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Ann Thorac Surg 2003;76:407-412
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Intracostal sutures decrease the pain of thoracotomy

^a Departments of Cardiothoracic Surgery, Birmingham, AL USA
^b Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA

Accepted for publication February 14, 2003.

^* Address reprint requests to Dr Cerfolio, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd., THT 712, Birmingham, AL 35294, USA.
e-mail: robert.cerfolio{at}ccc.uab.edu

Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.

	Abstract

Top Abstract Introduction Material and methods Results Comment Discussion References

 
BACKGROUND: General thoracic surgeons spend much time dealing and treating patients’ pain after thoracotomy.

METHODS: Two hundred eighty consecutive patients underwent elective thoracotomy for pulmonary resection. Patients with a history of chronic pain were excluded. One general thoracic surgeon performed all procedures. All patients had a functioning preoperative epidural, a skin incision the width of their latissimus dorsi muscle which was cut, sparing of the serratus anterior muscle, undercutting of the rib, preemptive analgesia of the intercostal nerve before rib spreading, and similar number of chest tubes and postoperative pain management. The first 140 patients had their chests closed with pericostal sutures (stitches placed on top of the fifth rib and on top of the seventh rib), and the next 140 patients had their chest closed with intracostal sutures (stitches placed on top of the fifth rib and through the small holes drilled in the bed of the sixth rib). Pain was objectified by a numeric pain score and by the McGill pain questionnaire at 2 weeks, and 1, 2, and 3 months postoperatively.

RESULTS: There were 140 patients in each group, and the groups were matched for age, gender, race, types of pulmonary resections, number of chest tubes, number of broken ribs, length of chest tube duration, and length of hospital stay (p > 0.05 for all). The mean pain score for the pericostal group (P group) at 2 weeks, 1 month, 2 months, and 3 months postoperatively was 5.5, 3.8, 2.3, and 1.6, respectively. For the intracostal group it was 3.3, 1.7, 1.1, and 0.6, respectively (p = 0.004, p = 0.0001, p < 0.0001, and p < 0.0001, respectively). Descriptors of pain in the P group were more likely to be, hot/burning, shooting or stabbing (p < 0.003).

CONCLUSIONS: Intracostal sutures seem to be less painful than pericostal sutures at 2 weeks, 1 month, 2 months, and 3 months after thoracotomy. The pain is less likely to be described as burning or shooting.

	Introduction

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One of the most common problems general thoracic surgeons deal with after thoracotomy is pain. We spend a considerable amount of time on rounds and in the office answering questions and treating this pain. Although several studies have examined this problem [1–10] it remains poorly understood. For these reasons, minimally invasive techniques have caught on quickly. However, the vast majority of pulmonary resections are done through thoracotomy. Therefore, we decided to prospectively study the issue of pain after thoracotomy. We planned several prospective randomized trials and wanted to control for only one variable at a time. We used the best score and scales to objective and quantify pain and had only one surgeon perform all operations. Postoperatively, patients received identical computerized postoperative algorithms. The plan was to build one trial’s finding on top of another. One of the concepts we wanted to investigate, because much of patient’s pain seemed to be from the intercostal nerves, was a way to avoid impingement of the nerve at the time of chest closure. We believed the only way to consistently avoid the nerve on closure was to drill holes in the bottom rib. We feared that if we tried to avoid the nerve by hugging the bottom rib we might inadvertently catch it in some patients. In this trial we evaluated the amount of pain associated with intracostal sutures (placed after drilling four small holes in the underlying rib) and compared that to the pain associated with pericostal sutures.

	Material and methods

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Two hundred eighty patients who meet this study’s entry criteria underwent thoracotomy by a single general thoracic surgeon in a university setting over the course of 17 months. Patients with a history of chronic pain syndrome, a previous use of methadone, a history of psychiatric illness, refusal to enter the trial, or a history of a previous ipsilateral thoracotomy were excluded. Operations at the Veterans Administrative Hospital and patients who had chest wall resections were also excluded.

