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Eur J Cardiothorac Surg 2000;18:711-716
© 2000 Elsevier Science NL

Review article

Surgical aspects of chronic post-thoracotomy pain

Mark L. Rogers, John P. Duffy

Department of Cardiothoracic Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK

Received 16 May 2000; received in revised form 14 August 2000; accepted 5 September 2000.

Corresponding author. Tel.: +44-115-969-1169; fax: +44-115-840-2605
e-mail: mrogers999{at}hotmail.com


   Abstract
Top
 Abstract
1. Introduction
 2. Epidemiology
 3. Aetiology
 4. Thoracic incisions
 5. Treatment
 6. Future directions
 7. Conclusion
 References
 
Chronic post-thoracotomy pain is a continuous dysaesthetic burning and aching in the general area of the incision that persists at least 2 months after thoracotomy. It occurs in approximately 50% of patients after thoracotomy and is usually mild or moderate. However, in 5% the pain is severe and disabling. No one technique of thoracotomy has been shown to reduce the incidence of chronic postthoracotomy pain. The most likely cause is intercostal nerve damage, although the precise mechanism for this is not known. Future work needs to examine surgical technique in detail. Until then, patients need to be adequately warned of this sequela of thoracotomy.

Key Words: Chronic postthoracotomy pain • Thoracotomy • Surgery • Pain • Neuralgia • Intercostal nerve


   1. Introduction
Top
 Abstract
 1. Introduction
2. Epidemiology
 3. Aetiology
 4. Thoracic incisions
 5. Treatment
 6. Future directions
 7. Conclusion
 References
 
Chronic post-thoracotomy pain (postthoracotomy pain syndrome or post-thoracotomy neuralgia) is defined by the International Association for the Study of Pain as ‘pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure’ [1]. Usually, it is burning, dysaesthetic and aching in nature displaying many features of neuropathic pain [2,3]. Unfortunately, ‘though common, post-thoracotomy neuralgia is rarely mentioned in the medical literature and is dismissed by many thoracic surgeons as a banal, very transient postoperative sequela’ [4].


   2. Epidemiology
Top
 Abstract
 1. Introduction
 2. Epidemiology
3. Aetiology
 4. Thoracic incisions
 5. Treatment
 6. Future directions
 7. Conclusion
 References
 
The first reference to chronic post-thoracotomy pain (CPP) was in 1944 by United States Army surgeons who noted ‘chronic intercostal pain’ in men who had had a thoracotomy for chest trauma during the Second World War [5]. They identified the serious problem of chronic pain and the subsequent difficulty of rehabilitation and return to duty. From neurological examinations, they concluded that intercostal nerve damage was responsible and that there was no satisfactory treatment of damaged intercostal nerves and thus chronic intercostal pain. They recommended careful handling of the nerves and avoidance of any operative technique which would result in unnecessary injury.

There was very little interest in CPP until 1991. Prior to this, it was generally assumed that transient chest discomfort lasted for several weeks or months after thoracotomy, and that if pain persisted or recurred, it was due to recurrent malignant disease [4,6]. Dajczman et al. [6] published the first data demonstrating the existence of chronic postthoracotomy pain as a discrete entity. Fifty-six patients were interviewed at a time between 2 months and 5 years postthoracotomy. All were disease-free. Fifty-four percent of these patients had pain.

Further studies have estimated the incidence of chronic postthoracotomy pain at 11–80% [3,6–11] (Table 1), which, surely, makes CPP the commonest complication of thoracotomy. The wide variation in incidence can be attributed to differences in the definitions used to describe pain, with some studies requiring stricter criteria such as regular analgesia consumption and others using wider criteria such as any discomfort. Unfortunately, the trials are often small and retrospective and the classification of pain persisting beyond 2 months is infrequently applied.


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  		Table 1. Incidence of chronic postthoracotomy pain

 
Despite a commonly held belief that CPP is transient, there is no objective evidence that the pain diminishes significantly with time. In the only study of CPP beyond 2 years, Dajczman et al. [6] found pain present in 50% of patients at one year postthoracotomy, in 73% at 2 years, in 54% at 3 years, in 50% at 4 years and in 30% of patients at 5 years postthoracotomy. The mean pain intensity (using a visual analogue score) did not differ throughout this time [6]. However, the total number of patients in this study is only 56 and larger prospective observational studies are required to determine the natural history of CPP.

