title: Effect of Cryoanalgesia Combined with Intravenous Continuous Analgesia in Thoracotomy Patients Prediction of Postoperative Pain by Preoperative Nociceptive Responses to Heat Stimulation Low-dose Intravenous Ketamine Potentiates Epidural Analgesia after Thoracotomy Risk Factors for Chronic Pain after Hysterectomy: A Nationwide Questionnaire and Database Study The Effects of Three Different Analgesia Techniques on Long-Term Postthoracotomy Pain Intercostal muscle flap reduces the pain of thoracotomy: a prospective randomized trial. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Role of cryoanalgesia in the control of pain after thoracotomy. Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post‐thoracotomy pain control Epidural block with mepivacaine before surgery reduces long-term post-thoracotomy pain Effect of pre-emptive ketamine on sensory changes and postoperative pain after thoracotomy: comparison of epidural and intramuscular routes. A study exploring the role of intercostal nerve damage in chronic pain after thoracic surgery. Long-term Pain and Activity during Recovery from Major Thoracotomy Using Thoracic Epidural Analgesia Pain and physical function are similar following axillary, muscle-sparing vs posterolateral thoracotomy. Prediction of post‐operative pain by an electrical pain stimulus The role of video-assisted thoracic surgery for the treatment of lung cancer: lung lobectomy by thoracoscopy versus the standard thoracotomy approach. Has postoperative pain been eradicated? Muscle-sparing versus posterolateral thoracotomy: a prospective study. A Randomized Study of the Effects of Gabapentin on Postamputation Pain The influence of preamputation pain on postamputation stump and phantom pain Pre-emptive effect of multimodal analgesia in thoracic surgery. A nondivided intercostal muscle flap further reduces pain of thoracotomy: a prospective randomized trial. Pain management and spirometry following thoracotomy: a prospective, randomized study of four techniques. The effects of cryoanalgesia combined with thoracic epidural analgesia in patients undergoing thoracotomy Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints. Post‐thoracotomy pain after thoracic epidural analgesia: a prospective follow‐up study Lobectomy--video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery. Women Suffer More Short and Long-term Pain Than Men After Major Thoracotomy Five-Year Follow-Up of Patients Undergoing Laparoscopic or Open Groin Hernia Repair: A Randomized Controlled Trial A prospective, double-blinded, randomized trial evaluating the use of preemptive analgesia of the skin before thoracotomy. Women’s Recovery from Sternotomy-Extension (WREST-E) study: examining long-term pain and discomfort following sternotomy and their predictors
abstract: Fifty patients undergoing thoracotomy was studied to compare the effects of cryoanalgesia combined with intravenous continuous analgesia ( IVCA ) .  Patients were r and omized into two groups : IVCA group and IVCA-cryo group .  Subjective pain intensity was assessed on a visual analogue scale at rest ( VAS-R ) and during movement ( VAS-M ) . Analgesic requirements were evaluated over the 7 days following surgery . Forced vital capacity ( FVC ) and forced expiratory volume in 1 sec ( FEV1 ) were measured before operation , on the 2nd and 7th postoperative days ( POD ) . We interviewed patients by telephone to evaluate the prevalence of post-thoracotomy pain at the 1st , 3rd , and 6th months postoperatively . No significant differences were observed between the two groups with respect to postoperative pain , analgesic requirements , side effects , respiratory complications , or prevalence of post-thoracotomy pain . However , a significant increase in FVC and FEV1 was observed on the 7th POD in IVCAc-ryo group . The incidence of the post-thoracotomy pain at the 1st , 3rd , and 6th months postoperatively was 68 , 60 , and 44 % in IVCA group , and 88 , 68 , and 28 % in IVCA-cryo group , respectively . Our study showed that cryoanalgesia combined with IVCA effectively restore respiratory function on 7th POD , but that it was not effective at reducing the incidence of post-thoracotomy pain Background Despite major advances in the underst and ing of the neurobiologic mechanisms of pain , the wide variation in acute pain experience has not been well explained . Therefore , the authors investigated the potential of a preoperatively induced heat injury to predict subsequent postoperative pain ratings in patients undergoing knee surgery . Methods Twenty patients were studied . The burn injury was induced 6 days before surgery with a contact thermode ( 12.5 cm2 , 47 ° C for 7 min ) . The sensory testing , before and 1 h after the injury , included pain score during induction of the burn , secondary hyperalgesia area , thermal and mechanical pain perception , and pain thresholds . Postoperative analgesia consisted of ibuprofen and acetaminophen . Pain ratings ( visual analog scale ) at rest and during limb movement were followed for 10 days after surgery . Results The burn injury was associated with development of significant hyperalgesia . There was a significant correlation between preoperative pain ratings during the burn injury and early ( 0–2 days , area under the curve ) and late ( 3–10 days , area under the curve ) postoperative dynamic pain ratings during limb movement . Conclusion The results of this study suggest that the pain response to a preoperative heat injury may be useful in research in predicting the intensity of postoperative pain . These findings may have important implication s to identify patients at risk for development of chronic pain and to stratify individuals for investigations of new analgesics Background : Ketamine potentiates intravenous or epidural morphine analgesia . The authors hypothesized that very-low-dose ketamine infusion reduces acute and long-term postthoracotomy pain . Methods : Forty-nine patients scheduled to undergo open thoracotomy were r and omly assigned to receive one of two anesthesia regimens : continuous epidural infusion of ropivacaine and morphine , along with intravenous infusion of ketamine ( 0.05 mg · kg−1 · h−1 [ approximately 3 mg/h ] , ketamine group , n = 24 ) or placebo ( saline , control group , n = 25 ) . Epidural analgesia was continued for 2 days after surgery , and infusion of ketamine or placebo was continued for 3 days . Pain was assessed at 6 , 12 , 24 , and 48 h after surgery . Patients were asked about their pain , abnormal sensation on the wound , and inconvenience in daily life at 7 days and 1 , 3 , and 6 months after surgery . Results : The visual analog scale scores for pain at rest and on coughing 24 and 48 h after thoracotomy were lower in the ketamine group than in the control group ( pain at rest , 9 ± 11 vs. 25 ± 20 and 9 ± 11 