ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Frank C. Detterbeck
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Detterbeck, F. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Detterbeck, F. C.

Ann Thorac Surg 2005;80:1550-1559
© 2005 The Society of Thoracic Surgeons

Review

Efficacy of Methods of Intercostal Nerve Blockade for Pain Relief After Thoracotomy

Frank C. Detterbeck, MD *

Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina

Accepted for publication November 24, 2004.

* Address reprint requests to Dr Detterbeck, Division of Cardiothoracic Surgery, University of North Carolina, CB 7065, Medical School Wing C—Room 354, Chapel Hill, NC 27599-7065 (Email: fdetter{at}med.unc.edu).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Intercostal nerve blockade for postthoracotomy pain relief can be accomplished by continuous infusion of local anesthetics through a catheter in the subpleural space or through an interpleural catheter, by cryoanalgesia, and by a direct intercostal nerve block. A systematic review of randomized studies indicates that an extrapleural infusion is at least as effective as an epidural and significantly better than narcotics alone. The other techniques of intercostal blockade do not offer an advantage over narcotics alone.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

Dr Detterbeck discloses that he has a financial relationship with I-Flow, Corp.

 

A thoracotomy is particularly painful, and good pain control is crucial to maximize the ability to cough and breathe. The most common methods of postoperative pain management are systemic narcotics and epidural administration of local anesthetic agents or narcotics [1]. Techniques involving intercostal nerve blockade are used less often, although this may be unjustified. This article is a systematic review of intercostal nerve blockade after thoracotomy. It is restricted to efficacy data from randomized studies involving any techniques of intercostal nerve blockade.

The simplest method of intercostal nerve blockade is injection of local anesthetics in multiple intercostal nerves before closure of a thoracotomy incision. A longer-lasting method involves cryotherapy of intercostal nerves. Continuous infusion or serial administration of local anesthetics through an indwelling catheter for several days can be performed through an interpleural catheter (by anesthetic diffusion across the pleura and inner chest wall to the intercostal nerves) or through a catheter placed in a subpleural (extrapleural) pocket (closer to the nerves). Each of these methods is discussed separately.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
A MEDLINE English-language literature search was performed using the key words thoracotomy, pain, postoperative, analgesia, intercostal nerve, epidural, subpleural, extrapleural, interpleural and intrapleural, cryoanalgesia, and randomized. The references of included studies, selected textbooks, practice guidelines, systematic reviews, and meta-analyses were also reviewed to identify all relevant studies.

Predetermined inclusion criteria were a randomized study of patients undergoing thoracotomy in which a method of intercostal nerve blockade was compared with either systemic narcotics or an epidural analgesia technique. Randomized studies involving a different control group are included in the discussion as appropriate. Duplicate publications were excluded, ie, earlier publications of patients included in a subsequent larger report. However, studies were included if it was unclear whether the same patients were reported elsewhere. Evidence tables were constructed according to the criteria listed in the legend of each table. The relative paucity of studies, the variability in the durations of patient assessments, and the subjective nature and variability in pain assessment prevent a formal meta-analysis of these data.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Extrapleural Infusion of Local Anesthetics
Technique
A portion of the parietal pleura can be easily lifted away from the inner chest wall during a thoracotomy to create an extrapleural pocket. A catheter is introduced percutaneously into this pocket under direct vision, often with a Tuohy needle (typically used for epidural catheter placement). The overlying pleura is sutured closed at the thoracotomy incision site. Some authors have used a curved vascular clamp to simultaneously create the tunnel and pull the catheter along [2], while others use flexible bronchoscopy biopsy forceps through a small nick in the pleura to pull the catheter into the subpleural pocket [3]. Percutaneous catheter placement into this space without intraoperative visualization has also been described [4, 5], albeit with technical failure in 10% to 30% and complications in 10% (hypotension, vascular or pleural puncture) [4, 5].

Infusion of local anesthetics through the catheter fills the extrapleural pocket, and diffuses across the endothoracic fascia and internal intercostal muscles to cause intercostal nerve blockade. Postoperative imaging studies have shown that the fluid remains in the extrapleural space without leakage into the pleural space [6, 7]. Some authors place the catheter when convenient lateral to the spine [8–10], while others emphasize placement close to the heads of the ribs in the paravertebral space [6, 7, 11] because there the intercostal nerves are not enveloped by a fascial sheath and the sympathetic ganglia, posterior intercostal rami, and nerve branches to the costovertebral joints are also blocked [7, 12].

Although many types of catheters are used, a small catheter with multiple side holes, such as an epidural-type catheter or an On-Q soaker catheter (I-Flow Corporation, Lake Forest, CA), is most appealing. Most authors have placed a catheter with side holes across multiple intercostal levels [10, 11], while others have placed one catheter above and one below the incision [8], and others have used multiple intercostal catheters [13].

The vast majority of authors use 0.5% bupivacaine as a local anesthetic [3, 9, 11, 14–18], although some use 0.25% bupivacaine [6, 10, 19–22], 1% lidocaine [9, 23], or 1% lignocaine [6]. The rate of infusion is generally 5 to 7 mL/h for an average-sized adult (0.1 mL·kg–1 ·h–1) [3, 6, 9, 11, 14–16, 18, 19, 21–23]. Analgesia to pinprick (approximately 5 dermatomes unilaterally) is similar to a thoracic epidural (bilaterally) [19].

