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Ann Thorac Surg 2001;72:2180
© 2001 The Society of Thoracic Surgeons

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Correspondence

Amelioration of postthoracotomy pain

^a California Cardiothoracic Associates, 3630 E Imperial Hwy, Ste 2101, Lynwood, CA 90262, USA

To the Editor

I read with interest the article by Bucerius and colleagues [1]. Attempts to ameliorate postthoracotomy pain have included, either individually or in combination, epidural block, intercostal nerve blocks, muscle-sparing incisions, use of smaller diameter chest tubes that do not compress the intercostal neurovascular bundle, and patient-controlled analgesia with various agents.

In this study, perineural muscular tissue in the fifth intercostal space, after right or left anterolateral minithoracotomies for coronary artery bypass grafting or for mitral valve procedures, was frozen by three 2 minute applications of nitrous oxide gas at minus 80 degrees centigrade. Cryoablation to this degree is ordinarily lethal to tissue under proper conditions [2, 3]. The fact that only 16.7% of patients experienced transient postoperative numbness can be explained either from sensation provided by overlapping dermatomes or that overlying muscle tissue insulated the intercostal nerve from permanent damage. Clinically, the perception of pain was reduced in the treated cohort of patients compared with controls.

There is yet another method to dramatically reduce postthoracotomy pain that does not require the time, expense, and risk of permanent tissue damage of cryoablation. It is predicated on the assumption that most postthoracotomy pain results from neurovascular entrapment by pericostal sutures placed during wound closure. The solution is to pass these ties through drill holes placed in the caudal rib and then around the cranial rib. In this way, there is no nerve entrapment. This simple variation in technique, in combination with a muscle-sparing incision in which the latissimus dorsi and all muscles posterior to it remain intact, and without intercostal or epidural blocks, consistently results in a remarkable reduction of postoperative discomfort.

I have used this method in numerous thoracotomies over many years with consistent experiences reported by most patients. These include the relative ease of coughing and mobility and consistently early dismissal from the hospital, usually by postoperative day 3 or 4. It is not unusual for patients to report having no need for antiinflammatory or analgesic medication after going home. I have not seen a single case of chronic postthoracotomy pain.

The authors did not state whether a rib was removed during their procedures or if pericostal sutures were used. I am confident, however, that the method I have outlined will obviate the need for pericostal nerve cryoablation as described in their article.

References

1. Bucerius J., Metz S., Walther T., et al. Pain is significantly reduced by cryoablation therapy in patients with lateral minithoracotomy. Ann Thorac Surg 2000;70:1100-1104.[Abstract/Free Full Text]
2. Lee M.E. Epicardial cryoablation of myocardial tissue using endocardial thermal isolation. Mt Sinai J Med 1992;62:357-361.
3. Lee M.E. Regarding the surgical ablation of the sinus node. J Thorac Cardiovasc Surg 1998;115:1391.[Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Myles Edwin Lee Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lee, M. E. Search for Related Content PubMed PubMed Citation Articles by Lee, M. E. Related Collections Cerebral protection Chest wall Related Article