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J Thorac Cardiovasc Surg 1994;107:1079-1086
© 1994 Mosby, Inc.

GENERAL THORACIC SURGERY

Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery

Pittsburgh, Pa., Dallas, Tex., Milwaukee, Wis., and St. Louis, Mo.

Address for reprints: Rodney J. Landreneau, MD, Head, Section of Thoracic Surgery, University of Pittsburgh, Suite 811, Liliane Kaufmann Building, 3471 Fifth Ave., Pittsburgh, PA 15213.

Abstract

The prevalence and severity of chronic pain after video-assisted thoracic surgery for pulmonary resection remains to be defined. Three hundred forty-three of 391 consecutive patients 3 to 31 months after pulmonary resection by lateral thoracotomy (n = 165) or video-assisted thoracic surgery (n = 178) responded to a questionnaire aimed at comparing the relative occurrence of chronic postoperative pain after video-assisted thoracic surgery and lateral thoracotomy approaches for pulmonary resection. Patients less than 1 year after operation (video-assisted thoracic surgery = 142; thoracotomy = 97) and more than 1 year after operation (video-assisted thoracic surgery = 36; thoracotomy = 68) were analyzed as individual cohorts. Chronic pain was assessed by questioning patients about the presence and the intensity of discomfort on the side of the operation (using a visual analog scale) and their need for analgesic medication and the presence of ongoing limitations in shoulder function. Patients who underwent video-assisted thoracic surgery (less than 1 year from operation) had less pain and subjective shoulder dysfunction although their pain medication requirements were similar to those of thoracotomy patients less than 1 year from operation. After 1 year, there was no significant difference in these "pain related" morbidity parameters between the two surgical approach groups (video-assisted thoracic surgery or thoracotomy). (J THORACCARDIOVASCSURG1994;107:1079-86)

Although chronic postthoracotomy pain is a recognized adverse sequela that can follow thoracic operations, the prevalence of this problem has been scarcely addressed in the literature. ^1-5 Incapacitating chronic pain or upper extremity disability, or both, after standard lateral thoracotomy incisions are uncommon events (estimated to occur in 2% to 4% of patients) ^1,2,4; however, a significant minority of patients having thoracic operations may have chronic postoperative discomfort related to the thoracic incision and will report this when they are carefully questioned (Fig. 1). ¹ Indeed, a recent report revealed that approximately 40% of patients had troublesome (mild to moderate) chronic postthoracotomy pain for up to several years after the thoracic surgical procedure. ¹ The collaborative effort among the four institutions involved in this study was done to further substantiate the actual prevalence of chronic postthoracotomy pain across broad geographic and practice activity biases in thoracic surgery today.

View larger version (51K): [in this window] [in a new window]   Fig. 1. Usual sites of thoracotomy incisional trauma leading to cases of chronic post thoracotomy pain. Direct injury to ribs and neurovascular intercostal bundle along with injuries to anterior and posterior intercostal articulations are detailed.

PATIENT COHORTS AND STUDY DESIGN

Three hundred forty-three of 391 patients at more than 3 months after pulmonary resection (less than pneumonectomy) by lateral thoracotomy or VATS were responders to a questionnaire sent to this group inquiring into their present ongoing pain and disability related to their thoracic operation. One hundred sixty-five patients had undergone a lateral thoracotomy approach and 178 patients had undergone VATS to accomplish pulmonary resection. A malignant diagnosis was present in two thirds of the patients who underwent pulmonary resection by lateral thoracotomy and in 42% of patients who underwent VATS pulmonary resection. Wedge resection was the most commonly done resective procedure in the VATS group. Approximately half of the patients who had thoracotomy had undergone formal lobar resection. The mean age of the patients in both groups was similar (thoracotomy, 59 years versus VATS, 60 years of age). There were more men in the VATS group (56%) than in the thoracotomy group (42%).

The postoperative care was equivalent for patients in both the VATS and lateral thoracotomy groups with regard to chest tube management and perioperative monitoring. Chest tubes were removed when any pulmonary parenchymal air leak that may have been present had resolved and when pleural drainage was less than 100 ml in a 24-hour period. However, no consistent pattern of perioperative pain control management in either surgical approach group (thoracotomy versus VATS) was found by any surgeon involved in this study. Epidural narcotic analgesia was commonly, but not universally, used after operation in the thoracotomy group but was rarely used in the VATS group. ⁶ Patient-controlled narcotic analgesia was commonly used to treat early postoperative pain in both patient groups, although this was also variably applied by the individual investigators. ⁷ The same pattern was found with regard to the use of intermittent intramuscular narcotic injection for pain control. Intercostal nerve block was also inconsistently done. ^8-12 Although the trend was to discharge most of the patients in this study on a regimen of oral narcotic analgesics during the period of early postoperative convalescence, a minority of patients in the VATS group were sent home receiving nonsteroidal antiinflammatory agent pain control treatment alone. ^13-17 The postoperative courses of these primary patient cohorts were similar, although patients in the VATS group had a shorter postoperative stay (VATS, 5.7 days versus thoracotomy, 7.8 days). Finally, it is important to state that the patients with a history of malignancy included in this study had been seen in clinical follow-up within 3 months of the questionnaire contact. None of these patients enrolled in this group had clinical evidence of local recurrence of the malignancy.

