAS) scores for pain were measured at one hour before surgery (T1), two hours after surgery (T2), 12 hours after surgery (T3), and 24 hours after surgery (T4). Blood samples were collected at each time point, and plasma levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), IL-10, and S100-β were measured using an enzyme-linked immunosorbent assay (ELISA). Cognitive function was determined using the Mini-Mental State Examination (MMSE) scale. RESULTS The VAS scores in group A were significantly lower compared with group B (p<0.05). In the T2, T3, and T4 time points, group A had significantly increased MMSE scores compared with group B (p<0.05). Compared with group B, the levels of IL-6 and TNF-a were significantly decreased in group A at T3 and T4 (p<0.05), while the levels of IL-10 were significantly increased (p<0.05) when compared with group A. CONCLUSIONS The use of the intercostal nerve block, ropivacaine, improved early PCOD in patients following thoracotomy for esophageal cancer.

Physiotherapy management of patients undergoing thoracotomy procedure: A survey of current practice in Gauteng

BACKGROUND

Physiotherapy is included in the management of patients undergoing thoracic surgery. The aim of this study was to describe physiotherapy practice in the management of patients who undergo an open thoracotomy.

METHODS

A cross-sectional study using convenience sampling was undertaken. An electronic self-administered questionnaire was distributed via SurveyMonkey to 1389 physiotherapists registered with the South African Society of Physiotherapy in Gauteng. The data collection period was August and September 2014 and data were analysed descriptively.

RESULTS

A total of 323 physiotherapists (23.3%) responded to the survey and 141 (10.2%) indicated that they treated patients with open thoracotomies. Preoperative treatment was done by 65 (41.6%) and consisted of teaching supported coughing (92.3%; n = 60), sustained maximal inspiration (70.8%; n = 46) and the active cycle of breathing technique (69.2%; n = 45). One hundred and sixteen (82.3%) respondents treated patients during their hospital stay. Deep breathing exercises (97.6%; n = 83), coughing (95.3%; n = 81), early mobilisation (95.3%; n = 81), upper limb mobility exercises (91.8%; n = 78), chest wall vibrations (88.2%; n = 75) and trunk mobility exercises (85.9%; n = 73) were done frequently. Pain management modalities were less common, for example transcutaneous electrical nerve stimulation (12.9%; n = 11). Post hospital physiotherapy management was uncommon (32.6%; n = 46).

CONCLUSION

Physiotherapy related to early mobilisation in hospital is in line with evidence-based practice, but further education is needed regarding the need for physiotherapy post hospital discharge and pain management.

The Effect of Pre-Emptive Dexmedetomidine on the Incidence of Post-Thoracotomy Pain Syndrome in Patients Undergoing Coronary Artery Bypass Grafting

Background

Post-thoracotomy pain syndrome (PTPS) is pain that recurs or persists along a thoracotomy incision for at least two months following surgery. Dexmedetomidine (dex) is an α-2 agonist that also has analgesic, sedative-hypnotic, and sympatholytic properties.

Objectives

To determine the effect of pre-emptive dexmedetomidine on the incidence of PTPS in patients undergoing coronary artery bypass grafting (CABG).

Patients and Methods

This randomized clinical trial enrolled 104 candidates for elective coronary artery bypass grafting (CABG) and randomly assigned them to either a dex group or a control group. In the dex group, dexmedetomidine 0.5 µg/kg/hour was infused from the initiation of anesthesia until postoperative extubation in the intensive-care unit. Two months after surgery, the patients were contacted by telephone and interviewed to determine the presence of pain at the thoracotomy scars.

Results

Fifty-four patients were placed in the control group, and 50 patients were assigned to the dex group. The age, sex, and body mass index were not significantly different between the two groups of study (P > 0.05). The incidence of PTPS was 11/50 (22%) patients in the dex group and 28/54 patients (52%) in the control group. A chi-square test revealed a significant difference in the incidence of PTPS after two months between the dex and control groups (P = 0.032).