The majority of patients do not seek help for their pain, only declaring it upon direct questioning [3]. However, almost 50% of patients find that their normal daily life is limited by CPP at 1 year after thoracotomy [11]. There are some patients who are incapacitated by CPP. Even the gentlest stimulation can provoke intense and disabling pain [2]. These patients require specialist intervention in chronic pain management clinics. Severe persistent pain affects 5% of patients postthoracotomy [2,7,11,12].

Several factors have been identified as associated with a higher incidence of CPP. Sabanathan reviewed 883 thoracotomies retrospectively to identify risk factors [9]. Patients with recurrent disease were excluded. There was a strong association with benign oesophageal disease, less so with malignant oesophageal disease or benign lung disease, and least with malignant lung disease. Postoperative radiotherapy and cryoprobe neurolysis of intercostal nerves increased the likelihood of chronic postthoracotomy pain, whereas rib resection and postoperative continuous extrapleural intercostal nerve block decreased it. Others have described a higher incidence in benign oesophageal disease [12], chest wall resections [8] and following cryoanalgesia [13]. In no study concerning the incidence of CPP has surgical technique been accurately described. Hence, it is difficult to identify particular aspects of the thoracotomy which may contribute to CPP.


   3. Aetiology
Top
 Abstract
 1. Introduction
 2. Epidemiology
 3. Aetiology
4. Thoracic incisions
 5. Treatment
 6. Future directions
 7. Conclusion
 References
 
Landreneau et al. [3,14] have described the following list of factors as contributing to CPP: posttraumatic intercostal neuroma, healing rib fracture, ‘frozen’ shoulder, local infection/pleurisy, costochondritis/costochondral dislocation, local tumour recurrence and psychological overlay. Others have stressed tumour recurrence [15], neuroma formation [2,9,16,17] and suprasensitization [2,9]. However, there has been little objective work into the exact mechanisms of surgical injury.

3.1. Intercostal nerve damage
The sensation of pain in response to a normally non-painful stimulus, especially when accompanied by numbness, is virtually pathognomonic for nerve injury [2]. This is a frequent feature of CPP. In a study of 42 patients, patients with complete disappearance of the superficial abdominal reflexes after thoracotomy experienced more severe acute and chronic postoperative pain than those in whom the reflexes were maintained [16]. Additionally, patients who do not show any recovery of abdominal reflexes 2–3 months after operation (i.e. who have an anatomical rather than functional deficit) are more likely to complain of pain [16]. Benedetti et al. [17] performing neurophysiological recordings on 24 patients 1 month after thoracotomy, showed that patients with a higher degree of intercostal nerve impairment had greater postthoracotomy pain.

3.2. Suprasensitization
The neurological mechanisms for the production of neuropathic pain, hyperalgesia and somatic pain are well described [2,18]. The concept of suprasensitization has led researchers to believe that controlling acute pain by an effective afferent blockade may reduce the development of CPP. High consumption of analgesics during the first postoperative week is associated with a higher incidence of CPP [11]. Katz et al. [10] concluded that aggressive management of early postoperative pain may reduce the likelihood of CPP after showing that early postoperative pain was the only predictor of long-term pain. Pre-emptive multimodal analgesia not only improves short-term recovery, but may theoretically prevent CPP by preventing suprasensitization of the central nervous system irrespective of the surgical injury [9,18]. Preoperative opiates and non-steroidal anti-inflammatory drugs (NSAIDs), preincisional regional block and postoperative continuous paravertebral block or epidural together with NSAIDs has been promoted as the ideal combination for near total analgesia following thoracotomy [17]. Certainly, Sabanathan believed his favourable CPP incidence of 23% at 2 months and 14% at 12 months was achieved by employing this regime [9,19].

3.3. Tumour recurrence
The importance of excluding recurrent disease in patients with CPP cannot be overstated [2,8]. Kanner et al. [15] in a prospective study of 126 patients (110 with malignant disease), identified 33 patients with pain at 5 months post-operation. Of these patients, one was benign, two had local infections and 30 had disease recurrence.


   4. Thoracic incisions
Top
 Abstract
 1. Introduction
 2. Epidemiology
 3. Aetiology
 4. Thoracic incisions
5. Treatment
 6. Future directions
 7. Conclusion
 References
 
Various thoracic incisions have been devised in order to decrease the incidence of postoperative pain and morbidity. There is little evidence that any technique is superior in reducing the development of chronic pain. As mentioned earlier, the general absence of detailed descriptions of surgical technique generate difficulties in identifying a cause of CPP.