Efficacy
Randomized studies of an extrapleural catheter in patients undergoing thoracotomy are summarized in Table 1. All but two of the studies involving narcotics are double-blind and placebo-controlled. Overall, the data demonstrate that extrapleural analgesia is superior to systemic narcotics. All of the studies have found that pain relief was better, although the difference was not statistically significant in two of seven studies. Moreover, better pain relief was achieved despite a decreased use of supplemental narcotics in most studies. The incidence of pulmonary complications was generally lower in the extrapleural group. There was also better preservation of the forced expiratory volume in 1 second (FEV1) in most studies (although one found a trend to worse results).


View this table:
[in this window]
[in a new window]
  		Table 1. Studies of the Value of Extrapleural Local Anesthetics a
 
Randomized studies comparing an extrapleural technique with epidural analgesia suggest that outcomes are at least as good, if not better, using an extrapleural approach. Pain relief is somewhat better and narcotic usage somewhat less with an extrapleural catheter, but the differences are not consistent and often not statistically significant. Extrapleural analgesia may preserve FEV1 better, but the effect on pulmonary complications is unclear.

One study compared extrapleural with interpleural administration of local anesthetics [14]. No difference in pain was noted, although pulmonary complications were decreased and FEV1 better preserved by the extrapleural approach. The lack of a difference in pain control is surprising, given how consistently better extrapleural analgesia is compared with systemic narcotics, which yield similar relief compared with interpleural analgesia (see next section). The poor FEV1 results with interpleural bupivacaine in this study [14] may be caused by bupivacaine pooling above the diaphragm, causing diaphragmatic impairment.

Randomized studies comparing extrapleural infusions of bupivacaine and lidocaine or lignocaine found no difference in pain relief, need for supplemental narcotics, or pulmonary function [6, 9]. These authors argue that lidocaine may be better than bupivacaine because of a larger therapeutic window, a lower risk of cardiac toxicity, and the notion that a constant infusion thwarts any advantage of a longer-acting agent. However, this argument is countered by the extensive experience and minimal toxicity with bupivacaine.

Toxicity
Extrapleural infusion of bupivacaine has been very well tolerated. Local complications were seen in 0.6% of patients (2 of 311) in studies that specifically reported complications (1 patient each with transient hypotension and transient Horner's syndrome) [3, 6, 9–11, 15–17, 22, 24–26]. Systemic bupivacaine toxicity (confusion) was noted in 0.8% of patients (3 of 383) [3, 6, 8–11, 14–20, 22, 24, 26]. Two additional patients experienced confusion thought to be unrelated because their plasma bupivacaine levels were well below the toxic range [19]. One patient experienced rib osteomyelitis as a result of the catheter [21]. No other complications have been reported. Toxicity to other local anesthetics has not been reported. More side effects have occurred in patients receiving an epidural in studies comparing extrapleural bupivacaine with epidural techniques [18, 22, 26].

Average plasma bupivacaine levels during continuous infusion for several days are 3 to 4 µg/mL (range, 2.1 to 4.92 µg/mL) in studies that have measured this [8, 16, 19, 26, 29, 30], which is close to the commonly accepted threshold of 5 µg/mL for central nervous system toxicity [30]. Maximal levels of 7.48 µg/mL [29] and 10.25 µg/mL [16] have been reported, but these patients did not experience toxicity. The explanation may be that the vast majority of plasma bupivacaine during an infusion is bound to serum proteins and is thereby rendered biologically inactive [30]. Furthermore, studies attempting to define a toxic plasma level have been unable to do so, and the incidence of toxicity appears to be related to the rapidity of administration [31].

Interpleural Administration of Local Anesthetics
Technique
Interpleural administration of local anesthetics is accomplished by introducing a small catheter percutaneously into the pleural space before thoracotomy closure. An epidural-type catheter with multiple side holes is generally used, and positioned posteriorly in the paravertebral gutter, spanning several intercostal spaces above and below the incision. Usually intermittent doses of bupivacaine are given every 4 [32–37], 6 [38], or 8 hours [39, 40], but some authors use a constant infusion [14, 41]. The dose of bupivacaine is not consistent, but the most common volume is 20 mL, and the most common concentration is 0.5% (with epinephrine in about half of the studies). In approximately half of the studies the chest tubes were clamped for 5 to 30 minutes after the dose was given [33–35, 37, 38, 40, 42]; in others, gravity drainage [39] or suction was maintained throughout [14, 32, 36, 41, 43]. Management of the chest tubes may be important because a large portion (about 30%) of the administered dose drains from the tubes within 15 minutes [33, 36, 43, 44]. One randomized study suggested that epinephrine was not needed, and that two catheters may be better than one [36].

Efficacy
Randomized studies (mostly double-blind, placebo-controlled) of interpleural local anesthetics after thoracotomy suggest that the benefit of this approach is marginal, at best (Table 2). Most studies have found no difference in patients' perception of pain or need for narcotics, although two studies found both of these outcomes to be significantly better using an interpleural approach compared with narcotics alone. The limited available data regarding pulmonary function tests or respiratory complications do not suggest that interpleural local anesthetics offer a benefit. The few studies comparing an interpleural with an epidural approach have either found no difference in pain control or found a benefit to an epidural technique. In general, blockage of approximately four dermatomes has been achieved in the one study that assessed this [36].


