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Ann Thorac Surg 1997;64:890-891
© 1997 The Society of Thoracic Surgeons
Departments of Neuroscience and Thoracic Surgery University of Torino Medical School Corso Raffaello 30 10125 Torino, Italy
To the Editor:
Although we are very happy to open a discussion with Brodsky and Mark [1] on the effectiveness of transcutaneous electrical nerve stimulation (TENS) in postoperative pain, we are sorry to realize that they did not read carefully our article on the use of TENS after thoracic operations [2]. A few examples: Brodsky and Mark talk of "visual analogue pain scores." Actually, we used a numeric rating scale (see the Material and Methods section). Similarly, regarding the video-assisted thoracic surgery group, they say "We are not told how many patients made up each subgroup." Take a look at Table 1: 31, 27, and 37! Further, "Because the opioid analgesic regimens differed ... the intergroup comparisons are not valid." As a matter of fact, we never compared different groups (see the statistical analysis in the Results).
Although Brodsky and Mark seem to recognize the impressive reduction in ketorolac intake in video-assisted thoracic surgery, they assert that the major shortcoming of our article is the "failure to address the important question concerning the apparent effectiveness of TENS versus its expense." Actually, they appear to be more interested in the costs of drugs, ampules, TENS stimulators, and institution charges rather than the apparent effectiveness of TENS in some surgical procedures. Although we understand their financial concerns, our study was simply aimed at investigating whether or not TENS relieves postoperative pain soon after operation.
As far as the details of intraoperative anesthetic management are concerned, we believe that this information is probably desirable but certainly not necessary. We try to explain why. As pointed out by many authors (see, for example, [3]), the effectiveness of TENS in postoperative pain is still controversial because the surgical procedures are so different that pain intensity varies markedly. Accordingly, we believe that the variability of operation and anesthesia can be overcome by starting the analgesic treatment on the same pain baseline. In fact, our subgroups (TENS, placebo TENS, and control) showed the same pain intensity scores soon after the operation (see the Results), so that each subgroup in each group was represented by patients with the same pain baseline. Again, we stress that comparisons were made among the three subgroups of each group (cohort), which is thus independent of the other groups. This is an important point that we believe Brodsky and Mark misunderstood. In other words, we recorded the time from the beginning of TENS treatment to the request for analgesic (assumed to represent the effectiveness of TENS), irrespective of the analgesic we used. In this sense, the type of analgesic is irrelevant because it was administered at the end of this interval and therefore did not influence the course of TENS analgesia. Needless to say, the reduction of analgesic intake is the direct consequence of the increase of this time interval.
We also emphasize that our results are in good agreement with previous studies [3] showing that some surgical procedures appear to be too painful for TENS to have a significant effect on the pain.
Last but not least, we would like to make a further consideration. We are glad that Brodsky and Mark assert "... it seems clear from this study that TENS did reduce the amount of ketorolac ...". That was the aim of our study, to demonstrate the short-term effects of TENS! Therefore, we were very surprised to read that we failed to answer questions like length of hospitalization, improvement of pulmonary function, postoperative complications, and extra cost of TENS. We believe that these are too many questions for a single article.
References
Departments of Anesthesiologyan and Cardiothoracic Surgery Stanford University School of Medicine Rm H3580 300 Pasteur Dr Stanford, CA 94305-5115
To the Editor:
We agree that Benedetti and associates' study [1] demonstrated the short-term effects of TENS after a variety of thoracic surgical procedures. However, the concerns we expressed in our editorial [2] are still appropriate. Without documentation of any benefit to the patient (such as decreased length of stay or improved pulmonary function), the increased cost of TENS therapy cannot be justified, especially when a modest increase in ketorolac appears to be equianalgesic. Yes, Benedetti and associates are correct when they state that Brodsky and Mark are "interested in the cost of drugs, ampules, TENS stimulators, and institution charges ...". These concerns are completely valid within the context of current medical practice in this country. Postthoracoscopy pain: is TENS the answer? Based on the information presented by Benedetti and colleagues, our response is "no."
References
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