All patients had a posterior lateral thoracotomy and all had preoperative epidurals placed. If the epidurals did not function, those patients were excluded from this trial. The length of each patient’s skin incision was equivalent to the width of his or her latissimus dorsi muscle at the level of about the sixth rib. This muscle was cut. The underlying serratus anterior muscle was spared and the chest was entered over the top of the unresected and unshingled sixth rib. The rib was not cut, removed, or shingled. An electrocautery was used to undercut the top of the sixth rib from the erector spinae fascia to the internal mammary artery. Marcaine (Abbott Laboratories, South Plainfield, NJ) with epinephrine was injected into the intercostal muscle bundle that contains the sixth intercostal nerve, along with fourth, fifth, seventh, and eighth intercostal nerves and their associated muscle bundle in all patients. These nerves were injected by placing a needle into the intercostal muscle surrounding them and injecting Marcaine (Abbott Laboratories) directly into it. After this was performed a chest retractor was placed, and it was slowly opened over the course of the operation to try to avoid rib fracture. If the rib was broken it was recorded.

After completion of the appropriate pulmonary resection or procedures, all patients had one or two 28F soft chest tubes placed. Patients who underwent lobectomy had two tubes placed, and patients who had wedge resections for metastasectomy or segmentectomies received only one chest tube. Patients were given identical postoperative pain regimens. The members of the pain service (who managed the epidural only) were blinded to which group patients were in and used identical epidural analgesia in both groups. The epidural was removed on postoperative day 2 in all patients. Patients were then given oxycodone and acetaminophen (Tylox; McNeil Pharmaceutical, Springhouse, PA) as well as ketorolac tromethamine (Toradol; Roche, Nutley, NJ).

This study was initially planned to be a prospective randomized trial with intraoperative randomization into one group or another. Because of logistical concerns and cost factors of setting up the drill and the console, the decision was made to perform a series of two groups of consecutive patients over a short period of time. After a statistical power analysis, the study was designed to have 140 patients in each group. The first group had their operations performed between March 1 and December 31, 2000. These patients had their chests closed with pericostal sutures (P group). The sutures used were #5 Ethibond (Ethicon, Summerville, NJ) placed around their ribs in the standard pericostal fashion as illustrated in Figure 1. Four stitches were placed just over the top of the fifth rib, and the other end was placed just over the top of the seventh rib. The next 140 patients had their operations performed between January 1 and September 30, 2001. These patients had intracostal sutures placed (I group) and had their chests closed by drilling four evenly spaced holes (Fig 2) using a 5-mm bit attached to the end of a Stryker drill (San Jose, CA) in the bed of the sixth rib. The sutures used were also #5 Ethibond (Ethicon). The suture was placed through the hole and then it was placed similar to the first group, just over the top of the fifth rib. The only difference between the two operations was the placement of the intracostal suture in the lower rib.

View larger version (43K): [in this window] [in a new window]   Fig 1. This figure depicts how the stitches were placed in the group of patients who received pericostal sutures (P group), as viewed from the surgeon’s side during a right thoracotomy.

View larger version (47K): [in this window] [in a new window]   Fig 2. This figure depicts how the stitches were placed in the group of patients who received intracostal sutures (I group), as viewed from the surgeon’s side during a right thoracotomy.

Results are reported as means ± SD for continuous variables and as percentages for categorical variables. Base line characteristics of the study groups were compared using the Student’s t test, or Mann-Whitney test where appropriate for continuous data. The Chi-Square or Fischer’s exact test was used to compare categorical data. A two-sided p value of less than 0.05 was considered to represent a statistically significant difference between two groups unlikely to be due to chance.

	Results

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There were 280 patients in this trial; 140 patients were in the pericostal group (P group) and 140 in the intracostal group (I group). The demographics of these groups are illustrated in Table 3. The types of operative procedures performed, number of chest tubes, mean time chest tubes were left in the patients, the length of stay, and the complications that may have increased pain are indicated in Table 3 as well. There were no significant differences between the two groups with respect to any of these variables.

View larger version (15K): [in this window] [in a new window]   Fig 3. Mean pain scores with standard deviations. ( = P group; = I group.)