View this table:
[in this window]
[in a new window]
  		Table 2. Studies of the Value of Interpleural Local Anesthetics a
 
Toxicity
No complications owing to interpleural catheter placement have been reported. Confusion thought to be related to systemic bupivacaine toxicity was reported in 5% (7 of 147) of patients overall [14, 32, 35, 37, 41–43], although this complication occurred primarily in one study using a constant infusion (5 of 23 patients) [14]. Among studies using intermittent dosing, bupivacaine toxicity occurred in 2.1% (2 of 94) [32, 35, 37, 42]. Other complications have included upper extremity tingling and urinary retention [42, 43]. Average plasma bupivacaine levels have generally been approximately 1 µg/mL (0.32 to 2.29 µg/mL) [33, 39, 42, 43, 45], but there is wide individual variation among patients [35]. The amount of bupivacaine lost in the chest tubes does not seen to correlate with either the plasma levels or the degree of pain relief [36, 37]. The variability in efficacy and toxicity of interpleural analgesia may be related to pleural permeability, inflammation, adhesions, and dilution with blood or effusion.

Cryoanalgesia
Technique
Cryoanalgesia involves freezing intercostal nerves to –60°C for 30 to 45 seconds, which causes damage to the myelin sheath, thereby interrupting nerve conduction. The nerve axon, however, is unharmed, so that functional recovery of the nerve occurs once the myelin sheath has regenerated [46, 47]. This process generally takes about 1 to 3 months in the case of intercostal nerves [47, 48].

Usually the intercostal nerves are isolated and the cryoprobe is applied directly, although some authors have applied the probe over the intact pleura, provided the pleura is thin [48]. In some studies the nerve has been frozen twice, in others a single application of a cryoprobe was used. Usually the nerve along the intercostal incision and at least one nerve above and one below are frozen (range, three to eight nerves). This technique was practiced fairly commonly during the 1980s, especially in several European centers, but fell out of favor around 1990. This corresponded with more widespread availability of epidural anesthesia, as well as concerns about the efficacy and the potential for neuralgia.

Efficacy
Randomized studies of cryoanalgesia for postthoracotomy pain relief (Table 3) compared with narcotics suggest marginally better pain relief and a trend to less supplemental narcotics with cryotherapy, although many studies have found no difference. However, no study suggested that cryoanalgesia resulted in worse pain control. Three studies found no difference in the postoperative FEV1 [38, 49, 50], although one study noted a benefit to cryotherapy versus narcotics [51], and two found a trend to a benefit [47, 52]. The studies addressing pulmonary complications suggested that cryoanalgesia was beneficial [47, 53]. Most of these studies were conducted in a blinded fashion. Comparison of cryoanalgesia with epidural analgesia suggests worse pain relief and more supplemental narcotics with cryoanalgesia, although the data are limited.


View this table:
[in this window]
[in a new window]
  		Table 3. Studies of the Value of Cryoanalgesia a
 
Toxicity
Concern has been raised about the development of neuralgia after cryoanalgesia of intercostal nerves, generally occurring after about 6 weeks, and lasting for 2 to 4 weeks [38, 47, 49, 54, 55, 57]. The incidence is reported to be 20% to 30% in several studies [38, 49, 54, 57, 58], although other authors have not encountered this problem in a large cohort of patients (71 patients) who were monitored for 3 months [53]. In addition, the incidence of postthoracotomy pain syndrome—which may or may not be the same as neuralgia after cryoanalgesia—was found to be less after cryoanalgesia than after epidural, narcotic, or interpleural management of postthoracotomy pain in one study [38]. Other complications of cryoanalgesia have not been reported.

Direct Intercostal Nerve Block
Technique
Intercostal nerves can be injected percutaneously from outside the chest or under direct vision from inside the chest before thoracotomy closure. The blocks are administered just below a rib in the region of the intercostal bundle, being careful not to inject the dose intravascularly. In most studies 2 mL of 0.5% bupivacaine per intercostal nerve is used, although some have injected larger volumes [59–61] or used 0.25% bupivacaine [62]. In most studies bupivacaine without epinephrine has been used. Some authors have administered the first block percutaneously before the incision [63]. Most authors have administered the intercostal block only once, although some have repeated the blocks during the course of 24 hours [63].

Efficacy
Intercostal nerve block before thoracotomy closure has generally provided better pain relief than narcotics alone, although a reduction in supplemental medication is less clear (Table 4). Interestingly, better pain relief occurred even in studies that assessed pain more than 3 to 5 days, even though the intercostal block was not repeated [60, 64]. Segmental analgesia to pinprick extended to 18 hours in one study after 0.5% bupivacaine without epinephrine [19]. Pulmonary function also appears to be better preserved, even several days later, but an effect on pulmonary complications is unclear. Almost all of these studies were not blinded.


View this table:
[in this window]
[in a new window]
  		Table 4. Studies of the Value of Direct Intercostal Nerve Injection a
 
In studies comparing intercostal nerve block with epidural analgesia, neither technique is clearly superior. Pain control may be slightly better with intercostal blocks, although narcotic use may be less with an epidural. There is no apparent difference in pulmonary function testing. Most studies were small, so that small differences may be missed. Nevertheless, the lack of consistent trends among these studies calls into question the widely presumed superiority of the epidural approach [1].

