Ann Thorac Surg 1997;63:1411-1414
© 1997 The Society of Thoracic Surgeons
Original Article: General Thoracic
Pain Treatment After Thoracotomy: Is It a Special Problem?
Georg M. Salzer, MD,
Paul Klingler, MD,
Anton Klingler, PhD,
Andreas Unger, MD
Department of Thoracic Surgery and Division of Theoretical Surgery, Second Surgical Clinic, University Hospital, Innsbruck, Austria
Accepted for publication November 8, 1996.
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Abstract
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Background. Although it is frequently stated in the literature that thoracotomy is one of the most painful operative incisions, few data supporting this view are available.
Methods. Patients' postoperative pain experience can be assessed on the basis of their usage of patient-controlled analgesia. In a prospective trial the daily self-administered doses of analgesics in 55 patients within the first 4 days after posterolateral thoracotomy were compared with those in 30 patients for the same number of days after median laparotomy. The visual analog scale was used as a second measure to evaluate postoperative pain.
Results. On the basis of patient-controlled analgesia usage on the first postoperative day and the visual analog scale score for the first 2 days, a small but significant difference between the two patient groups was found which showed that thoracotomy is less painful than median laparotomy.
Conclusions. The common belief that posterolateral thoracotomy is a very painful operative access is not true. Therefore it is not necessary to use special techniques for postthoracotomy pain relief in these patients. Patient-controlled analgesia is sufficient for pain relief after major thoracic or abdominal incisions.
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Introduction
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Posterolateral thoracotomy is one of the standard approaches for pulmonary operations. However, this incision has often been reported to be associated with severe postoperative pain that may have deleterious effects on pulmonary function [1, 2].
Because of the supposition that painful, restricted respiration and the hampered mobility of the patient may lead to frequent pulmonary complications [3], various techniques were developed to reduce postthoracotomy pain [4]. Despite this widespread opinion, however, we could not find firm data in the literature regarding the pain after thoracotomy as opposed to the pain after other incisions such as laparotomy.
Loan and Dundee [5] were the first to mention a difference in the postoperative pain after thoracotomy and laparotomy but did not present results of their own or others' investigations to support this claim. It therefore seems that these authors adopted this preconvinced view as a fact without attempting to verify it.
In our department at the University Hospital in Innsbruck, patients who have undergone abdominal and thoracic operations are cared for in the same rooms by the same staff, and our daily experience has proved to be very different in that we never have had the impression that thoracotomy is considerably more painful than laparotomy. In fact, it has been our impression that the pain after an upper median laparotomy and after thoracotomy compromises breathing, coughing, and moving to a similar degree.
Because we have adopted patient-controlled analgesia (PCA) [6] as a routine postoperative pain treatment, the records kept of the daily self-administered doses of analgesic drugs make it possible to estimate patients' subjective pain perception. Specifically we realized we could use the PCA data to compare the severity of postthoracotomy pain with that of postlaparotomy pain.
We therefore undertook a prospective study in which the postoperative usage of analgesics was recorded for patients who had undergone thoracotomy and patients who had undergone laparotomy and the respective usages compared. We used the visual analogue scale (VAS) as a second measure to estimate the degree of patients' subjective pain. Our study had two specific objectives:
- To determine whether the pain after thoracotomy is more severe than that after laparotomy.
- To determine whether there is any correlation between patients' postoperative usage of analgesics and their sex, age, and body weight.
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Material and Methods
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The patients in group I were operated on through a posterolateral thoracotomy that included preservation of the serratus anterior muscle and an intercostal incision. The intrathoracic procedures consisted of pneumonectomy, lobectomy, segmental resection, and exploratory thoracotomy. One or two pleural drainage tubes were placed in each patient. These tubes were passed through the thoracic wall and brought out through the surgical wound. Wound closure started with the placement of four or five very tightly knotted pericostal sutures and was completed with a continuous suture of the latissimus dorsi muscle and interrupted subcutaneous sutures. The skin was closed with clamps.
The patients in group II were operated on through an upper and middle median laparotomy (no patients with a xiphopubic incision were included) for the purpose of resections in the region of the stomach, bowel, liver, pancreas, and so on, as well as for explorative laparotomy or the management of an abdominal injury. Usually easy-flow drainage was used in these patients. The wound was closed by a continuous peritoneal suture, interrupted fascia sutures, and interrupted subcutaneous sutures. Skin was closed with interrupted sutures or clamps.