	Comment

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Despite these facts there still are numerous potential flaws in this trial, or probably in any study that attempts to scientifically study the issue of pain. The first is that there could be a small, unrecognized difference in these two groups of patients that were not randomized and had their operations performed over two separate time periods. This criticism is somewhat countered by the fact that the trial only took 9 months in each group and the two groups were consecutive. The second flaw is that despite our attempts to objectify pain, the pain scores used and the data reported by the patients are subjective. We found that some patients would vacillate on their pain and others found it difficult to assign a precise number or descriptor to quantify or describe their pain. This was partly due to the fact that it varied during different times of the day or with activity.

The pain many patients describe after thoracotomy is often searing, burning, referred numbness, or what some call a "neurologic type" pain. For that reason we wanted to study a way to avoid injury to the intercostal nerve. One way is to use a retractor that pulls the ribs apart without spreading the ribs apart and compressing the nerve. Another is to avoid the nerve on closure. The concept of drilling holes in the rib to avoid intercostal nerve impingement is not new. By verbal report it has been used for many years. Although the drill we used in this study is very easy, quick, and safe to use there are costs and risks. In our experience, it only took about 1 minute to drill the four 5-mm holes, but it took time and effort for the circulator to set up the drill and its console.

Although we experienced no injuries to underlying structures in this series, the lung and the heart (when on the left side drilling medially) are at risk and must be carefully avoided when drilling the lower rib. Drilling holes in the ribs may have other problems as well. Thin ribs can split, which makes chest closure more difficult. This is especially true in thin, elderly females or in patients who are malnourished or immunocompromised. In our experience, the splitting of the lower rib happens as the intracostal sutures are brought together and tied not during the actual drilling. This occurred three times in this series. Given this small number, an analysis of these patients’ pain is meaningless but it seemed to be no different. However, this problem with drilling is clinically important and must be reported.

Although we did not experience pulmonary herniation postoperatively, we have noticed that in a few patients the ribs can drift apart over time. This data, not reported in this study’s results section, was noted in long-term follow-up in 2 patients who described a fullness in their operated side several months after surgery while coughing or straining. Chest roentgenograms and computed tomography revealed no evidence of a pulmonary herniation, but there was noted to be an increased fifth intercostal space. Both of these patients were elderly women and both were on steroids. We therefore now recommend hugging the very bottom of the lower rib in these patients in an attempt to avoid the intercostal nerve and avoid these other potential problems. If one could reliably and consistently avoid the intercostal nerve and vessels in all patients by hugging the inferior or lower rib this could obviate the need for drilling holes and avoid its inherent risks, costs and set-up time. Although this technique is an option, we believed the only way to consistently avoid the nerve to accurately study it was to drill holes in the lower rib.

In conclusion, patients perceive the pain of thoracotomy differently. It remains a significant problem in general thoracic surgery and adds to morbidity, respiratory complications, costs, and decreased patient satisfaction. There is little surgeons can do to influence preconditioned factors and therefore, we are left with operative factors and postoperative pain management to try to decrease the pain. The use of intracostal sutures, placed by drilling small holes in the bottom rib, seems to be associated with less pain then standard pericostal sutures. Further prospective randomized trials are needed to scientifically study the common and vexing issues of pain after thoracotomy.

	Discussion

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DR LYNN H. HARRISON (New Orleans, LA): I think this paper is characteristic of the meticulous approach that Bob has brought to a number of important practical issues in thoracic surgery, and as we increase in age and become more likely to become recipients rather than providers of thoracic surgical care, then issues like pain are of increasing importance to us.

I want to know what your experience has been with subperiosteal rib resection and closure without pericostals and do you think that might be a comparable means of alleviating pain?

DR CERFOLIO: I appreciate your comments. Thank you very much. I really don’t have any experience to answer that question. I know some people have mentioned that to me, and I would say that to really answer it we would have to do a prospective randomized trial and carefully look at that. Our preference has been not to resect the rib. Over the last 4 or 5 years we try not to break or cut the rib, we do not shingle the rib, we just undercut it–and then if you slowly open the retractor and take that time to start taking nodes and incising the pleura around the lung, etc, you do not waste time. I don’t have enough experience in the type of technique you have described.

DR KAMAL A. MANSOUR (Atlanta, GA): Robert, I enjoyed the presentation very much. I have two questions. Number one, you put about four or five sutures?