Toxicity
Intercostal nerve blocks are associated with minimal side effects. A study of almost 11,000 patients receiving percutaneous intercostal nerve blocks found no episodes of systemic toxicity to local anesthetics [70]. The incidence of pneumothorax was 0.07%, although this is not germane to intraoperative administration of the block [70]. Plasma bupivacaine levels have been low after intercostal nerve blocks (0.19 to 1.46 µg/mL with a peak at 10 minutes) [19]. Even a continuous infusion for more than 5 days has been found to be safe, with local anesthetic levels that are below toxic levels [71].


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Although intercostal nerve blockade (by any method) for treatment of postthoracotomy pain is not currently widely practiced, the data presented here suggest that perhaps this should be reconsidered. The most common method of postthoracotomy analgesia, a thoracic epidural infusion [1], is associated with frequent side effects, including urinary retention (42%), nausea (22%), itching (22%), and hypotension as a result of decreased sympathetic tone (3%) [72, 73]. A more rare effect is respiratory depression (0.07%), necessitating management of patients in a highly monitored setting, or the involvement of a specialized pain service [72, 73]. Furthermore, the epidural placement lengthens the operative time and is associated with occasional technical failure or dislodgement (8%) [72]. The most common alternative analgesic method, systemic narcotics, also has frequent side effects, including constipation, nausea, somnolence, and respiratory depression. Nevertheless, both epidural analgesia and systemic narcotics are used in the vast majority of patients undergoing thoracotomy because of the importance of providing postoperative pain relief.

A continuous infusion of local anesthetics through an extrapleural catheter results in more effective pain relief than systemic narcotics. In fact, the pain relief afforded by the extrapleural technique appears to be at least as good as an epidural approach. Catheter placement at the time of thoracotomy or thoracoscopy can be accomplished quickly and reliably. Because the extrapleural route results in only a unilateral blockade, the incidence of side effects such as hypotension and urinary retention is greatly diminished. There is no risk of respiratory depression and no need for intensive monitoring or specialized services for management. Although an extrapleural approach does not always eliminate the need for systemic narcotics, the amount needed is reduced.

The value of other techniques of intercostal nerve blockade is less clear. Interpleural local anesthetic results in inconsistent pain relief. Although catheter placement is straightforward, the risk of side effects appears to be slightly higher than with an extrapleural route. As a result, this technique is currently used only rarely. Cryoanalgesia appears to be of some benefit relative to systemic narcotics, but the results are less consistent compared with an extrapleural catheter, and appear to be worse than with an epidural approach. Furthermore, cryoanalgesia carries a significant risk of postoperative hyperesthesia. Direct intercostal nerve blockade appears to provide a benefit compared with narcotics alone in several older studies, particularly during the first day, but the short duration of action makes this approach less appealing.

A more detailed understanding of the pathophysiology of postoperative pain has evolved [74]. Tissue injury causes peripheral sensitization through the release of mediators, so that there is both an exaggerated response of the high-threshold A{delta} and C fibers that are responsible for transmission of true noxious stimuli. This results in exaggerated responsiveness of nerves in the affected area (primary hyperalgesia), as well as an exaggerated response in surrounding uninjured tissue (secondary hyperalgesia) [74]. In addition, noxious stimuli (pain) elicit changes in the dorsal horn neurons of the spinal cord known as central sensitization. This has the effect that stimuli from low-threshold Aß fibers, which are normally perceived as relatively innocuous, are now perceived as pain (pathologic pain) [74]. These physiologic changes have been demonstrated in humans using a variety of experimental approaches. In addition, there is evidence from several avenues of investigation that these early changes precipitate the development of chronic pain [57, 74, 75].

The more sophisticated understanding of the physiology of pain has led to the recommendation for a multifaceted approach to postoperative analgesia to prevent the sensitization that amplifies the sensation of pain. Nonsteroidal antiinflammatory agents decrease peripheral as well as central sensitization [74, 76]. Preoperative narcotics decrease central sensitization. However, the major factor in decreasing sensitization seems to be blocking the neural transmission of nociceptive stimuli that result from the incision, something that systemic narcotics alone cannot achieve. An intercostal block leads to a more effective block of nociceptive stimuli than an epidural approach [74]. Highly effective postthoracotomy pain relief has been demonstrated using such a multifaceted approach [77], and the intercostal block appears to be the most important component [77]. Whether analgesic agents are given preoperatively or postoperatively does not seem to be important [78]. Better early pain relief has been associated with a lower incidence of chronic postthoracotomy pain [75, 79], consistent with the theory of the pathophysiology of chronic pain.