The characteristics of the patients in the two groups are summarized in Table 1
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Because in our unit surgical patients are cared for in the intensive care unit under the observation of the anesthesiologist immediately after the operation, we began to collect our study data on the morning of the first postoperative day.
For pain relief, all patients were treated with piritramide (Dipidolor), an opioid analgesic with actions and uses similar to those of morphine [7], administered intravenously by a portable infusion pump (Fa. Pharmacia 5058, Vienna, Austria). Patients were allowed to self-administer a 2-mg bolus of piritramide by pressing the appropriate button on the device. The total dose per hour was restricted automatically to 6 mg. Patients did not receive any other analgesic medication. The daily and the total consumption of piritramide were then recorded as a measure of patients' subjective pain. The PCA was discontinued when the patient declared no further need for routine analgesics. This occurred after the third postoperative day in about 93% of all patients.
We used a linear VAS as a second way to estimate patients' subjective pain [8]. This is a widely used means for patients to assess their subjective experience of pain [9]. Twice a day patients were asked to rate the intensity of their pain on the colored scale, with white representing no pain (score of 0) and dark red representing maximal pain (score of 10). The numeric score was shown on the opposite side of the scale. The cumulative numerical scores for days 1 to 4 or the daily mean scores were then used for statistical analysis. The VAS scores were no longer recorded after the PCA was discontinued.
The total dose of analgesics administered and the VAS scores for the first 4 postoperative days were summed up and compared between the two groups using the Mann-Whitney test. These were the only tests used of a confirmatory nature. The Mann-Whitney test was also used for the comparisons of daily data as well as of the continuous demographic variables (age and body weight). 
2 analysis was used to examine sex-related differences. Results were expressed as the median and interquartile range or in frequency tables, if applicable. A p value of less than 0.05 was considered significant. Linear regression analysis was used to test for possible relations between patients' ages and weights and the cumulative consumption of analgesics.
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Results
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The data in Table 2 show that the patients who underwent thoracotomy (group I) medicated themselves on average significantly less (p = 0.02) with piritramide during the first 4 postoperative days than the patients who underwent laparotomy (group II). The difference in the VAS scores between groups I and II was also highly significant (p = 0.0001).
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Table 2. . Cumulative Analgesic Consumption and Visual Analogue Scale Scores for Postoperative Days 1 to 4 in Both Study Groups
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Analysis of the respective PCA data for patients in the two groups on each of the 4 postoperative days showed that the difference between the groups was significant only on the first day (Fig 1). Further, it was found that only about 7% of the patients in both groups needed PCA for more than 3 days. The VAS scores were in accordance with the PCA data (Fig 2). On the basis of our findings, thoracotomy was found to be less painful than laparotomy during the first 2 days after operation.
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Fig 1. . Analgesic consumption on postoperative days 1 to 4 (range, quartiles, and median). Note that the number of patients taking analgesics decreased daily.
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Fig 2. . Visual analogue scale (VAS) ratings on postoperative days 1 to 4 (range, quartiles, and median). Note that the number of patients decreased daily.
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As far as a possible correlation between analgesic consumption and the sex, age, and body weight of patients, univariate linear regression analysis showed that there was no statistically significant relationship between age (y = 77.99 - 0.13*age; r2 = 0.0048; p = 0.53) and body weight (y = 63.46 + 0.12*weight; r2 = 0.0018; p = 0.70) and the cumulative dose of analgesics taken. The median total dose of analgesics taken by male patients was 78 mg (range, 14 to 146 mg), and that taken by female patients was 66 mg (range, 4 to 210 mg). However, this difference was not statistically significant (p = 0.84).
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Comment
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The results of this study are in contradiction to the common opinion that thoracotomy is associated with particularly severe postoperative pain necessitating the use of special pain relief techniques to prevent pulmonary complications and confirmed our clinical impression that there is no apparent difference between the pain after thoracotomy and that after median abdominal incisions. Moreover it was surprising to find that laparotomy is significantly more painful than thoracotomy during the first 2 postoperative days. The possibility that our findings were biased by the significant difference in age between the two study groups is refutable, because no positive correlation between analgesic usage and age could be demonstrated.
Although both of the methods used to evaluate postoperative pain-PCA usage and VAS scores-showed a statistically significant difference in the pain experienced in the first days postoperatively in the patients in the two groups, the clinical importance of this may be negligible. From the standpoint of daily practice, we think that posterolateral thoracotomy should be regarded as being as painful as median laparotomy and therefore not a special problem in terms of pain relief.