vs. 18 ± 13 ; pain on coughing , 26 ± 16 vs. 50 ± 17 and 30 ± 18 vs. 43 ± 18 , mean ± SD ; P = 0.002 and P = 0.01 , P < 0.0001 and P = 0.02 , respectively ) . The numerical rating scale scores for baseline pain 1 and 3 months after thoracotomy were significantly lower in the ketamine group ( 0.5 [ 0–4 ] vs. 2 [ 0–5 ] and 0 [ 0–5 ] vs. 1.5 [ 0–6 ] , median [ range ] , respectively ; P = 0.02 ) . Three months after surgery , a higher number of control patients were taking pain medication ( 2 vs. 9 ; P = 0.03 ) . Conclusions : Very-low-dose ketamine ( 0.05 mg · kg−1 · h−1 ) potentiated morphine-ropivacaine analgesia and reduced postthoracotomy pain Background : Women scheduled to undergo hysterectomy for benign indications frequently have preoperative pelvic pain , but it is largely unknown why pain in some cases persists or even develops after surgery . This nationwide question naire and data base study describes pain and identifies risk factors for chronic  postsurgical pain  1 yr after hysterectomy for benign indications . Methods : A pain question naire was mailed to 1,299 women 1 yr after hysterectomy .  The response rate was 90.3 % , and the presence of persistent pain was correlated to indication for surgery , surgical procedure , type of anesthesia , and other perioperative data . Results : Pain was reported by 31.9 % 1 yr after hysterectomy ( chronic pain ) , and 13.7 % had pain more than 2 days a week . Pain was not present before surgery in 14.9 % of women with chronic postsurgical pain . Risk factors for chronic pain were preoperative pelvic pain ( odds ratio [ OR ] , 3.25 ; 95 % confidence interval [ CI ] , 2.40–4.41 ) , previous cesarean delivery ( OR , 1.54 ; CI , 1.06–2.26 ) , pain as the main indication for surgery ( OR , 2.98 ; CI , 1.54–5.77 ) , and pain problems elsewhere ( OR , 3.19 ; CI , 2.29–4.44 ) . Vaginal hysterectomy versus total abdominal hysterectomy was not significantly associated with a lower risk of chronic pain ( OR , 0.70 ; CI , 0.46–1.06 ) . Importantly , spinal versus general anesthesia was associated with less chronic pain ( OR , 0.42 ; CI , 0.21–0.85 ) . Conclusions : Thirty-two percent had chronic pain after hysterectomy , and risk factors were comparable to those seen in other operations . Interestingly , spinal anesthesia was associated with a lower frequency of chronic pain , justifying prospect i ve study of spinal anesthesia for patients with a high risk for development of chronic postsurgical pain In this clinical , r and omized , prospect i ve study , we compared the effects of three different analgesia techniques ( thoracic epidural analgesia [ TEA ] with and without preoperative initiation and IV patient-controlled analgesia [ IV-PCA ] ) on postthoracotomy pain in 69 patients . In two groups , a thoracic epidural catheter was inserted preoperatively . Group Pre-TEA had bupivacaine and morphine solution preoperatively and intraoperatively . Postoperative analgesia was maintained with epidural PCA with a similar solution . Group Post-TEA , with no intraoperative medication , had the same postoperative analgesia as Group Pre-TEA plus the bolus dose . Group IV-PCA received only IV-PCA with morphine for postoperative analgesia . Pain was evaluated every 4 h during the first 48 h at rest , cough , and movement . Pre-TEA was associated with decreased pain compared with the other groups . Six months later , the patients were asked about their pain . The incidence and the intensity of pain were most frequent in Group IV-PCA ( 78 % ) and were the least in Group Pre-TEA ( 45 % ) ( Group Pre-TEA versus Group IV-PCA , P = 0.0233 ; Group Pre-TEA versus Group IV-PCA , P = 0.014 ) . Patients having pain on the second postoperative day had 83 % chronic pain . TEA with preoperative initiation is a preferable method in preventing acute and long-term thoracotomy pain BACKGROUND Thoracotomy is associated with significant pain and morbidity . METHODS We performed a prospect i ve r and omized trial over 4 months . Patients were r and omized to a st and ard posterior-lateral thoracotomy or an identical procedure , except an intercostal muscle was harvested from the lower rib ( to protect the intercostal nerve ) before chest retraction . To ensure an equal distribution among both groups , patients were stratified by race , sex , and type of pulmonary resection . All patients received similar pain management . Pain was assessed by using multiple pain scores during hospitalization and after discharge . Outcomes assessed were pain scores , spirometric values , analgesic use , and activity level . RESULTS There were 114 patients . The median time for intercostal muscle harvesting was 3.7 minutes . The numeric pain scores were lower for the intercostal muscle group on postoperative days 1 and 2 and at weeks 1 , 2 , 3 , 4 , 8 , and 12 ( P < .05 for all ) . In addition , patients in the intercostal muscle group had a smaller decrease in spirometric values , were less likely to be using analgesics , and were more likely to have returned to normal activity . CONCLUSIONS The harvesting of an intercostal muscle flap before chest retraction decreases the pain of thoracotomy and leads to a lower decrease in spirometry . In addition , patients have less pain at 1 , 2 , 3 , 4 , 8 , and 12 weeks postoperatively and are less likely to be using narcotics . Finally , it offers a pedicled muscle flap that takes little time to harvest and is able to buttress all bronchi after lobectomy OBJECTIVE Long-term pain is a common sequela of thoracotomy , occurring in approximately 50 % of patients 2 years after thoracic surgery . Despite this alarming statistic , little is known about the factors responsible for the transition of acute to chronic pain . The aim of the present study is to identify predictors of long-term post-thoracotomy pain . DESIGN Follow-up was for 1.5 years for patients who had participated in a prospect i ve , r and omized , controlled trial of preemptive , multimodal analgesia .  SETTING Subjects were recruited from a tertiary care center . PATIENTS Thirty patients who had undergone lateral thoracotomy  were followed up by telephone , administered a structured interview , and classified according to long-term pain status . MAIN OUTCOME MEASURES Present pain status was measured by a verbal rating scale ( VAS ) . Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later . These include VAS pain scores at rest and after movement , McGill Pain Question naire data , patient-controlled morphine consumption ( mg ) , and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision . RESULTS Fifty-two percent of patients reported long-term pain . Early postoperative pain was the only factor that significantly predicted long-term pain . Pain intensity 24 h after surgery , at rest , and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients . A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Question naire . Cumulative morphine was comparable for the two groups . Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups . CONCLUSION Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain Thoracotomy causes severe postoperative pain , which is difficult to manage since the use of systemic analgesics often causes respiratory depression . Cryoanalgesia of the intercostal nerves has been advocated as an effective means of local analgesia without serious side effects . A prospect i ve r and omised blind trial to investigate the efficacy of the technique was carried out . A total of 53 patients undergoing thoracotomy  were allocated to either the trial or a control group . At thoracotomy the surgeon was informed of the patient 's trial allocation . The trial group received one minute of direct cryotherapy to at least five intercostal nerves related to the incision . All patients received methadone via the lumbar epidural route in a dose calculated according to their weight . A linear analogue assessment of postoperative pain was made by the patients as soon as they were sufficiently awake . An independent record of all postoperative analgesia was kept . After discharge from hospital further assessment s were made at least six weeks after operation . Statistical analysis of the scores of postoperative pain and analgesic consumption showed that there was no significant difference between the trial and the control group . There was , however , a suggestion of an increase in the long term morbidity , although these figures were not amenable to statistical analysis . Thus is has not been possible to demonstrate a role for cryoanalgesia in the control of post thoracotomy pain Epidural analgesia is regarded as the gold method for controlling post‐thoracotomy pain . Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects , but is suspected to increase the incidence of chronic pain . However , r and omized controlled trials comparing these two methods for post‐thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously . We studied 107 adult patients , allocated r and omly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia .  Acute pain scores and opioid‐related side effects were evaluated for three postoperative days . Chronic pain information , including the incidence , severity , and allodynia‐like pain , was acquired on the first , third , sixth and twelfth months postoperatively . There was no significant difference on numeral rating scales ( NRS ) at rest or on motion between the two groups during the three postoperative days . The patient satisfaction results were also similar between the groups . The side effects , especially mild pruritus , were reported more often in the epidural group . Both groups showed high incidence of chronic pain ( 42.1–72.1 % ) , and no significance between the groups . The incidence of allodynia‐like pain reported in cryo group was higher than that in Epidural group on any postoperative month , with significance on the sixth and the twelfth months postoperatively ( P<0.05 ) . More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life ( P<0.05 ) . Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post‐thoracotomy acute pain . The incidence of post‐thoracotomy chronic pain is high . Cryoanalgesia may be a factor that increases the incidence of neuropathic pain Purpose To examine the effect of continuous epidural block initiated before thoracic surgery upon early and long-term postoperative pain . Methods In a double-blind study , 70 patients scheduled for thoracic surgery under general anesthesia were assigned r and omly to receive continuous epidural block with mepivacaine 1.5 % initiated either 20 min before surgical incision ( Pre group ) or at completion of surgery ( Post group ) . In both groups the initial dose was 4 ml , followed by a continuous infusion at 4 ml·hr−1 until 72 hr after operation . Indomethadn suppositories , 50 mg , were administered on request as supplementary analgesics . Visual analogue scale at rest was assessed four hours after operation , and then every 24 hr after operation on postoperative days 1 through 7 , and also days 14 and 30 . At three and six months after operation , all patients were interviewed by telephone with respect to postoperative pain . The most severe pain was assessed using modified numerical rating scale . Results By a visual analogue scale , postoperative pain was less in the Pre group than in the Post group at four hours , two and three days after operation ( P < 0.05 ) . By a numerical rating scale six months after operation , pain was less in the Pre group than in the Post group ( P = 0.015 ) . The percentage of pain-free patients was higher in the Pre group than in the Post group at three ( P = 0.035 ) and six ( P = 0.0086 ) months after operation . Conclusion Continuous epidural block initiated prior to surgery may reduce long-term post-thoracotomy pain . RésuméObjectifExaminer l’effet d’un blocage épidural continu , amorcé avant une intervention chirurgicale thoracique , sur la douleur postopératoire précoce et de long terme . MéthodeLétude à double insu a porté sur 70 patients qui devaient subir une opération thoracique sous anesthésie générale . Répartis au hasard , ils ont reçu un blocage épidural continu avec de la mépivacaïne à 1,5 % , administrée soit 20 min avant l’incision chirurgicale ( groupe Pré ) , soit à la fin de l’intervention ( groupe Post ) . Pour tous , la dose initiale a été de 4 ml suivie d’une perfusion continue à 4 ml·hr−1 jusqu’à 72 h après l’opération . Des suppositoires de 50 mg d’indométhacine ont été administrés sur dem and e pour compléter l’analgésie . La douleur a été évaluée au repos selon l’échelle visuelle analogique , 4 h après l’opération et puis à toutes les 24 h des jours 1 à 7 et aussi les jours 14 et 30 . Trois mois et six mois après l’opération , tous les patients ont été interrogés par téléphone au sujet de la douleur postopératoire . La douleur la plus sévère a été évaluée en utilisant une échelle d’estimation numérique modifiée . RésultatsSelon l’échelle visuelle analogique , la douleur postopératoire était plus faible chez les patients du groupe Pré que chez ceux du groupe Post à 4 h , deux et trois jours après l’opération ( P < 0,05 ) . Selon une échelle d’estimation numérique , la douleur était moins intense chez les patients du groupe Pré que chez ceux du groupe Post ( P = 0,015 ) six mois après l’opération . Le pourcentage de patients sans douleur était plus élevé dans le groupe Pré que dans le groupe Post à trois mois ( P = 0,035 ) et à six mois ( P = 0,0086 ) après l’opération . Conclusion Le blocage épidural continu amorcé avant l’intervention chirurgicale peut réduire la douleur qui se prolonge après une thoracotomie BACKGROUND In this study we have evaluated the efficacy of ketamine via i.m . and epidural routes for the control of  post-thoracotomy pain .  