In conclusion, continuous intercostal nerve blockade after thoracotomy using an extrapleural catheter results quite consistently in better pain relief and preservation of pulmonary function than systemic narcotics, and appears to be at least as good as an epidural approach. The ease of the extrapleural approach and the low incidence of complications suggest this technique should be used more frequently. Other methods of intercostal nerve blockade appear to be less effective, although direct intercostal nerve injection may decrease pain in the immediate postoperative period. The use of a multifaceted approach to postthoracotomy analgesia that includes intercostal nerve blockade may be beneficial in the immediate postoperative period as well as reduce the incidence of chronic pain.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
The author acknowledges financial support from I-Flow, Corp, which has provided remuneration for the author's participation in educational programs regarding use of its catheter.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Cook TM, Riley RH. Analgesia following thoracotomya survey of Australian practice. Anaesth Intensive Care 1997;25:520-524.[Medline]
  2. Detterbeck FC. Subpleural catheter placement for pain relief after thoracoscopic resection Ann Thorac Surg 2005(in press).
  3. Bilgin M, Akcali Y, Oguzkaya F. Extrapleural regional versus systemic analgesia for relieving postthoracotomy paina clinical study of bupivacaine compared with metamizol. J Thorac Cardiovasc Surg 2003;126:1580-1583.[Abstract/Free Full Text]
  4. Conacher ID, Kokri M. Postoperative paravertebral blocks for thoracic surgery. A radiological appraisal Br J Anaesth 1987;59:155-161.[Abstract/Free Full Text]
  5. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications Anaesthesia 1995;50:813-815.[Medline]
  6. Barron DJ, Tolan MJ, Lea RE. A randomized controlled trial of continuous extra-pleural analgesia post-thoracotomyefficacy and choice of local anaesthetic. Eur J Anaesthesiol 1999;16:236-245.[Medline]
  7. Eng J, Sabanathan S. Site of action of continuous extrapleural intercostal nerve block Ann Thorac Surg 1991;51:387-389.[Abstract/Free Full Text]
  8. Chan VW, Chung F, Cheng DC, Seyone C, Chung A, Kirby TJ. Analgesic and pulmonary effects of continuous intercostal nerve block following thoracotomy Can J Anaesth 1991;38:733-739.[Medline]
  9. Watson DS, Panian S, Kendall V, Maher DP, Peters G. Pain control after thoracotomybupivacaine versus lidocaine in continuous extrapleural intercostal nerve blockade. Ann Thorac Surg 1999;67:825-829.[Abstract/Free Full Text]
  10. Majid AA, Hamzah H. Pain control after thoracotomyan extrapleural tunnel to provide a continuous bupivacaine infusion for intercostal nerve blockade. Chest 1992;101:981-984.[Abstract/Free Full Text]
  11. Sabanathan S, Smith PJ, Pradhan GN, Hashimi H, Eng JB, Mearns AJ. Continuous intercostal nerve block for pain relief after thoracotomy Ann Thorac Surg 1988;46:425-426.[Abstract/Free Full Text]
  12. Nunn JF, Slavin G. Posterior intercostal nerve block for pain relief after cholecystectomy. Anatomical basis and efficacy Br J Anaesth 1980;52:253-260.[Abstract/Free Full Text]
  13. Olivet RT, Nauss LA, Payne WS. A technique for continuous intercostal nerve block analgesia following thoracotomy J Thorac Cardiovasc Surg 1980;80:308-311.[Abstract]
  14. Richardson J, Sabanathan S, Mearns AJ, Shah RD, Goulden C. A prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery Br J Anaesth 1995;75:405-408.[Abstract/Free Full Text]
  15. Mozell EJ, Sabanathan S, Mearns AJ, Bickford-Smith PJ, Majid MR, Zografos G. Continuous extrapleural intercostal nerve block after pleurectomy Thorax 1991;46:21-24.[Abstract/Free Full Text]
  16. Kaiser AM, Zollinger A, De Lorenzi D, Largiader F, Weder W. Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain Ann Thorac Surg 1998;66:367-372.[Abstract/Free Full Text]
  17. Deneuville M, Bisserier A, Regnard JF, Chevalier M, Levasseur P, Herve P. Continuous intercostal analgesia with 0.5% bupivacaine after thoracotomya randomized study. Ann Thorac Surg 1993;55:381-385.[Abstract/Free Full Text]
  18. Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses Br J Anaesth 1999;83:387-392.[Abstract/Free Full Text]
  19. Perttunen K, Nilsson E, Heinonen J, Hirvisalo EL, Salo JA, Kalso E. Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain Br J Anaesth 1995;75:541-547.[Abstract/Free Full Text]
  20. Richardson J, Sabanathan S, Eng J, et al. Continuous intercostal nerve block versus epidural morphine for postthoracotomy analgesia Ann Thorac Surg 1993;55:377-380.[Abstract/Free Full Text]
  21. Debreceni G, Molnar Z, Szelig L, Molnar TF. Continuous epidural or intercostal analgesia following thoracotomya prospective randomized double-blind clinical trial. Acta Anaesthesiol Scand 2003;47:1091-1095.[Medline]
  22. Matthews PJ, Govenden V. Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy Br J Anaesth 1989;62:204-205.[Abstract/Free Full Text]
  23. Sullivan E, Grannis Jr FW, Ferrell B, Dunst M. Continuous extrapleural intercostal nerve block with continuous infusion of lidocaine after thoracotomya descriptive pilot study. Chest 1995;108:1718-1723.[Abstract/Free Full Text]
