Postthoracotomy Pain Syndrome

Abstract

Essentially all patients who undergo thoracotomy suffer from acute postoperative pain. This acute pain syndrome invariably responds to the rational use of systemic and spinal opioids, as well as intercostal nerve block. Unfortunately, in a few patients who undergo thoracotomy, the pain persists beyond the postoperative period and can be difficult to treat. The causes of postthoracotomy pain syndrome include direct surgical trauma, fractured ribs, compressive neuropathy, neuroma, and stretch injuries. When the syndrome is caused by fractured ribs, it produces local pain that is worse with deep inspiration, coughing, or movement of the affected ribs. The other causes of the syndrome result in moderate to severe pain that is constant and follows the distribution of the affected intercostal nerves. The pain may be characterized as neuritic and may occasionally have a dysesthetic quality.

Keywords

chest wall pain, postthoracotomy pain, fractured ribs, osteoarthritis, sports injury, diagnostic sonography, ultrasound guided injection, intraarticular injection, chest pain, non-cardiogenic chest pain, devil’s grip, acute herpes zoster, costovertebral syndrome, thoracic radiculopathy

ICD-10 CODE R07.1

Keywords

chest wall pain, postthoracotomy pain, fractured ribs, osteoarthritis, sports injury, diagnostic sonography, ultrasound guided injection, intraarticular injection, chest pain, non-cardiogenic chest pain, devil’s grip, acute herpes zoster, costovertebral syndrome, thoracic radiculopathy

ICD-10 CODE R07.1

The Clinical Syndrome

Essentially all patients who undergo thoracotomy suffer from acute postoperative pain. This acute pain syndrome invariably responds to the rational use of systemic and spinal opioids, as well as intercostal nerve block. Unfortunately, in a few patients who undergo thoracotomy, the pain persists beyond the postoperative period and can be difficult to treat. The causes of postthoracotomy pain syndrome are listed in Box 68.1 and include direct surgical trauma, fractured ribs, compressive neuropathy, neuroma, and stretch injuries. When the syndrome is caused by fractured ribs, it produces local pain that is worse with deep inspiration, coughing, or movement of the affected ribs. The other causes of the syndrome result in moderate to severe pain that is constant and follows the distribution of the affected intercostal nerves. The pain may be characterized as neuritic and may occasionally have a dysesthetic quality.

Box 68.1

Causes of Postthoracotomy Pain Syndrome

Direct surgical trauma to the intercostal nerves
Fractured ribs resulting from use of the rib spreader
Compressive neuropathy of the intercostal nerves resulting from direct compression by retractors
Cutaneous neuroma formation
Stretch injuries to the intercostal nerves at the costovertebral junction

Signs and Symptoms

Physical examination generally reveals tenderness along the healed thoracotomy incision ( Fig. 68.1 ). Occasionally, palpation of the scar elicits paresthesias, a finding suggestive of neuroma formation. Patients suffering from postthoracotomy syndrome may attempt to splint or protect the affected area. Careful sensory examination of the affected dermatomes may reveal decreased sensation or allodynia. With significant motor involvement of the subcostal nerve, patients may complain that the abdomen bulges outward. Occasionally, patients suffering from postthoracotomy syndrome develop reflex sympathetic dystrophy of the ipsilateral upper extremity that, if left untreated, may result in a frozen shoulder.

Testing

For all patients who present with pain that is thought to be emanating from the intercostal nerve, plain radiographs are indicated to rule out occult bony disorders, including unsuspected fracture or tumor. Radionuclide bone scanning may be useful to exclude occult fractures of the ribs or sternum. Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing. Computed tomography scanning of the thoracic contents is indicated if an occult mass or pleural disease is suspected ( Fig. 68.2 ). The injection technique described later serves as both a diagnostic and a therapeutic maneuver. Electromyography is useful in distinguishing injury of the distal intercostal nerve from stretch injuries of the intercostal nerve at the costovertebral junction.