Conclusions

PTPS is a common problem following CABG, and pre-emptive therapy with dex may decrease neuropathic pain.

Incobotulinum Toxin-A Improves Post-Surgical and Post-Radiation Pain in Cancer Patients

Cancer patients who undergo surgery or radiation can develop persistent focal pain at the site of radiation or surgery. Twelve patients who had surgery or radiation for local cancer and failed at least two analgesic medications for pain control were prospectively enrolled in a research protocol. Patients were injected up to 100 units of incobotulinum toxin A (IncoA) intramuscularly or subcutaneously depending on the type and location of pain (muscle cramp or neuropathic pain). Two patients passed away, one dropped out due to a skin reaction and another patient could not return for the follow up due to his poor general condition. All remaining 8 subjects (Age 31-70, 4 female) demonstrated significant improvement of Visual Analog Scale (VAS) (3 to 9 degrees, average 3.9 degrees) and reported significant satisfaction in Patients' Global Impression of Change scale (PGIC) (7 out of 8 reported the pain as much improved). Three of the 8 patients reported significant improvement of quality of life.

Postthoracotomy Pain Syndrome Following Surgery for Lung Cancer: Symptoms and Impact on Quality of Life

Postthoracotomy pain syndrome (PTPS) is a common complication following thoracic surgery. Most studies examining the influence of PTPS on patient-reported symptoms include few patients managed using a minimally invasive approach. Associated sensory changes, potentially neuropathic in origin, are not well described. We therefore examined the symptoms and quality of life (QOL) of patients with and without PTPS who underwent a standard thoracotomy (n = 43) or minimally invasive surgery (n = 54). Patients in this prospective, cross-sectional study completed questionnaires to assess pain (McGill Pain Questionnaire), neuropathic symptoms (Neuropathic Symptom Questionnaire), symptom distress (Symptom Distress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and QOL (Functional Assessment Cancer Therapy–Lung). Excepting younger age (p = .009), no demographic or surgical characteristic differentiated patients with and without PTPS. Patients with PTPS described discomfort as pain only (15.1%), neuropathic symptoms only (30.2%) or pain and neuropathic symptoms (54.7%). Scores differed between patients with and without PTPS for symptom distress (p < .001), anxiety and depression (p < .001), and QOL (p = .009), with higher distress associated with PTPS. Despite new surgical techniques, PTPS remains common and results in considerable distress. A focused assessment is needed to identify all experiencing this condition, with referral to pain management specialists if symptoms persist.

The Qualitative Hyperalgesia Profile: A New Metric to Assess Chronic Post-Thoracotomy Pain

Thoracotomy often results in chronic pain, characterized by resting pain and elevated mechano-sensitivity. This paper defines complex behavioral responses to tactile stimulation in rats after thoracotomy, shown to be reversibly relieved by systemic morphine, in order to develop a novel qualitative "pain" score. A deep incision and 1 hour of rib retraction in male Sprague-Dawley rats resulted in reduced threshold and a change in the locus of greatest tactile (von Frey filament) sensitivity, from the lower back to a more rostral location around the wound site, and extending bilaterally. The fraction of rats showing nocifensive responses to mild stimulation (10 gm) increased after thoracotomy (from a pre-operative value of 0/10 to 8/10 at 10 days post-op), and the average threshold decreased correspondingly, from 15 gm to ∼4 gm. The nature of the nocifensive responses to tactile stimulation, composed pre-operatively only of no response (Grade 0) or brief contractions of the local subcutaneous muscles (Grade I), changed markedly after thoracotomy, with the appearance of new behaviors including a brisk lateral "escape" movement and/or a 180° rotation of the trunk (both included as Grade II), and whole body shuddering, and scratching and squealing (Grade III). Systemic morphine (2.5 mg/kg, i.p.) transiently raised the threshold for response and reduced the frequency of Grade II and III responses, supporting the interpretation that these represent pain. The findings support the development of a Qualitative Hyperalgesic Profile to assess the complex behavior that indicates a central integration of hyperalgesia.