METHODS The study was r and omized , double blinded and placebo controlled . With the approval of the Faculty Ethics Committee , 60 patients undergoing elective thoracotomy were r and omized into three equal groups . Group IM had i.m . ketamine 1 mg kg(-1 ) in 2 ml plus epidural normal saline ; Group EPI had epidural ketamine 1 mg kg(-1 ) in 10 ml plus i.m . normal saline ; Group C had epidural normal saline 10 ml plus i.m . normal saline 10 ml . Anaesthesia was st and ardized . Postoperative analgesia was maintained with epidural patient-controlled analgesia using bupivacaine and morphine .  Visual analogue scale values and analgesic consumption were evaluated at 2 , 4 , 6 , 8 , 10 , 12 , 24 and 48 h after surgery . The areas of allodynia , pin-prick hyperalgesia and pressure hyperalgesia were measured at 48 h , and days 15 and 30 in all groups . RESULTS Intraoperative fentanyl requirement was significantly lower in Group EPI than Group C. The morphine and bupivacaine requirements were significantly lower in Group EPI than the other two groups in the postoperative period . There was reduced pin-prick hyperalgesia and touch allodynia in the EPI group . There were no side-effects attributable to ketamine . CONCLUSION The results of the present study demonstrate that pre-emptive epidural ketamine is effective in reducing intra- and postoperative analgesic requirements , hyperalgesia and touch allodynia OBJECTIVE Our aim was to investigate the prevalence of intra-operative nerve damage and its association with  chronic pain .  METHODS Our prospect i ve study of 33 patients used nerve conduction studies to assess intercostal nerve function during elective thoracic surgical procedures . We used two methods to study nerve conduction : pre-operative magnetic stimulation ( in 10 patients ) and intra-operative nerve conduction studies ( in all patients ) We correlated these findings with specific intra-operative parameters , pain and psychological question naires pre-op and 3 month post-op and altered cutaneous sensation . RESULTS Magstim ( magnetic stimulation ) assessment s were not reliable and were therefore ab and oned . Intraoperative intercostal nerve studies revealed two distinct patterns of nerve injury and also that nerve injury was less in those cases where a rib was not resected . However , intercostal nerve damage detected at the time of operation is not associated with chronic pain or altered cutaneous sensation at 3 months post-op . CONCLUSIONS The study findings suggest that either the amount of intra-operative intercostal nerve damage is not indicative of long-term nerve damage or that there is a more significant cause for chronic pain other than intercostal nerve injury Background Pain  following thoracotomy  can persist for years with an undetermined impact on quality of life . Factors hypothesized to modulate this painful experience include analgesic regimen , gender , and type of incision . Methods A total of 157 generally healthy patients of both genders scheduled for segmentectomy , lobectomy , or bilobectomy through a posterolateral or muscle-sparing incision were r and omly assigned to receive thoracic epidural analgesia initiated prior to incision or at the time of rib approximation .  Pain and activity scores were obtained 4 , 8 , 12 , 24 , 36 , and 48 weeks after surgery . Results Overall , there were no differences in pain scores between the control and intervention groups during hospitalization ( P ≥ 0.165 ) or after discharge ( P ≥ 0.098 ) . The number of patients reporting pain 1 yr following surgery ( 18 of 85 ; 21.2 % ) was not significantly different ( P = 0.122 ) from the number reporting preoperative pain ( 15 of 120 ; 12.5 % ) . During hospitalization , women reported greater pain than men ( worst pain , P = 0.007 ; average pain , P = 0.016 ) . Women experienced fewer supraventricular tachydysrhythmias ( P = 0.013 ) and were thus discharged earlier ( P = 0.002 ) . After discharge women continued to report greater discomfort than men ( P ≤ 0.016 ) , but did not differ from men in their level of physical activity ( P = 0.241 ) . Conclusions Initiation of thoracic epidural analgesia prior to incision or the use of a muscle-sparing incision did not significantly impact pain or physical activity . Although women reported significantly greater pain during hospitalization and after discharge , they experienced fewer complications , were more likely to be discharged from the hospital sooner , and were just as active after discharge as men STUDY OBJECTIVES We set out to determine whether there is a difference in postoperative pain and recovery after the patient undergoes the axillary muscle-sparing incision ( ie  ,  muscle-sparing thoracotomy [ MT ] ) vs the modified posterolateral incision ( ie  ,  posterolateral thoracotomy [ PT ] ) .  DESIGN Analysis of a data base originally collected to determine the effect of the timing of epidural analgesia on long-term outcome after thoracotomy . SETTING The Hospital of the University of Pennsylvania . PATIENTS Patients presenting for lobectomy , segmentectomy , or bilobectomy . MEASUREMENTS Pain , physical activity , and the extent that pain interfered with activities following major thoracotomy were prospect ively assessed with st and ard question naires ( ie , the brief pain inventory and the Medical Outcomes Study 36-item short form ) on postoperative days 1 to 5 , and at postoperative weeks 4 , 8 , 12 , 24 , 36 , and 48 by a blinded research assistant . Perioperative care was st and ardized and included patient-controlled thoracic epidural analgesia until thoracostomy tube removal . RESULTS Eighty-two subjects underwent MT and 38 subjects underwent PT  during the 16-month accrual period . There were no significant differences in demographics . Pain reported during hospitalization and after hospital discharge did not differ with respect to incision type ( p > or = 0.17 ) . Postoperative physical activity levels were significantly less than those reported preoperatively , with a trend toward better functioning in the MT groups after 8 weeks . Incision type did not predict complications , morbidity , or mortality . CONCLUSIONS When comparing patients who had undergone vertical , axillary , wholly MT to those who had undergone modified serratus muscle-sparing PT , postoperative differences in pain were not apparent . One should not anticipate reduced pain or more rapid overall recovery following MT , at least when epidural analgesia is used aggressively for perioperative pain control Background : Treatment of  post‐operative pain  is still a significant problem . Recently , interest has focused on pre‐operative identification of patients who may experience severe post‐operative pain in order to offer a more aggressive analgesic treatment . The nociceptive stimulation methods have included heat injury and pressure algometry . A simple method , Pain Matcher ® ( PM ) , using electrical stimulation , is vali date d for pain assessment , but has not been evaluated as a tool for prediction of post‐operative pain . Our aim was to assess the predictive value of pre‐caesarean section pain threshold on intensity of post‐caesarean section pain using the PM Our objective was to evaluate the usefulness , safety , validity and benefits of video-assisted thoracoscopic surgery ( VATS ) for performing pulmonary lobectomy in 24 patients with clinical NO stage I primary non-small-cell lung cancer compared with 30 patients who underwent a conventional thoracotomy .  