  24. Sabanathan S, Mearns AJ, Bickford Smith PJ, et al. Efficacy of continuous extrapleural intercostal nerve block on post-thoracotomy pain and pulmonary mechanics Br J Surg 1990;77:221-225.[Medline]
  25. Eng J, Sabanathan S. Continuous extrapleural intercostal nerve block and post-thoracotomy pulmonary complications Scand J Thorac Cardiovasc Surg 1992;26:219-223.[Medline]
  26. Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral extrapleural infusion for post-thoracotomy pain management Surgery 1999;126:650-657.[Medline]
  27. Berrisford RG, Sabanathan SS, Mearns AJ, Bickford-Smith PJ. Pulmonary complications after lung resectionthe effect of continuous extrapleural intercostal nerve block. Eur J Cardiothorac Surg 1990;4:407-411.[Abstract/Free Full Text]
  28. de la Rocha AG, Chambers K. Pain amelioration after thoracotomya prospective, randomized study. Ann Thorac Surg 1984;37:239-242.[Abstract/Free Full Text]
  29. Berrisford RG, Sabanathan S, Mearns AJ, Clarke BJ, Hamdi A. Plasma concentrations of bupivacaine and its enantiomers during continuous extrapleural intercostal nerve block Br J Anaesth 1993;70:201-204.[Abstract/Free Full Text]
  30. Dauphin A, Gupta RN, Young JE, Morton WD. Serum bupivacaine concentrations during continuous extrapleural infusion Can J Anaesth 1997;44:367-370.[Medline]
  31. Scott DB. Toxic effects of local anaesthetic agents on the central nervous system Br J Anaesth 1986;58:732-735.[Free Full Text]
  32. Mann LJ, Young GR, Williams JK, Dent OF, McCaughan BC. Intrapleural bupivacaine in the control of postthoracotomy pain Ann Thorac Surg 1992;53:449-454.[Abstract/Free Full Text]
  33. Scheinin B, Lindgren L, Rosenberg PH. Treatment of post-thoracotomy pain with intermittent instillations of intrapleural bupivacaine Acta Anaesthesiol Scand 1989;33:156-159.[Medline]
  34. Schneider RF, Villamena PC, Harvey J, Surick BG, Surick IW, Beattie EJ. Lack of efficacy of intrapleural bupivacaine for postoperative analgesia following thoracotomy Chest 1993;103:414-416.[Abstract/Free Full Text]
  35. Francois T, Blanloeil Y, Pillet F, et al. Effect of interpleural administration of bupivacaine or lidocaine on pain and morphine requirement after esophagectomy with thoracotomya randomized, double-blind and controlled study. Anesth Analg 1995;80:718-723.[Abstract/Free Full Text]
  36. Ferrante FM, Chan VW, Arthur GR, Rocco AG. Interpleural analgesia after thoracotomy Anesth Analg 1991;72:105-109.[Abstract/Free Full Text]
  37. Silomon M, Claus T, Huwer H, Biedler A, Larsen R, Molter G. Interpleural analgesia does not influence postthoracotomy pain Anesth Analg 2000;91:44-50.[Abstract/Free Full Text]
  38. Miguel R, Hubbell D. Pain management and spirometry following thoracotomya prospective, randomized study of four techniques. J Cardiothorac Vasc Anesth 1993;7:529-534.[Medline]
  39. Symreng T, Gomez MN, Rossi N. Intrapleural bupivacaine v saline after thoracotomyeffects on pain and lung function—a double-blind study. J Cardiothorac Anesth 1989;3:144-149.[Medline]
  40. Tartiere J, Samba D, Lefrancois C, et al. Intrapleural bupivacaine analgesia after thoraco-abdominal incision for oesophagectomy Eur J Anaesthesiol 1991;8:145-149.[Medline]
  41. Brockmeier V, Moen H, Karlsson BR, Fjeld NB, Reiestad F, Steen PA. Interpleural or thoracic epidural analgesia for pain after thoracotomy. A double blind study Acta Anaesthesiol Scand 1993;38:317-321.
  42. Kambam JR, Hammon J, Parris WC, Lupinetti FM. Intrapleural analgesia for post-thoracotomy pain and blood levels of bupivacaine following intrapleural injection Can J Anaesth 1989;36:106-109.[Medline]
  43. Rosenberg PH, Scheinin BM, Lepantalo MJ, Lindfors O. Continuous intrapleural infusion of bupivacaine for analgesia after thoracotomy Anesthesiology 1987;67:811-813.[Medline]
  44. Raffin L, Fletcher D, Sperandio M, et al. Interpleural infusion of 2% lidocaine with 1:200,000 epinephrine for postthoracotomy analgesia Anesth Analg 1994;79:328-334.[Abstract/Free Full Text]
  45. Bachmann-Mennenga B, Biscoping J, Kuhn DF, et al. Intercostal nerve block, interpleural analgesia, thoracic epidural block or systemic opioid application for pain relief after thoracotomy? Eur J Cardiothorac Surg 1993;7:12-18.[Abstract/Free Full Text]
  46. Barnard D. The effects of extreme cold on sensory nerves Ann R Coll Surg Engl 1980;62:180-187.[Medline]
  47. Moorjani N, Zhao F, Tian Y, Liang C, Kaluba J, Maiwand MO. Effects of cryoanalgesia on post-thoracotomy pain and on the structure of intercostal nervesa human prospective randomized trial and a histological study. Eur J Cardiothorac Surg 2001;20:502-507.[Abstract/Free Full Text]
  48. Maiwand MO, Makey AR, Rees A. Cryoanalgesia after thoracotomy. Improvement of technique and review of 600 cases J Thorac Cardiovasc Surg 1986;92:291-295.[Abstract]
  49. Müller LC, Salzer GM, Ransmayr G, Neiss A. Intraoperative cryoanalgesia for postthoracotomy pain relief Ann Thorac Surg 1989;48:15-18.[Abstract/Free Full Text]
  50. Keenan DJ, Cave K, Langdon L, Lea RE. Comparative trial of rectal indomethacin and cryoanalgesia for control of early postthoracotomy pain BMJ 1983;287:1335-1337.