The first intercostal thoracotomy was described by Tuffier in 1892 [20]. The posterolateral thoracotomy was the standard for many years until Browne described a thoracotomy via a limited incision in 1948 [21]. In simple terms, thoracotomy is best considered as comprising two parts: incision of the skin and muscles, and incision into the thorax at the level of the ribs. Serratus anterior and latissimus dorsi may be cut (muscle-cutting) or retracted (muscle-sparing). The options for entering the pleural space include (i) dividing the intercostal muscle from the superior rib edge with the electrocautery, (ii) reflecting the periosteum off the superior rib edge and entering through the periosteal bed without rib resection, (iii) subperiosteal rib resection, and (iv) an intercostal approach with short segment rib resection posteriorly [22]. Some have stated that there is no advantage in resecting a rib as exposure is determined by length of incision alone [23], whereas others have advised removing the posterior 1 cm of rib to relieve the tension on the posterior structures and prevent severe pain [24].

Intercostal incision may damage the intercostal nerves directly. Rib spreading will stretch anterior and posterior structures and may also compress the intercostal nerves. Closure and reapproximation of the ribs may be responsible for CPP. If a rib is resected, it is easy to see how the intercostal nerve may be damaged by a suture closing the intercostal muscles. Hardy described a case where scar exploration was undertaken as a last resort in a young man with CPP and found that several sutures closing the thoracotomy incision ran through the nerve bundles [25]. Pericostal sutures, whilst sparing the intercostal nerve adjacent to the incision, may damage the nerve in the intercostal groove of the rib below the incision. A technique of drilling small holes in the ribs to pass the sutures through and avoid the intercostal nerves has been developed [26], although it is not known whether this has made any difference to CPP.

Thoracoscopy was born in 1913 when Jacobaeus introduced a cystoscope into the pleural cavity to lyse adhesions and enhance pneumothorax therapy for tuberculosis [27]. The technique has rapidly developed in the last 10 years with the introduction of video systems and instruments that allow more complex surgery to be undertaken. Prevention of short- and long-term morbidity is frequently cited as an indication for thoracoscopic surgery.

4.1. Muscle-cutting versus muscle-sparing thoracotomy (Table 2)
Muscle-sparing thoracotomies have been devised to reduce soft tissue injury, acute postoperative pain and complications [28–30]. One large trial has shown there to be no difference in developing CPP [31]. Another study, whilst demonstrating that muscle-sparing thoracotomy was less painful at 1 week after thoracotomy, showed no difference in pain scores by 1 month [32]. However, 1 month is outside the definition of CPP and the patients were not followed through. Rib spreading and rib closure is the same in these two techniques, and surgical injury attained during these processes could account for the similar pain outcomes in the two groups [33].


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  		Table 2. Muscle-cutting versus muscle-sparing thoracotomy

 
4.2. Rib resection versus no rib resection
Opinion differs as to whether rib resection creates trauma itself or prevents trauma from rib spreading [3,31,32]. Rib removal at operation significantly decreased the likelihood of developing CPP pain in Sabanathan's retrospective analysis of 883 thoracotomies. The incidence of pain after 2 months was 16.8% in 274 patients who had rib resection compared with 24.8% in 609 patients whose ribs were retained [9,19]. However, the indications for rib resection and thus potential confounding variables are not discussed. Hansen studied 230 patients in 1973 who had undergone thoracotomy or thoracolaparotomy from the level of the eighth rib downwards. He noted that ‘persistent neuralgia’ was considerably higher in patients who had a rib resected (14.8%) that those who did not (3.1%) [34].

4.3. Preservation of intercostal nerves
The neuropathic nature of CPP has led clinicians to devise techniques to preserve the intercostal nerves. However, the mechanism of any intercostal nerve damage is not known. Specifically, is the nerve above or below the incision affected or both? The nerve above is more likely to be damaged during rib spreading [3,32] and the nerve below by closure [26]. However, many techniques are based on the belief that intercostal nerves run in the intercostal groove below the whole of the rib. This may be a false premise. Firstly, the costal groove ceases to exist 5–8 cm anterior to the angle of the rib and the nerve is thus exposed [35]. Secondly, Schalow et al. [36] having dissected the intercostal nerves in 20 human cadavers, found that ‘the intercostal nerve normally runs under the rib of the same number, but sometimes also on top of the rib below or sometimes as a split nerve which runs below its own rib and on top of the rib below before fusing again’. Perhaps, at this current time, preservation of the intercostal nerves cannot be guaranteed whichever technique is used.

At present, no technique of open thoracotomy can effectively prevent CPP and, therefore, patients should be warned of the possibility of developing it. However, since most evidence points to intercostal nerve injury as a major factor in the aetiology, then all efforts should be made by the surgeon to avoid damage to the intercostal nerves by careful intercostal incision, minimal rib spreading and meticulous closure. This, combined with effective multimodal analgesia in the perioperative period, is the best that we can offer to prevent CPP from open thoracotomy until advances are made in understanding the aetiology of CPP.