There were no significant differences in the intra-operative blood loss , duration of operation , or duration of chest tube drainage between the VATS group and the st and ard lobectomy group , but in this VATS ' experience , patients had less postoperative pain . Numbers and distributions of dissected lymph-nodes were similar in patients whether undergoing st and ard thoracotomy or VATS lobectomy . We can confirm that the safety and validity of VATS are virtually identical to those of the st and ard thoracotomy approach in the lobectomy . However , the former technique causes less discomfort to patients and requires a shorter recovery period of laboratory data and IL-6 concentrations in thoracic drainage fluid . We conclude that VATS major lung resection is technically feasible . Stringent patient selection is important and special training is needed Recent evidence suggests that surgical trauma induces a process of central nervous system sensitisation that contributes to and enhances postoperative pain . These changes are also thought to be the underlying cause of much chronic pain . Central sensitisation is generated not only during surgery , but also postoperatively as a result of the inflammatory response to the damaged tissue . This knowledge provides a rational basis for pro-active , pre-emptive and postoperative analgesic strategies to reduce the neuronal barrage associated with tissue damage . Reduction or elimination of postoperative pain is therefore possible . We advocate the use of continuous extrapleural intercostal nerve block for postoperative analgesia in patients undergoing thoracotomy .  When this is begun pre-emptively ( by precutaneous , pre-incisional paravertebral block ) it is combined with an opiate and a non-steroidal anti-inflammatory drug premedication . In a r and omised study of 56 patients , pain scores of less than 0.5 cm on a 10 cm scale were produced , postoperative lung function was preserved and glucose and cortisol responses were significantly unchanged from preoperative values . Evidence that effective perioperative analgesia reduces the incidence of chronic post-thoracotomy chest wall pain was found in a retrospective study of 1000 consecutive thoracotomies . The endpoints of a zero pain score , complete preservation of preoperative lung function and prevention of the stress response to trauma are currently achievable and should be provided for virtually all patients undergoing chest surgery . Pre-empting pain must be the goal for all those involved in the postoperative care of patients OBJECTIVE Although the thoracotomy incision is guided in part by the exposure required , both cosmesis and the potential for improved recovery are important factors to be taken into account . We conducted a prospect i ve r and omized study in order to compare muscle sparing thoracotomy ( MST ) and st and ard posterolateral thoracotomy ( PLT ) for postoperative pain and physical function during and after hospitalization . MATERIAL AND METHOD One hundred patients operated from June through December 2004 were recruited in this study . Fifty patients underwent MST of 6 - 8 cm and 50 had a PLT of more than 8 cm with division of latissimus dorsi and serratus anterior muscles . Operations performed were atypical resections and lobectomies . Pneumonectomies and operations on tumors invading the chest wall or brachial plexus were excluded . Perioperative care was st and ardized concerning analgetics and physiotherapy . Postoperative pain ( quantitated by the visual analogue scale ) , preoperative and postoperative pulmonary function , shoulder strength , and range of motion were evaluated . RESULTS There was no difference in demographics , tumor stage , and type of lung resection . Patients were also matched for the number of chest tubes , length of chest tube duration , and length of hospital stay . Pain reported during hospitalization and after hospital discharge within 1 and 2 months did not differ within the two groups ( p>0.05 ) . Shoulder function was shown to decrease less in cases of MST , but physical function was not found statistically significant in comparison of the two groups ( p>0.05 ) within 1 month . Rehabilitation was also similar . CONCLUSION The rates of occurrence of acute or chronic pain and morbidity were equivalent after MST and PLT . It appears that the single advantage of MST over PLT involves the preservation of chest wall musculature in case rotational muscle flaps should be needed along with a better cosmetic result Background : Pain after amputation is common but difficult to treat . Therefore , the authors examined whether postoperative treatment with gabapentin could reduce postamputation stump and phantom pain . Methods : Forty-six patients scheduled to undergo lower limb amputation were r and omly assigned to receive oral gabapentin or placebo . Treatment was started on the first postoperative day and continued for 30 days . The daily dose of gabapentin or placebo was gradually increased to 2,400 mg/day . The intensity of stump and phantom pain was recorded every day on a numeric rating scale ( 0–10 ) during the 30-day treatment period . Five interviews were performed after 7 , 14 , and 30 days and after 3 and 6 months . Results : Results from 41 patients were included in the data analysis . The risk of phantom pain  ( gabapentin vs. placebo ) was 55.0 % versus 52.6 % ( risk difference , 2.4 % ; 95 % confidence interval , −28.9 to 33.7 % ; P = 0.88 ; 30 days ) and 58.8 % versus 50.0 % ( risk difference , 8.8 % ; 95 % confidence interval , −23.3 to 40.9 % ; P = 0.59 ; 6 months ) . The median intensity of phantom pain  ( gabapentin vs. placebo ) was 1.5 ( range , 0–9.0 ) versus 1.2 ( range , 0–6.6 ) ( P = 0.60 ; 30 days ) and 1.0 ( range , 0–6.0 ) versus 0.5 ( range , 0–5.0 ) ( P = 0.77 ; 6 months ) . The median intensity of stump pain was 0.85 ( range , 0–8.2 ) versus 1.0 ( range , 0–5.4 ) ( P = 0.68 ; 30 days ) and 0 ( range , 0–8.0 ) versus 0 ( range , 0–5.0 ) ( P = 0.58 ; 6 months ) . Conclusion : Gabapentin administered in the first 30 postoperative days after amputation does not reduce the incidence or intensity of postamputation pain Abstract The significance of preamputation pain for the development of postamputation stump and phantom pain has been discussed over the years and is still a matter of dispute . It has been argued that preamputation pain increases the risk of phantom pain and that phantom pain is a revivification of pain experienced before the amputation . The purpose of this prospect i ve study was to clarify the relation between preamputation pain and phantom pain . Fifty‐six patients scheduled for amputation of a lower limb were interviewed the day before the amputation about preamputation pain and about stump and phantom pain 1 week , 3 and 6 months after the amputation .  