To more closely analyze the patterns of chronic postoperative pain in these patients, the primary study groups (thoracotomy and VATS) were further divided into cohorts on the basis of whether the operation was done less than a year or more than a year from this questionnaire contact. There were 142 patients in the VATS group and 97 in the thoracotomy group in the cohort of those less than 1 year (3 months to 12 months) from operation. Thirty-six patients in the VATS group and 68 in the thoracotomy group who were beyond 1 year (13 months to 31 months) from operation responded to the questionnaire (Tables I and II).

The primary questions asked were these: Are you having continued pain on the side of your lung operation? Are you currently taking narcotic pain medication for pain from your chest operation? Do you have any limitations in the use of your arm or shoulder on the side of your chest operation? This questionnaire format was the same used by us in two recent studies that compared the differences in early postoperative pain between posterolateral thoracotomy and muscle-sparing thoracotomy approaches ¹⁸ and between muscle-sparing thoracotomy and VATS approaches to pulmonary resection. ¹⁹

The patients were also asked to respond according to standard visual analog scale designs to mark a point on a 10 cm line where the intensity of their pain was during any moment of a usual 24-hour day. The patients were finally asked to grade, on a scale of 0 to 5, the intensity of their pain at that particular moment (pain intensity scale).

The questionnaire responses were transferred to a common computer-driven database for statistical analysis. Statistical procedures used in this analysis consisted of the Mann-Whitney test for ordinal data, Fisher's exact probability test, and analysis of variance techniques for continuous data.

Techniques of lateral thoracotomy and VATS
Most of the lateral thoracotomies in this series were muscle-sparing fifth or sixth intercostal space approaches done in accordance with previously described techniques. ^18,20-23 A minority of the patients who underwent lateral thoracotomy had division of the latissimus dorsi muscle, however, the serratus anterior muscle was consistently spared in all patients (Fig. 1).

The VATS techniques most commonly used for pulmonary resection have been described in detail in many recent reviews of this subject (Fig. 2). ^24-33 Generally, a "triple-site intercostal access" approach aimed at triangulating the endosurgical instrumentation about the pathologic target was used. ^24,28-30

View larger version (42K): [in this window] [in a new window]   Fig. 2. Intercostal instrument access commonly used for VATS wedge resection of lung.

Tables I and II summarize the results of this study. Basically, patients in the VATS group less than 1 year from operation appeared to have less pain and subjective shoulder dysfunction than patients in the thoracotomy group less than 1 year from their procedure (Table I). Pain medication requirements were, however, similar between patients in the VATS and thoracotomy groups during this first year after operation. After 1 year, there was no significant difference in these pain-related morbidity parameters between the two surgical approach groups as depicted in Table II.

COMMENT

Attempting to quantitate the subjective quality postoperative pain and postoperative pain-related morbidity is difficult and at best these efforts can only give us imprecise answers regarding this problem. ^18,19,34 To our knowledge, there has been but one recent report in the medical literature that attempted to determine the basic prevalence of "chronic postthoracotomy pain." ¹ That study was also designed in a questionnaire format similar to ours. Furthermore, we are unaware of any other study in the literature, at the time of reporting this data, that has addressed the prevalence of chronic incisional pain after VATS.

Our use of simple, direct study questions in this clinical assessment can be looked on as lacking elegance in protocol design, but such simple methods do have merit in helping us appreciate the general prevalence of chronic postoperative pain in our patients who undergo thoracic operations. More detailed assessments of the quality of pain perceived, the relationship of chronic pain prevalence to specific operative techniques used, and the psychologic contribution to these patients' pain patterns are presently being explored by our group. These evaluations are incomplete at this time and also beyond the primary intentions of this basic investigation.