Obviously all the reasons for the increased pain occurring after posterolateral thoracotomy, such as the fact that a large amount of muscle tissue is dissected, rib fractures are a frequent occurrence, costovertebral junctions are distorted, and stiff drainage tubes are regularly placed, are not true, though these arguments seem very plain. A possible explanation for the relatively minor pain observed in our patients after posterolateral thoracotomy may be that we try to obtain a very stable thoracic wall during wound closure by splinting both ribs adjacent to the intercostal incision-each by the other-with four to five strongly knotted pericostal sutures. In the event of rib fractures we achieve this goal by placing two of the sutures in the vicinity of the fracture line.
The pain experienced after median laparotomy may result from the fact that the sudden innervation of the broad muscles of the abdominal wall during coughing or sitting up results in a very strong pull in opposite directions on either side of the incision, causing intense pain. The application of a tight abdominal bandage can considerably reduce this pain, which shows that stabilizing the body wall is an important factor in postoperative pain relief. This is accomplished by operative measures in patients with thoracotomies and by mechanical means in patients with laparotomies. Because during the first postoperative days an abdominal bandage is uncomfortable for many patients, this can easily explain the higher doses of analgesics used by patients with laparotomies.
One of our conclusions from this study is, that it is unnecessary and not useful to develop and apply special methods of treatment for postthoracotomy pain, especially because this not only entails much work on the part of researchers but also these methods are not infrequently associated with complications. For example, in 1989 we showed that cryoanalgesia, which was very modern at that time [10], has no advantage over conventional pain therapy and in some cases even leads to long-lasting neuralgiform pain in that particular region of the thoracic wall [11]. However, this is not to be misunderstood: sufficient postoperative pain relief is an integral part of any surgical therapy and a very important factor in ensuring an uncomplicated postoperative course. Our point here is that it is not necessary to use special pain-reducing techniques after thoracotomy.
In our experience, PCA is an excellent method of pain relief after a major surgical procedure, regardless of the kind of operation, because it takes into sufficient consideration the very different subjective pain sensitivities of each patient. If one does away with the continuous application of an analgesic and restricts pain relief treatment to patient-controlled administration of limited doses of piritramide, PCA appears to be mostly free of complications [12]. We had no problems at all with this technique of postoperative pain relief in our patients.
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Footnotes
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Address reprint requests to Dr Salzer, Department of Thoracic Surgery, University Hospital, Anichstraße 35, 6020 Innsbruck, Austria.
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References
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- Hazelrigg SR, Landreneau RJ, Boley TM, et al. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg 1991;101:394–401.[Abstract]
- Kavanagh BP, Katz J, Sandler AN. Pain control after thoracic surgery. A review of current techniques. Anesthesiology 1994;81:737–59.[Medline]
- Brichon PY, Pison C, Chaffanjon P, et al. Comparison of epidural analgesia and cryoanalgesia in thoracic surgery. Eur J Cardiothorac Surg 1994;8:482–6.[Abstract]
- Loan WB, Dundee JW. The clinical assessment of pain. Practitioner 1967;198:759–68.[Medline]
- Uelner C, Klaschik E, Huhmann A, Au G. Postoperative, patient-kontrollierte Analgesie (PCA) auf Allgemeinstationen. Eur J Pain 1990;11:122–6.
- Troidl H, Neugebauer E. Akuter Schmerz in der Chirurgie. Chirurg 1990;61:485–93.[Medline]
- Parfitt K, ed. Martindale, The extra Pharmacopoeia, 13th ed. London: Pharmaceutical Press, 1993.
- Huskisson EC. Measurement of pain. Lancet 1974;1:1127–31.[Medline]
- Maiwand MO, Makey AR. Cryoanalgesia for relief of pain after thoracotomy. J Thorac Cardiovasc Surg 1986;92:291–5.[Abstract]
- Müller LC, Salzer GM, Ransmayer G, Neiss A. Intraoperative cryoanalgesia for postthoracotomy pain relief. Ann Thorac Surg 1989;48:15–8.[Abstract]
- Etches RC. Respiratory depression associated with patient-controlled analgesia: a review of eight cases. Can J Anaesth 1994;41:125–32.[Medline]
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Abstract
Introduction