Pain was quantitated and described using a  visual analogue scale ( VAS ) , 10 different word descriptors , the McGill Pain Question naire ( MPQ ) and the patients ' own words . If phantom pain was present patients were asked if the pain was similar to any pain experienced before the amputation . At each postoperative interview patients were asked to recall preamputation pain intensity . Location of pain and analgesic requirements were registered . Preamputation pain significantly increased the incidence of stump pain ( P=0.04 ) and phantom pain ( P=0.04 ) after 1 week and the incidence of phantom pain after 3 months ( P=0.03 ) . About 42 % of the patients reported that their phantom pain resembled the pain they had experienced at the time of the amputation . However , there was no relation between the patients ' own opinion about similarity between preamputation pain and phantom pain and the actual similarity found when comparing pre‐ and postoperative recordings of pain . Patients significantly overestimated preamputation pain intensity after 6 months Thirty subjects undergoing posterolateral thoracotomy were allocated r and omly to receive one of two analgesic regimens : group Pre received i.v . morphine , i.m . diclofenac and intercostal nerve blocks from T2 to T11 , 20 min before operation and placebo injections after operation . Group Post received placebo injections before operation , and i.v . morphine , i.m . diclofenac and intercostal nerve blocks from T2 to T11 at the end of surgery , before discontinuation of anaesthesia . Visual analogue pain scores , extent and duration of intercostal nerve block , analgesic consumption and complications were assessed during the postoperative period by a single blinded observer . Subjects were followed-up for a minimum of 12 months to determine the incidence of post-thoracotomy pain syndrome . During the first 48 h after operation there were lower pain scores in group Pre when taking a vital capacity breath but there were no significant differences between the groups in any other measure . The effects of pre-emptive analgesia given before surgery appeared to be relatively modest in terms of analgesia , analgesic consumption and long-term outcome and were of limited clinical significance BACKGROUND The pain of thoracotomy  may be related to trauma to the intercostal nerves . METHODS This was a prospect i ve r and omized study of 160 patients . All patients had a functioning epidural , similar type and size thoracotomy , an intercostal muscle flap  ( ICM ) harvested before rib spreading , inferior rib drilling , and postoperative pain management . In one group , the ICM was left intact distally and it dangled ( D group ) ; the ICM in the other was cut distally ( C group ) . Pain was assessed using multiple pain scores . Outcomes assessed were qualitative and quantitative pain scores , number of ribs broken , spirometric values , analgesic use , and return to baseline activity for postoperative days 1 to 5 and weeks 2 , 3 , 4 , 8 , and 12 . RESULTS The D group had 85 patients and the C group , 75 . The groups had similar demographics , types of procedures , and histology . Intrahospital pain scores were similar ; however , at postoperative weeks 3 , 4 , 8 , and 12 , the D group had significantly lower mean numeric pain scores and was using fewer analgesics ( p < 0.05 for all ) . At 12 weeks , patients in the D group were more likely to have returned to baseline activity ( p = 0.002 ) . CONCLUSIONS An ICM flap reduces pain . Harvesting and then leaving the ICM flap intact instead of cutting it before rib spreading further reduced thoracotomy pain . This technique , when added to rib drilling , leads to reduced pain on postoperative weeks 3 to 12 , to quicker return to baseline activity , and lessens the need for analgesics Forty-five patients who underwent anterolateral and posterolateral thoracotomy  were studied to compare the relative efficacy of cryoanalgesia , epidural morphine , intrapleural analgesia , and intravenous morphine for relief of postoperative pain and prevention of deterioration in pulmonary function . Spirometry ( FEV1 , FVC ) was performed preoperatively and postoperatively . Patients '  pain was assessed using the 0 to 100 mm visual analog scale . Because intravenous morphine was used to supplement pain relief in the patients who received intrapleural analgesia and cryoanalgesia , total morphine use was compared to that administered to patients in the intravenous morphine group . Epidural morphine was found to offer better pain relief than the other treatment modalities . There were no differences in spirometric testing between the groups at any time during the study . Although the number of evaluable patients was insufficient to draw definitive conclusions , 12-week follow-up suggested a difference in the incidence of post-thoracotomy pain syndrome in patients who received cryoanalgesia . It is concluded that post-thoracotomy pain is best relieved with epidural morphine , compared to intrapleural analgesia , cryoanalgesia , and parenteral morphine . There was no change in the deterioration in spirometric tests after thoracotomy , nor was there any advantage offered by cryoanalgesia or intrapleural analgesia over intravenous morphine , with respect to pain relief This study was performed to evaluate the effects of cryoanalgesia combined with thoracic epidural analgesia on pain and respiratory complications in patients undergoing thoracotomy . Ninety patients were prospect ively r and omised to epidural analgesia alone ( n = 45 ) or epidural analgesia and cryoanalgesia combined ( n = 45 ) . We monitored the use of rescue pain medication and changes in forced vital capacity and forced expired volume in 1 s , and recorded pain and opioid‐related side‐effects during the immediate postoperative period . The incidence of post‐thoracotomy pain and numbness were also assessed up to the sixth month after surgery . Cryoanalgesia combined with thoracic epidural analgesia was associated with earlier recovery in pulmonary function , less pain during movement and a lower daily requirement for rescue analgesia one week after surgery . However , the combination of cryoanalgesia and epidural analgesia failed to decrease the incidence of long‐term pain and numbness . In view of its associated long‐term morbidity , cryoanalgesia combined with thoracic epidural analgesia is not recommended for patients undergoing thoracotomy OBJECTIVE Two different surgical accesses combined with st and ard pain management procedures are compared regarding early and intermediate pulmonary function and pain relief . METHODS In a prospect i ve study , 15 consecutive patients undergoing video-thoracoscopy for pulmonary wedge resection ( group 1 ) were matched to 15 patients undergoing st and ard postero-lateral thoracotomy for lobectomy ( group 2 ) according to age , gender and preoperative pulmonary function . Postoperative pain control consisted of patient controlled analgesia in group 1 and epidural analgesia in group 2 .  