  51. Rooney SM, Jain S, McCormack P, Bains MS, Martini N, Goldiner PL. A comparison of pulmonary function tests for postthoracotomy pain using cryoanalgesia and transcutaneous nerve stimulation Ann Thorac Surg 1986;41:204-207.[Abstract/Free Full Text]
  52. Brichon PY, Pison C, Chaffanjon P, et al. Comparison of epidural analgesia and cryoanalgesia in thoracic surgery Eur J Cardiothorac Surg 1994;8:482-486.[Abstract/Free Full Text]
  53. Roberts D, Pizzarelli G, Lepore V, al-Khaja N, Belboul A, Dernevik L. Reduction of post-thoracotomy pain by cryotherapy of intercostal nerves Scand J Thorac Cardiovasc Surg 1988;22:127-130.[Medline]
  54. Roxburgh JC, Markland CG, Ross BA, Kerr WF. Role of cryoanalgesia in the control of pain after thoracotomy Thorax 1987;42:292-295.[Abstract/Free Full Text]
  55. Gough JD, Williams AB, Vaughan RS, Khalil JF, Butchart EG. The control of post-thoracotomy pain. A comparative evaluation of thoracic epidural fentanyl infusions and cryo-analgesia Anaesthesia 1988;43:780-783.[Medline]
  56. Orr IA, Keenan DJ, Dundee JW. Improved pain relief after thoracotomyuse of cryoprobe and morphine infusion. BMJ 1981;283:945-948.
  57. Richardson J, Sabanathan S, Mearns AJ, Sides C, Goulden C. Post-thoracotomy neuralgia Pain Clin 1994;7:87-97.
  58. Conacher ID. Percutaneous cryotherapy for post-thoracotomy neuralgia Pain 1986;25:227-228.[Medline]
  59. Galway JE, Caves PK, Dundee JW. Effect of intercostal nerve blockade during operation on lung function and the relief of pain following thoracotomy Br J Anaesth 1975;47:730-735.[Abstract/Free Full Text]
  60. Kaplan JA, Miller Jr ED, Gallagher Jr EG. Postoperative analgesia for thoracotomy patients Anesth Analg 1975;54:773-777.[Abstract/Free Full Text]
  61. Wurnig PN, Lackner H, Teiner C, et al. Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia? Eur J Cardiothorac Surg 2002;21:1115-1119.[Abstract/Free Full Text]
  62. Takamori S, Yoshida S, Hayashi A, Matsuo T, Mitsuoka M, Shirouzu K. Intraoperative intercostal nerve blockade for postthoracotomy pain Ann Thorac Surg 2002;74:338-341.[Abstract/Free Full Text]
  63. Asantila R, Rosenberg PH, Scheinin B. Comparison of different methods of postoperative analgesia after thoracotomy Acta Anaesthesiol Scand 1986;30:421-425.[Medline]
  64. Toledo-Pereyra LH, DeMeester TR. Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function Ann Thorac Surg 1979;27:203-205.[Abstract/Free Full Text]
  65. Roviaro GC, Varoli F, Fascianella A, et al. Intrathoracic intercostal nerve block with phenol in open chest surgerya randomized study with statistical evaluation of respiratory parameters. Chest 1986;90:64-67.[Abstract/Free Full Text]
  66. Delilkan AE, Lee CK, Yong NK, Ganendran A. Post-operative local analgesia for thoracotomy with direct bupivacaine intercostal blocks Anaesthesia 1973;28:561-567.[Medline]
  67. Holley HS, Shields TH, Raymon F. Post-thoracotomy intrathoracic intercostal block Anesthesiol Rev 1977:39-41(Jan).
  68. Faust RJ, Nauss LA. Post-thoracotomy intercostal blockcomparison of its effects on pulmonary function with those of intramuscular meperidine. Anesth Analg 1976;55:542-546.[Abstract/Free Full Text]
  69. Liu M, Rock P, Grass JA, et al. Double-blind randomized evaluation of intercostal nerve blocks as an adjuvant to subarachnoid administered morphine for post-thoracotomy analgesia Reg Anesth 1995;20:418-425.[Medline]
  70. Moore DC. Intercostal nerve block for postoperative somatic pain following surgery of thorax and upper abdomen Br J Anaesth 1975;47(Suppl):284-286.
  71. Safran D, Kuhlman G, Orhant EE, Castelain MH, Journois D. Continuous intercostal blockade with lidocaine after thoracic surgery. Clinical and pharmacokinetic study Anesth Analg 1990;70:345-349.[Abstract/Free Full Text]
  72. de Leon-Casasola OA, Parker B, Lema MJ, Harrison P, Massey J. Postoperative epidural bupivacaine-morphine therapy. Experience with 4,227 surgical cancer patients Anesthesiology 1994;81:368-375.[Medline]
  73. Stenseth R, Sellevold O, Breivik H. Epidural morphine for postoperative painexperience with 1085 patients. Acta Anaesthesiol Scand 1985;29:148-156.[Medline]
  74. Woolf CJ, Chong MS. Preemptive analgesia–treating postoperative pain by preventing the establishment of central sensitization Anesth Analg 1993;77:362-379.[Medline]
  75. Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgerya follow-up study. Acta Anaesthesiol Scand 1999;43:563-567.[Medline]
  76. McCrory C, Fitzgerald D. Spinal prostaglandin formation and pain perception following thoracotomya role for cyclooxygenase-2. Chest 2004;125:1321-1327.[Abstract/Free Full Text]
  77. Richardson J, Sabanathan S, Mearns AJ, Evans CS, Bembridge J, Fairbrass M. Efficacy of pre-emptive analgesia and continuous extrapleural intercostal nerve block on post-thoracotomy pain and pulmonary mechanics J Cardiovasc Surg 1994;35:219-228.[Medline]
  78. Møiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain reliefthe role of timing of analgesia. Anesthesiology 2002;96:725-741.[Medline]
  79. Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain Clin J Pain 1996;12:50-55.[Medline]



