1. Post-Thoracotomy Pain Syndrome Justin Wilson, M.D.

2. Disclaimer: The available studies have major inconsistencies in collection of data thus hindering conclusive methods for prevention and treatment.

3. Post-Thoracotomy Pain Syndrome (PTPS): Pain that recurs or persist along a thoracotomy scar at least 2 months following the surgery.

4. Variable, but high, roughly >50%, the majority experiencing mild pain, and 3-16% experience moderate-severe pain 82-90% report it is most profound around scar/surgical site Incidence

5. Pain: myofascial vs neuropathic allodynia- sensation of pain to a non-painful stimulus majority report aching dysthetic burning lancinating combination of above

6. Preoperative Risk risk of chronification decreased in elderly risk is increased in females existence of chronic pain elsewhere (hysterectomy and hernia surgery data) no relation to anxiety/depression

7. Intraoperative Risk surgical technique posterolateral vs muscle sparing posterolateral muscle sparing less pain at 1 month axillary vs anterior approach anterior reduced incidence PTPS Video assisted thoracic surgery (VATS) no difference, although decreased early pain

8. Intraoperative Risk surgical technique rib retractors causing nerve damage, confirmed by evoked motor potentials suture technique, 78% damage to inferior and 40% damage to nerve superior to incision due to pericostal suture

9. PTPS 60yo female with acute/chronic chest pain localized at 10yo thoracotomy scar

10. Intraoperative Risk analgesia Intrapleural analgesia: inferior to cryoanalgesia and opioids (23.4%) Thoracic epidural analgesia (TEA): variable (14.8%) TEA + NSAID (9.9%) Cryoanalgesia: no decrease in PTPS (31.6%) Pre-emptive analgesia: inconclusive, although TEA had less postop pain

11. Postoperatively Several studies from other procedures indicate the intensity of acute postop pain to be a risk factor for persistent post surgical pain. (data from hip arthroplasty, hernia, and c-section)

12. Management Acute TEA gold standard multimodal drug therapy (NSAID, IVPCA)

13. Management Chronic First rule out tumor recurrence First line: PT, NSAIDS, TENS, TCA, anti-epileptics, sodium channel blockers, and opioids 2nd: ISB (phrenic-shoulder), intercostal nerve block, PVB, SNRB, sympathetic nerve blocks, TPI, SCS

14. In conclusion, there is a need for large, prospective, randomized trials evaluating PTPS.

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