Pain intensity was scored from 0 - 4 . The predicted postoperative pulmonary function ( FVC and FEV 1 ) after lobectomies was calculated from the preoperative value according to the extent of resection . A clinical measurement was obtained after a mean follow-up time of 4.2 months . RESULTS The ratios of postoperative measured to predicted values of FVC and FEV1 for group 1 compared with group 2 were 0.64 + /- 0.15 and 0.65 + /- 0.14 compared with 0.60 + /- 0.19 and 0.59 + /- 0.13 , resp . ( both n.s . ) at the first day postoperative ; 0.92 + /- 0.18 and 0.95 /- 0.17 compared with 0.76 + /- 0.20 ( P < 0.05 ) and 0.83 + /- 0.23 ( n.s . ) , resp . at hospital discharge ; 0.98 + /- 0.10 and 0.94 + /- 0.14 compared with 1.01 + /- 0.17 ( n.s . ) and 1.10 + /- 0.17 ( P < 0.05 ) , resp . at follow-up . Pain intensity score one day after surgery ranged from 0.4 ( resting position ) to 1.6 ( coughing ) for group 1 , and from 0.3 to 1.2 for group 2 . Thirty-six percent of the thoracoscopy patients and 33 % of the thoracotomy group complained of persistent pain or discomfort on the site of the operation after 3 - 18 months . CONCLUSION Post-thoracotomy pain can be effectively controlled with epidural analgesia and pain intensity is no higher than in patients after thoracoscopy who are managed with patient controlled analgesia . FVC is slightly more decreased after thoracotomy during the early postoperative period . FVC and FEV 1 approach the predicted values after four months in both groups . The rate of persistent pain is similar after thoracoscopy and thoracotomy Background : Pain becomes chronic in 22–67 % of patients who undergo a thoracotomy . Thoracic epidural analgesia ( TEA ) has replaced less invasive methods to manage postoperative pain . We wanted to find out if active use of TEA , combined with extended pain management at home , reduces the incidence of chronic post‐thoracotomy pain Video-assisted thoracic surgery has been adopted by some thoracic surgeons as the preferred approach over thoracotomy for many benign and malignant diseases of the chest . However , little concrete evidence exists to support this technique as the superior approach . This r and omized study was carried out to define the advantages of video-assisted lobectomy over muscle-sparing thoracotomy and lobectomy .  Sixty-one patients with presumed clinical stage I non-small-cell lung cancer were entered into the study . Each patient was r and omized to muscle-sparing thoracotomy and lobectomy or video-assisted lobectomy .  Six patients were excluded from the study either because final pathologic results revealed nonmalignant disease ( 3 patients ) or because an attempted video-assisted lobectomy was converted to a thoracotomy . This left 30 patients in the thoracotomy group and 25 patients in the video-assisted group . No significant differences existed between the two groups in operating time , intraoperative blood loss , duration of chest tube drainage , or length of hospital stay . Significantly more postoperative complications occurred in the thoracotomy group ( p < 0.5 ) , the majority of which were prolonged air leaks . Return to work time was not an issue because the majority of the patients were either retired or not working at the time of the operation . Only three patients had persistent postthoracotomy pain ( thoracotomy , n = 2 ; video-assisted lobectomy , n = 1 ) . We conclude that video-assisted lobectomy was not associated with a significant decrease in duration of chest tube drainage , length of hospital stay , postthoracotomy pain , or , in this group of patients , a faster recovery time and return to work .  Video-assisted lobectomy continues to expose the patient to the risk of a major pulmonary resection being done in an essentially closed chest . These results illustrate the need for critical evaluation of video-assisted thoracic surgery before the procedure is accepted as a superior approach based on presumed and thus far unproved advantages OBJECTIVE Our question naire study set out to assess the prevalence of chronic pain after thoracic surgery , the contribution of the neuropathic component of chronic pain and the impact of chronic pain on patients ' lives . METHODS A question naire was sent to 1152 patients who had undergone thoracic surgery in our department between 7 months and 7 years ago . The question naire was design ed specifically for the study and included questions on neuropathic symptoms . Responses were correlated with data from our prospect ively entered data base for analysis . RESULTS Nine hundred and forty-eight people were included in the study , of which 600 responded ( 63 % ) . Prevalence of chronic pain is 57 % at 7 - 12 months , 36 % at 4 - 5 years and 21 % at 6 - 7 years . Patient age , consultant and time since the operation all have significant effects . Surgical approach ( video-assisted thoracoscopic surgery , thoracotomy ) and diagnosis are not significant . Thirty-nine percent of those with pain take analgesia , 46 % felt their pain is their worst medical problem and 40 % reported it limits their daily activities . The prevalence of each neuropathic symptom is between 35 and 83 % . The presence of a neuropathic symptom is associated with significantly more severe pain , more analgesia use and pain more likely to limit daily activity . CONCLUSIONS Chronic pain has a significant prevalence and impact on patients ' lives for several years after thoracic surgery . Nerve dysfunction is associated with more severe pain , a greater impact and tends to persist . The reason for the individual consultant being an important factor in post-thoracotomy pain needs further investigation Objectives Prolonged activation of pain centers is a proposed cause of chronic pain syndromes . Women are at particular risk for chronic pain as they tend to more readily detect pain and to attenuate it less than men . We set out to determine whether sex affected pain and recovery after major surgery by analyzing data originally collected to determine the effect of the timing of epidural analgesia on long-term outcome after thoracotomy . Methods Patients presenting for lobectomy , segmentectomy , or bilobectomy , but not pneumonectomy or chest wall resection , were enrolled .  Pain , physical activity , and the extent that pain interfered with activities after surgery were prospect ively assessed with st and ard question naires ( Brief Pain Inventory and physical component score of SF-36 ) on postoperative days 1 to 5 , and at postoperative weeks 4 , 8 , 12 , 24 , 36 , and 48 by a blinded research assistant . Perioperative care was st and ardized and included patient-controlled thoracic epidural analgesia until thoracostomy tube removal . Results Fifty eight men and 62 women were enrolled . Women reported more pain than men throughout the entire study period , and they had a higher rate of nonsteroidal anti-inflammatory drug use , but not opioid use . This increased pain was not explained by incision type , surgeon , tumor type , or tumor stage . Older patients reported less pain after discharge than younger patients . Postoperative physical activity levels were significantly less than those reported preoperatively , but did not differ by sex . Discussion Women have a distinctly different pain experience than men after thoracic surgery and probably require novel and /or multimodal analgesic regimens to improve their comfort Objective To compare laparoscopic with open hernia repair in a r and omized clinical trial at a median follow-up of 5 years . Summary Background Data Follow-up of patients in clinical trials evaluating laparoscopic hernia repair  has been short . Methods Of 379 consecutive patients admitted for surgery under the care of one surgeon , 300 were r and omized to totally extraperitoneal hernia repair or open repair , with the open operation individualized to the patient ’s age and hernia type . All patients , both r and omized and nonr and omized , were followed up by clinical examination annually by an independent observer . Results Recurrence rates were similar for both r and omized groups . In 1 of the 79 nonr and omized patients , a recurrent hernia developed . Groin or testicular pain was the most common symptom on follow-up of r and omized patients . The most common reason for reoperation was development of a contralateral hernia , which was noted in 9 % of patients ; 11 % of all patients died on follow-up , mainly as a result of cardiovascular disease or cancer . Conclusions These data show a similar outcome for laparoscopic and open hernia repair , and both procedures have a place in managing this common problem BACKGROUND Thoracic surgeons spend a lot of time treating the pain of thoracotomy . METHODS A total of 119 consecutive patients underwent elective thoracotomy .  They were prospect ively r and omized into two groups . One group received an injection of 1 % lidocaine with epinephrine in the planned skin incision just before thoracotomy , and the other group received an equal amount of saline and epinephrine . 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 sixth rib ; intercostal nerve blocks before rib spreading ; a similar number of chest tubes and pulmonary resections ; and comparable postoperative pain management . Pain was objectified by a numeric pain score , a visual pain score , and by the Modified McGill pain question naire each day in the hospital , and at 3 , 6 , and 12 months postoperatively . RESULTS There were 66 patients in the lidocaine group ( L group ) and 53 patients in the saline group ( S group ) . Although a trend was noted toward less pain in the L group during the first 3 postoperative days ( on the numeric pain scale only ) the difference was not statistically significant in overall pain in the hospital or at 3 , 6 , and 12 months after the operation . Other pain scores and descriptors were similar throughout . CONCLUSIONS The injection of lidocaine and epinephrine in the skin just before thoracotomy does not decrease the amount or type of pain during the hospital stay or at 3 , 6 , and 12 months after surgery Objective : To examine incision and breast pain and discomfort , and their predictors in women 12 months following sternotomy .  Design : Extension survey following participation in a clinical trial . Setting : 10 Canadian centres . Patients : Women ( n = 326 ) who completed the Women ’s Recovery from Sternotomy Trial . Interventions : None . Main outcome measures : Pain and discomfort data ( numeric rating scales ) collected by st and ardised interview at 5 days , 12 weeks and 12 months following sternotomy . Results : More patients reported having incision or breast discomfort ( 46.6 % ) than pain ( 18.1 % ) at 12 months postoperatively . No symptoms at 5 days postoperatively were significantly associated with symptom presence at 12 postoperative months . However , having incision pain and discomfort as well as breast pain and discomfort at 12 postoperative weeks was associated with incision pain ( odds ratio ( OR ) = 3.26 , 95 % confidence interval ( CI ) 1.51 to 7.07 ) , incision discomfort ( OR = 4.87 , 95 % CI 3.01 to 7.88 ) , breast pain ( OR = 9.36 , 95 % CI 3.91 to 22.38 ) and breast discomfort ( OR = 6.42 , 95 % CI 3.62 to 11.37 ) , respectively , at 12 postoperative months . Increasing chest circumference was associated with having ongoing incision pain ( OR = 1.12 , 95 % CI 1.03 to 1.21 ) and breast pain ( OR = 1.10 , 95 % CI 1.00 to 1.22 ) . Harvesting of bilateral internal mammary arteries ( IMAs ) was associated with having ongoing incision pain ( OR = 4.71 , 95 % CI 1.54 to 14.3 ) , while harvesting only the left IMA was associated with having ongoing breast pain ( OR = 2.78 , 95 % CI 1.06 to 7.32 ) and breast discomfort ( OR 1.80 , 95 % CI 1.02 to 3.19 ) . Conclusions : Patients reported incision and breast pain and discomfort as long as 12 months post-sternotomy . Improved management of postoperative pain and discomfort up to at least 12 weeks following surgery may render reduced long-term pain and discomfort symptoms
target: However , intercostal nerve injury seems to be the most important pathogenic factor .
background: Chronic pain complaints after thoracic surgery represent a significant clinical problem in 25 - 60 % of patients .
  Results from thoracic and other surgical procedures suggest multiple pathogenic mechanisms that include pre- , intra- , and postoperative factors .
  This review attempts to analyse the methodology and systematic s of the studies on the  post-thoracotomy pain syndrome ( PTPS ) after lung cancer surgery in adults , in order to clarify the relative role of possible pathogenic factors and to define future strategies for prevention .