4.4. Video-assisted thoracoscopic surgery (VATS) versus open thoracotomy (Table 3)
A primary goal of minimally invasive surgery is the reduction in pain-related operative morbidity associated with classic open thoracic surgical techniques [14]. VATS is accepted as reducing acute postoperative pain and analgesic requirements compared to both muscle-sparing and standard thoracotomy [14,37]. However, comparative studies have shown there to be no difference in CPP occurrence between VATS and open thoracotomy [3,38,39]. In one large study, there was less pain in the VATS group up to 1 year post-operation, but the incidence of pain after 1 year was identical [3]. An incidence of CPP of 31.7% was present in 60 patients undergoing VATS pleurectomy for spontaneous pneumothorax [40].


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  		Table 3. Video-assisted thoracoscopic surgery (VATS) versus open thoracotomy

 
Both intercostal nerve injuries and rib bruising or fractures can occur from trocar insertion or excessive torquing of instruments during VATS, which may explain the similar incidences of CPP in the two groups [3,41]. Recognizing this, Richardson and Sabanathan measured the intercostal spaces in 40 patients undergoing thoracotomy and found that the 10.5-mm port diameter was too large for insertion without trauma. They devised a surgical instrument which cleanly excised an ellipse of the superior aspect of a rib prior to the introduction of the ports and placed all the instruments through one intercostal space in a group of nine patients. No patient had pain 2 months later [42].

Yim et al. [43–45] devised the following measures to minimize chest wall trauma during thoracoscopy: (i) flex the operating table to 30° between the level of the nipples and umbilicus to open up the intercostal spaces, (ii) avoid torquing the thoracoscope (use a 30° lens if necessary), (iii) do not use rigid ports but introduce the instruments (except staple cutters) directly through the wound, (iv) use 5-mm telescopes for simpler procedures, and (v) deliver specimens through the anterior port as the anterior intercostal spaces are wider. They found that by using these techniques, the incidence of long-term pain fell.


   5. Treatment
Top
 Abstract
 1. Introduction
 2. Epidemiology
 3. Aetiology
 4. Thoracic incisions
 5. Treatment
6. Future directions
 7. Conclusion
 References
 
As with most forms of neuropathic pain, treatment is difficult and unsatisfactory. Early referral to pain management specialists is recommended once disease recurrence has been excluded. In the first instance, treatment includes NSAIDs, tricyclic antidepressants, antiepileptics and opioids. If these methods are ineffective, then more invasive measures can be used such as nerve blocks, transcutaneous electrical nerve stimulation, sympathectomy and long-term neuromodulation with epidural analgesia or spinal cord stimulation. For a full review on the treatment of chronic postthoracotomy pain, see d'Amours et al. [2].


   6. Future directions
Top
 Abstract
 1. Introduction
 2. Epidemiology
 3. Aetiology
 4. Thoracic incisions
 5. Treatment
 6. Future directions
7. Conclusion
 References
 
Large prospective observational trials are needed to determine the natural history of chronic postthoracotomy pain and thus the extent of the problem. The neuropathic features and the objective evidence from studies of surgical technique strongly suggest that intercostal nerve damage is a major factor in the cause of CPP. However, until the precise mechanism of intercostal nerve injury can be determined, then strategies can only be directed towards treating established chronic postthoracotomy pain. Detailed studies of surgical technique need to be performed. This could then allow modification of operative techniques to reduce the incidence of chronic postthoracotomy pain.


   7. Conclusion
Top
 Abstract
 1. Introduction
 2. Epidemiology
 3. Aetiology
 4. Thoracic incisions
 5. Treatment
 6. Future directions
 7. Conclusion
References
 
Chronic post-thoracotomy pain is a serious and underrated condition. It is present in approximately 50% of all patients postthoracotomy and severe and disabling in 5%. There is no evidence that it diminishes significantly over time. Intercostal nerve damage at thoracotomy is most likely a major factor in the development of chronic postthoracotomy pain, although the exact mechanism is not known. Future work should be directed to examining and refining surgical technique. Until this happens, patients need to be consented for the real possibility of chronic postthoracotomy pain whichever incision is used.


   References
Top
 Abstract
 1. Introduction
 2. Epidemiology
 3. Aetiology
 4. Thoracic incisions
 5. Treatment
 6. Future directions
 7. Conclusion
 References
 

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