PERSISTENT PAIN FOLLOWING THORACIC SURGERY

One of the most severe typesof postoperative pain is following a thoracotomy. Presence of inadequateanalgesia usually results in inability to breathe deeply and cough forcefully,both of which hamper postoperative pulmonary rehabilitation with subsequentretention of secretions, atelectasis and pneumonia1. Analgesictechniques such as Intercostal, paravertebral, interpleural and thoracicepidurals with local anesthetic and opioids have been employed for pain relief.2 Thoracic epidural analgesia (TEA) is by far the bestoption of relieving pain following a thoracotomy, especially with lowconcentration of local anesthetic and a lipophilic opioid.3Neuropathic pain following thoracotomy, known as post thoracotomy pain iscommon , sometimes severe enough to incapacitate and often becomes chronic.4,5Post-thoracotomypain syndrome or PTPS (chronic post-thoracotomy pain or post-thoracotomyneuralgia) is defined by the International Association for the Study of Pain(IASP) as ‘pain that recurs or persists along a thoracotomy incision at leasttwo months following the surgical procedure’. In general, it is burning andstabbing pain with dysesthesia and thus shares many features of neuropathicpain6. Over the years there has been agradual shift towards minimally invasive or thoracoscopic or VATS (videoassisted thoracoscopic surgery) approach. This approach has shown early andbetter recovery with early discharge from the hospital.7 Despitebeing less invasive, VATS procedures have not had a favourable impact on painas was anticipated.8 They too present with similar pain andsometimes even after discharge, and have been reported to be of neuropathicnature.9,10 The incidence of Chronic Post surgical pain11,12following VATS approach has been reported in the range of 20-47%.

Grosen et al13,reported sensory changes in the painful area in 62% patients with postthoracotomy pain syndrome.  Simultaneous occurrence of pain and sensorydisturbances caused by nerve injury is one of the mechanisms believed to causePTPS.14 However, it has been noticed that, sensory disturbances arenot always associated with pain15.

At Tata Memorial Hospital, over the last 10 years there hasbeen as steady shift towards minimally invasive VATS approach for thoracicsurgeries. A thoracic epidural catheterization, which is an important aspectfor providing analgesia for thoracotomy, is seldom employed in those undergoingVATS approach. The trend is to use IV opioids intraoperatively along withNSAIDS (if not contraindicated) & Paracetamol along with IV PCA (Patientcontrolled analgesia) postoperatively.

The purpose of the study is to determine the incidence,nature and severity of persistent pain if any at 3 and 6 months following thoracicsurgery with intercostal incisions

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