Chuck Connors: A 72-Year-Old Male With Persistent Pain Following a Thoracotomy for Lung Cancer

Learning Objectives

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Learn the common causes of pain following thoracic surgery.
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Develop an understanding of the anatomy and innervation of the chest wall and thorax.
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Develop an understanding of the unique relationship of the intercostal nerve to the rib.
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Develop an understanding of the causes of postthoracotomy pain.
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Develop an understanding of the differential diagnosis of postthoracotomy pain.
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Learn the clinical presentation of postthoracotomy pain.
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Learn how to use physical examination to postthoracotomy pain.
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Develop an understanding of the treatment options for postthoracotomy pain.

Chuck Connors

My first thought when I entered the exam room was that something was on fire. It took me a couple of beats to realize that it was Chuck, who smelled like a pile of smoldering newspapers. So much for my stop smoking lecture. Chuck Connors is a 72-year-old retired shop teacher with the chief complaint of, “Ever since I had my lung cancer surgery, my incision has been killing me.” Chuck stated that he wished he had never had it, as the pain since the surgery had just about done him in. “Doctor, I am convinced that surgeon cut something she shouldn’t have. She said they got it all, but if I had known that I was going to have to sleep in a chair, I would have said no to going under the knife! I must be the biggest idiot in the world. I’m an old man! I should have known better.” I tried to convince Chuck that he had done the right thing, but I could tell that he wasn’t going to change his mind in this regard when I saw the truculent look on his face. “Still smoking?” I asked. “Doctor, it’s all I have left. Please don’t start in again. Get rid of the pain, and then you can yell at me. Until then, please change the subject to how you are going to relieve this pain.”

Chuck said that he didn’t remember much about the surgery, but he clearly remembers waking up with a sharp pain in his side that was like a shock running from his surgical wound into the front of his chest. He said his chest incision still hurt a bit, but it was this electric shocklike pain that was the issue at hand. “Doctor, It’s 24/7! I can’t sleep in bed because every time I move I get the shock, and it wakes me up. Ever try sleeping in a chair every night? Take it from me, it is not much fun.” Chuck said when he went for his postoperative check and talked the surgeon, she seemed disinterested and told him not to worry, that it was just a little nerve irritation from the surgery and it would get better with time, but it never did. Chuck shook his head slowly and said, “I was never so angry at a doctor. She just blew me off. You know the deal, the surgery was great, so it must be the patient’s fault. She never sat down to listen to me. She was walking out the door as she blew me off. Well, I got even. Take a look at her Yelp reviews. No more five stars for her, for all the good it will do me. I tried to ask if she thought the cancer was back, but she was already out the door.”

I asked Chuck if he had experienced any numbness or weakness in the area of the pain, and he replied, “Doc, it’s funny that you asked because the area in front of the scar is really sensitive and feels like it’s dead, just not a part of me. There is an area at about the middle of the scar that is a no-man’s land. If I touch it, I cause that shock to shoot out.” I asked Chuck what he had tried to make it better. He said that the pain pills they gave him after his cancer surgery just made him sick to his stomach, so he quit taking them. He said that a heating pad and a highball or two or three helped him sleep for a bit.

He also volunteered that he had quit sleeping with his pajama top on because the skin over the painful area was so sensitive, kind of like a burn or something.

I asked Chuck to show me where the pain was located, and he pointed to his left anterior chest in front of his thoracotomy scar. I asked Chuck about any fever, chills, or other constitutional symptoms such as weight loss or night sweats, and he shook his head no. He replied, “In spite of everything, I am breathing pretty well, and my appetite is good. I was never a picky eater. Give me a can of chili or chicken noodle soup and I am good to go.”

On physical examination, Chuck was afebrile. His respirations were 18, his pulse was 74 and regular, and his blood pressure was 122/78. His oxygen saturation on room air was 94. Chuck’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his thyroid exam. (Honestly, he smelled so strongly of tobacco smoke that it was hard to examine him. It’s hard to believe that there was a time when almost everybody smoked.) Auscultation of his carotids revealed no bruits, and the pulses in all four extremities were normal. He had a regular rhythm without abnormal beats. His cardiac exam was otherwise unremarkable. There was a well-healed left thoracotomy scar without obvious defect or evidence of infection ( Fig. 11.1 ). The minute I tried to palpate the scar, Chuck pulled back and said, “Easy, Doc. It’s still kind of sore.” I promised to be gentle, and about midway along the scar as I worked from posterior to anterior, I found a trigger area, and Chuck cried out in pain. “I told you to be careful, Doc! That’s the spot that sends the electric shock out just to remind me I’m alive. It really hurts.” The area just in front of the anterior extent of the incision was allodynic, and there was decreased sensation as I followed the dermatome anteriorly. His abdominal examination revealed no abnormal mass or organomegaly. There was no peripheral edema. His low back examination was unremarkable. There was no costovertebral angle (CVA) tenderness. Visual inspection of the right chest wall was unremarkable. A careful neurologic examination was unremarkable. His prostate was slightly enlarged, but I couldn’t feel any nodules. The remainder of his rectal examination was normal.

Key Clinical Points—What’s Important and What’s Not

The History

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History of onset of right-sided chest wall pain immediately following a thoracotomy for lung cancer
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Associated numbness
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Difficulty sleeping
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Pain with electric shocklike quality in front of incision that feels like a burn
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No fever or chills

The Physical Examination

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Patient is afebrile
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Thoracotomy scar is well healed without evidence of defect or infection (see Fig. 11.1 )
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Trigger area about midscar elicits electric shocklike pain
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Area of allodynia in front of the thoracotomy scar
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Area of numbness just below the front of the scar

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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No carotid bruits

What Tests Would You Like to Order?

The following tests were ordered:

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Chest x-ray
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Computed tomography (CT) scan of the thorax
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Electromyography (EMG) and nerve conduction velocity testing of the affected thoracic nerve

Test Results

The chest x-ray revealed evidence of a left thoracotomy and a smoothly marginated opacity at the lateral margin of the chest wall that is worrisome for malignancy ( Fig. 11.2A ).