Post Thoracotomy Pain – Intercostal

Home/Pain Conditions/Post Thoracotomy Pain – Intercostal
Post Thoracotomy Pain – Intercostal 2016-11-17T09:52:54+00:00

What Is Post-Thoracotomy/Intercostal Pain?

A thoracotomy is a surgical procedure that involves opening up the chest cavity. It is regarded as one of the most painful incisions conducted, as the operating physician must penetrate several layers of muscle tissue, neurovascular bundles, and other soft tissue structures of the thoracic region, all while the patient is under constant motion as they continue to breathe. The most common location for thoracotomy incisions is at the side of the patient’s chest. Other incision sites can be used to provide the operating physician with access to the lungs, throat, diaphragm muscle, aorta, or heart as needed. The precise location for the thoracotomy incision will depend on the condition that is being treated.

LungsThe pain that occurs following a thoracotomy procedure, which is also known as post-thoracotomy pain, is quite commonly very severe. The International Association for the Study of Pain (IASP) defines post-thoracotomy pain as symptoms of pain occurring within the area of the thoracotomy incision and persisting for at least two months or more following the surgical procedure. During the Second World War, surgeons regularly described post-thoracotomy pain, which at the time was referred to as intercostal pain, in patients who had undergone a thoracotomy for the treatment of chest trauma. Post-thoracotomy pain that begins to interfere with daily function has been reported to occur following nearly half of all thoracotomy procedures.

The clinical presentation of post-thoracotomy pain nearly mirrors that of neuropathic pain, though a number of patients will also report experiencing symptoms of non-neuropathic pain as well.

The most common symptoms reported by patients suffering from post-thoracotomy pain include:

  • Sharp, stabbing pain along the area of the incision scar
  • Constant shooting pain
  • Pinching sensations
  • Constant dull, achy, and even vague feelings of pain and discomfort
  • Cramping
  • Either heightened or blunted sensory sensitivity (e.g., unable to tolerate anything coming into contact with the site of the scar)
  • Localized tenderness
  • Tingling, prickly, or even cool sensations
  • Itching
  • Shoulder dysfunction, which may lead to frozen shoulder

Following a thoracotomy procedure, patients may also report symptoms of fatigue, shortness of breath, bleeding or infection at the site of the incision, dyspnea, and even depression.

Managing symptoms of pain and effectively maintaining the patient’s comfort after surgery and during recovery is incredibly important, as this will decrease the risk for pulmonary complications. Moreover, patients who are not able to effectively manage their symptoms of post-thoracotomy pain are at risk for impairment in respiratory function. Patients suffering from severe pain within the thoracic region after thoracotomy surgery often have difficulty with inspiration, or taking air into the lungs. This may also lead to dysfunction of the diaphragm muscle.

Causes Of Post-Thoracotomy/Intercostal Pain

Post Thoracotomy Pain - Nerve BlockThe underlying mechanisms that account for a patient’s symptoms of post-thoracotomy pain are not fully understood. The most widely accepted source for symptoms is damage occurring to the intercostal nerve, which is not uncommon during the thoracotomy procedure. In fact, pericostal sutures, which are often used to suture the 5th and 7th ribs during the thoracotomy procedure, themselves are likely to cause damage and injury to the intercostal nerve fibers. In order to reduce the risk of injury to the intercostal nerve, physicians have begun to employ alternative techniques, such as using intracostal sutures. These alternative techniques have shown some promise in terms of preventing severe post-thoracotomy pain.

Of course, damage to the intercostal neural tissue does not completely account for the full symptom presentation of post-thoracotomy pain. Another explanation for a patient’s symptoms of pain and discomfort following thoracotomy surgery is tissue inflammation. The structures that are most commonly affected by this inflammation include the ribs, muscles of the chest wall, surrounding neural tissue, and pulmonary lining of the lungs. Further, it is not uncommon for patients to suffer from muscle wasting, or atrophy, of the chest muscles following thoracotomy surgery, as the result of rib spreading. The development of scar tissue is also believed to attribute to a patient’s symptoms of post-thoracotomy pain.

Treatments For Post-Thoracotomy/Intercostal Pain

Given the severity of symptoms typically associated with post-thoracotomy pain, it is not uncommon for patients with severe pain to be prescribed with opioids prior to trying other, more conservative, forms of treatment. Even so, previous studies have indicated that treatment with opioids alone may only provide partial relief from the pain. For cases of moderate to more mild symptoms of post-thoracotomy pain, traditional non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, or naproxen, may be sufficient in providing the patient with relief from pain.

For instances of persistent post-thoracotomy pain that have been unresponsive to oral analgesics, injection-based approaches may be warranted as these techniques allow for a more targeted delivery of the analgesic medication. During this procedure, an analgesic medication is injected into the epidural space or neural tissue in the affected area. These techniques are known as epidural injections and nerve blocks. For both methods, the goal is to interrupt the transmission of pain information from the peripheral nerves to the spinal cord and brain, thereby providing the patient with relief from pain.

In some cases, a single injection of analgesic medication is not sufficient to provide long-term relief from post-thoracotomy pain. Implants, which provide a continuous flow of medication directly to the targeted area, may be warranted for instances of chronic and refractory pain.

Conclusion

Thoracotomy surgery, or chest surgery, is regarded as one of the most painful surgeries. Patients who undergo this procedure are at a very high risk for developing severe symptoms of pain that are neuropathic in nature. Pain management is incredibly important for thoracotomy patients during the post-operative stage as these symptoms can lead to additional impairments in functioning and complications. For the most part, irritation, compression, and damage occurring to the intercostal nerves within the region of the incision is believed to account for much of the pain that persists following surgery. Other likely causes for pain include inflammation, muscle atrophy, and the development of scar tissue.

Given the severity of the symptoms, it is not uncommon for post-thoracotomy patients to be prescribed opioid medications as a first-line treatment method. Instances of moderate to mild post-thoracotomy pain, however, may be able to gain relief with the use of more traditional oral analgesics, such as non-steroidal anti-inflammatory drugs. For cases of persistent and refractory pain, epidural injections or nerve blocks may be warranted, as these techniques provide a more targeted approach to the delivery of medication. Patients are encouraged to speak with their physician prior to undergoing a thoracotomy procedure so that they are best prepared to manage any difficult symptoms that arise in post-operation.

References

  1. Hazelrigg SR, Cetindag IB, Fullerton J. Acute and chronic pain syndromes after thoracic surgery. Surg Clin N Am 2002;82:849–865.
  2. Gerner P. Post-thoracotomy pain management problems. Anesthesiol Clin 2008;26:355–vii.
  3. Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgery: A follow-up study. Acta Anaesthesiol Scand 1999;43:563-567.
  4. Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term post-thoracotomy pain. Chest 1991;99:270-274.
  5. Hopkins KG, Rosenzweig M. Post-thoracotomy pain syndrome: Assessment and intervention. Clin J Oncol Nurs 2012;16:365-370.
  6. Keller SM, Carp NZ, Levy MN, Rosen SM. Chronic post thoracotomy pain. J Cardiovasc Surg 1994;35:161-164.
  7. Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: A critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothoracic Surg 2009;36:170-180.

Pin It on Pinterest

Schedule Your Appointment