DR CERFOLIO: Four. Both groups received four of the same suture.

DR MANSOUR: And No. 5 Ethibond, big needle?

DR CERFOLIO: Yes.

DR MANSOUR: Do you worry about osteochondritis? I have been brought up to think that you should not really put any stitches in the ribs because you can develop traumatic osteochondritis with draining sinuses and all.

Number two, the second question is, what happens if you remove one rib? Would you be able to bring the lower rib up to the rib above under tension with the stitches through the rib, would it cut through?

Thank you.

DR CERFOLIO: Thank you again. I appreciate your comments. Your first one was about osteochondritis. We have not had that experience. Our follow-up is pretty good, and we haven’t had any draining sinuses and no patients had a wound infection. We had one patient, an NFL football player, who popped one of these stitches, he went back to activity a little sooner than we told him, but he told us up front he was not going to listen to our suggested convalescence period. Otherwise that is our only real problem we have had with these sutures, as far as we know.

In terms of resecting a rib, when we do chest wall resections or if we do an intercostal muscle flaps, which we do a lot of, we reapproximate the ribs just the way God had it before we started. So we believe it is a mistake to bring the ribs together–we just leave that space open. When we perform a redo thoracotomy on a patient that has had a rib removed elsewhere, we intentionally leave the space open where the missing rib used to be, we re-establish chest wall continuity with intracostal or pericostal sutures. Once a rib is resected the preservation of one intercostal nerve is probably less important.

DR JOHN D. OSWALT (Austin, TX): Bob, congratulations on your study, forgive me if I tell about a partner of mine, H.S. Arnold, that began doing the intracostal sutures 20 years ago. He is also a member of this group and he is one of our senior partners. He is now retired from the group, but still works for us and with us as a consultant.

We started doing this 20 years ago, and the only difference is we used resorbable sutures in a double-loaded PDS, but we have comparative patients where he has done bilateral resections on these patients at different years, and the first time he did the pericostals and the second operation he did by drilling the ribs, and the patient’s own words were that this is so much better.

This leads us to the fact that if we can cut down the amount of pain, maybe we won’t have to work so hard at doing smaller incisions, and we can go back to doing proper instruction for the residents. This will allow our residents to do some of these operations. Then they can see and feel and know what they need to be doing and still offer the patient a good operation with a minimal amount of pain.

But congratulations. I think it is a well written-up study.

DR CERFOLIO: I appreciate your comments. You are not upstaging me at all, as I mentioned in the presentation this was first reported in 1953. This is clearly not my idea, I have just chosen to try to study it.

DR KIT AROM (Minneapolis, MN): Would it be easier to rip off the intercostal nerve?

DR CERFOLIO: What? Would it be easier to do what to the nerve?

DR AROM: To rip off the intercostal nerve. You can accomplish the same thing.

DR CERFOLIO: I would say no, it would not be easier. We are trying to void the nerve. As I mentioned I wish we had a retractor that could be developed that could be placed in the holes in the rib and the nerve was spared the injury of retraction. To remove or "to rip it off" seems to me to be more painful, but I do not know–I guess I would have to study it and see if there would be any difference in pain. I prefer to leave the nerve untouched.

Ideally what I would like is a retractor, and we have been trying to work on this, so we could drill the holes and put a retractor that fits through the holes and spreads the rib apart without actually pressing on the nerve that we go over. I just haven’t had time to get a company to help me develop that. But, to me, that would be completely nerve sparing, and I would think that would even cause less pain, personally.

DR LAURENS R. PICKARD (Houston, TX): I really enjoyed your presentation very much, very nice. As incisions have gotten smaller over the years in my practice, I have taken it a step farther and used neither pericostal or intercostal sutures, and a lot of patients do very well with no closure of the intercostal space. So I was wondering what you thought about that.

DR CERFOLIO: My concern with that is it would lead to pulmonary herniation. Have you had pulmonary herniation yet?

DR PICKARD: No.

	References

Top Abstract Introduction Material and methods Results Comment Discussion References

 

1. Cerfolio RJ, Bryant A, Bass C, et al. A prospective randomized doubled-blinded trial evaluating the use of preemptive analgesia of the skin prior to thoracotomy. (In press)
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