This article has been cited by other articles:


Home page
 Eur J Cardiothorac SurgHome page
H. Esme, B. Apiliogullari, F. M. Duran, B. Yoldas, and T. T. Bekci
Comparison between intermittent intravenous analgesia and intermittent paravertebral subpleural analgesia for pain relief after thoracotomy
Eur J Cardiothorac Surg, January 1, 2012; 41(1): 10 - 13.
[Abstract] [Full Text] [PDF]

Home page
 Eur J Cardiothorac SurgHome page
K. Wildgaard, R. H. Petersen, H. J. Hansen, H. Moller-Sorensen, T. K. Ringsted, and H. Kehlet
Multimodal analgesic treatment in video-assisted thoracic surgery lobectomy using an intraoperative intercostal catheter
Eur J Cardiothorac Surg, December 21, 2011; (2011) ezr151v1.
[Abstract] [Full Text] [PDF]

Home page
 Br J AnaesthHome page
R. Meierhenrich, D. Hock, S. Kuhn, E. Baltes, B. Muehling, R. Muche, M. Georgieff, and G. Gorsewski
Analgesia and pulmonary function after lung surgery: is a single intercostal nerve block plus patient-controlled intravenous morphine as effective as patient-controlled epidural anaesthesia? A randomized non-inferiority clinical trial
Br. J. Anaesth., April 1, 2011; 106(4): 580 - 589.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
D. D'Souza, K. Sondergaard, and F. C. Detterbeck
Transient Brachial Plexus Palsy: An Unusual Complication of Paravertebral Infusion of Local Anesthetic
Ann. Thorac. Surg., November 1, 2010; 90(5): e75 - e76.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
I. Hunt, D. Eaton, O. Maiwand, and V. Anikin
Video-assisted intercostal nerve cryoablation in managing intractable chest wall pain
J. Thorac. Cardiovasc. Surg., March 1, 2010; 139(3): 774 - 775.
[Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
M. Scarci, A. Joshi, and R. Attia
In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management?
Interact CardioVasc Thorac Surg, January 1, 2010; 10(1): 92 - 96.
[Abstract] [Full Text] [PDF]

Home page
 Br J AnaesthHome page
A. Kotze, A. Scally, and S. Howell
Efficacy and safety of different techniques of paravertebral block for analgesia after thoracotomy: a systematic review and metaregression
Br. J. Anaesth., November 1, 2009; 103(5): 626 - 636.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. S. Allen, L. Halgren, F. C. Nichols III, S. D. Cassivi, W. S. Harmsen, D. A. Wigle, K. R. Shen, and C. Deschamps
A Randomized Controlled Trial of Bupivacaine Through Intracostal Catheters for Pain Management After Thoracotomy
Ann. Thorac. Surg., September 1, 2009; 88(3): 903 - 910.
[Abstract] [Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
K. M. Blechman and M. Zervos
Post-thoracotomy Horner syndrome associated with extrapleural infusion of local anesthetic
Interact CardioVasc Thorac Surg, August 1, 2009; 9(2): 309 - 310.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
J. M. Clavero, J. E. Cheyre, M. E. Solovera, and R. P. Aparicio
Transient Diaphragmatic Paralysis by Continuous Para-Phrenic Infusion of Bupivacaine: A Novel Technique for the Management of Residual Spaces
Ann. Thorac. Surg., March 1, 2007; 83(3): 1216 - 1218.
[Abstract] [Full Text] [PDF]

Home page
 Anesth. Analg.Home page
M. G. Byas-Smith and A. Gulati
Ultrasound-Guided Intercostal Nerve Cryoablation
Anesth. Analg., October 1, 2006; 103(4): 1033 - 1035.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
F. C. Detterbeck
Subpleural Catheter Placement for Pain Relief After Thoracoscopic Resection
Ann. Thorac. Surg., April 1, 2006; 81(4): 1522 - 1523.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Frank C. Detterbeck
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Detterbeck, F. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Detterbeck, F. C.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS