Post-thoracotomy pain syndrome: An opportunity for palliative care

Abstract

is a specialty in search of a niche. Referring providers often do not know what palliative care services do, or how they can help them to care for their patients; misconceptions that palliative care is just for patients at end of life or that it is synonymous with anesthesiology pain services abound. It will take years of providing services that improve the quality of life of thousands before palliative care becomes a household word. Identifying syndromes that are easily ameliorated, affect thousands every year, and commonly go untreated or unrecognized would not only be an opportunity to serve patients, but would provide a chance for palliative care to increase its profile. Due to an apparent statistical fluke over the last couple of weeks, our palliative care service has noted an increase in patients presenting with persistent pain after surgical thoracotomy. The patients, who generally have had moderate, persistent pain over the surgical site, following the intercostal space, report burning, tingling, and occasionally sharp pains that are constant and unremitting. These persons often reported that their surgeon told them that post-surgical pain was to be expected and to “live with it.” Until the creation of palliative care services around the country, patients with similar stories often had no other option. New data have emerged, however, that may improve outcomes and decrease patient suffering over the long term. Chronic post-thoracotomy pain syndrome (PTPS) is defined as “chronic dysesthetic burning and aching in the general area of the incision that persists at least two months after thoracotomy,”1 and is generally considered to be a post-surgical neuropathic syndrome of one or more intercostal nerves. Up to 60 percent of patients report persistent pain a month after surgery,2 and 35 to 50 percent report pain at one to two years.3 Most patients experience mild to moderate pain; the incidence of severe pain is 3 to 5 percent.4 Given the sheer numbers of thoracotomies performed in this modern age, the data indicate that the number of people suffering chronic sequelae is also large. Women and those with significant pain on post-op day one seem to be at highest risk for PTPS.2 In 1996, Katz followed patients 18 months after lateral thoracotomy and found that early post-operative pain was the only factor that significantly predicted longterm pain.3 The study showed a significant relationship between higher pain scores at 24 and 48 hours and longterm pain. However, cumulative morphine use was similar in both groups. Given that patients with decreased pain in the immediate post-op period had a decreased incidence of long-term pain, it would seem logical that improving post-operative pain control might proactively prevent chronic complications. However, in 2000, Hu published a study that seemed to argue against this concept. Hu’s project, a retrospective review of 159 patients