Postthoracotomy pain is generally defined as persistent pain along the thoracotomy scar and/or its intercostal dermatomic distribution lasting more than 2 months after operation. ^1-6,15,35-37 The local sequelae that are considered etiologic in the development of postoperative thoracic surgical pain are as follows: posttraumatic intercostal neuroma, healing rib fracture, "frozen" shoulder, local infection/pleurisy, costochondritis/costochondral dislocation, and local tumor recurrence. The "common cause" of chronic pain after thoracic operation in most clinical series is presumed to be secondary to posttraumatic intercostal neuroma formation. ^{1-5,15-17,34,37,38} Nevertheless, it remains important to exclude the possibility of local recurrence of the malignant process in the work-up of these cases. ^1,36

The characteristics of chronic postoperative pain may be pleuritic or aching in nature. The patient may also report burning or dysesthesia along the thoracic and possible thoracoabdominal dermatomic distribution of the intercostal nerve involved at the thoracic incision. The pain is frequently aggravated by touch, changes in the weather, or shoulder activity. We must also be aware that emotional overlay can contribute to the pattern and extent of pain the patient reports after operation. ³⁹

Thoracotomy incisions are prone to the development of subacute and chronic postoperative pain because of the possibility of direct intercostal nerve and rib injury from the spreading of the interspace by the thoracic retractor. ¹⁸ Division of the bulky lateral thoracic musculature (latissimus dorsi and serratus anterior) is also associated with increased postoperative pain. Additionally, excessive spreading of the ribs can result in posterior rib fractures at the costovertebral junction and also in painful costochondral separations anteriorly (see Fig. 1).

VATS approaches used for pulmonary resection may also be associated with significant local trauma to the chest wall structures that can result in chronic postoperative pain problems (Fig. 3, A and B). Excessive torquing of the thoracoscope and endosurgical instruments against the ribs at the intercostal access site can result in local rib bruising (or fractures) and also intercostal nerve injuries. Strategic intercostal access for the endosurgical instrumentation can reduce the likelihood of these injuries. ²⁴ The use of smaller-diameter thoracoscopes and the selective use of flexible or curved instrumentation may also potentially reduce such complications. Furthermore, direct injury to the intercostal structures can occur during the introduction of the thoracoscopic trocars or instruments through the intercostal access sites. This likelihood of intercostal neurovascular bundle injury is also potentially increased if proper caution is not exercised when instruments are introduced through the more narrow confines of the posterior aspect of the intercostal space (Fig. 4).

View larger version (31K): [in this window] [in a new window]   Fig. 3. A and B, Trocar-protected intercostal access site for thoracoscope introduction illustrated as potential site of intercostal neuronal injury and rib fracture as a result of excessive torquing of instrumentation at intercostal space.

View larger version (56K): [in this window] [in a new window]   Fig. 4. Direct intercostal neurovascular injury related to trocar or endosurgical access during VATS procedure.

Finally, this analysis suggests that VATS may reduce the occurrence and severity of chronic pain and shoulder dysfunction during the first year after thoracic operations, but the VATS approach is not likely to affect the prevalence of long-term chronic pain after pulmonary resection. The risk of chronic postthoracotomy pain should not be considered a significant variable when deciding on the operative approach for pulmonary resection.

We are indebted to Ron Filer for his consistently excellent artistic support of our work. We also thank Frank D'Amico, PhD, for his statistical analysis of this project.

Appendix: DISCUSSION

Dr. Richard G. FosburgLaJolla, Calif.)
One's perception of pain is a complex process, and a person's perception of pain is influenced by his or her cultural background, social or economic position, and state of fear and anxiety. Additional strong influences are the way the patient's family, loved ones, and coworkers respond to the patient's pain. The patient's understanding of the cause of pain and the patient's previous experience with pain are also influential.

The most common severe pain known to man probably results from surgical procedures, and there is an enormous body of information addressing its mechanism and its control. Despite a high level of interest, many authors have reported that hospitalized patients are still undertreated for their pain. The major reason identified is the way analgesics are administered, and this has resulted in one of the first practice guidelines promulgated by the Agency for Health Care Policy Research.

Because of the factors just given, I have trouble with the design of this study. The population is derived from four institutions, which very possibly reflects interactions of many caregivers. Without an effort to rigidly control the preoperative preparation, the education, the discussion of the study's design, and attempts to achieve uniformity in its analysis, I can conceptualize that there are a lot of problems in arriving at the conclusions.

In contrast to the report of Drs. Hazelrigg and Landreneau on their muscle-sparing thoracotomy, which was published in 1991 and was a single-institution, randomized, prospective, blinded study of 50 consecutive patients that used visual analog scales and the McGill questionnaire to assess pain, the current work lacks some of this sophistication. There are inherent faults in a questionnaire method, specifically the inability to achieve 100% response and the oftentimes subtle reasons responders tend to reply.

We all appreciate the limitation that pain places on deep breathing and coughing and the significance of retained secretions in producing atelectasis and pneumonia. The impact that an incentive spirometry has had on these complications is acknowledged. I believe that it also encourages resolution of pain just as continuous passive motion has aided our orthopedic colleagues. I likewise believe that the earlier ambulation and the earlier discontinuation of the chest tube associated with VATS is influential in the observations that they have made as compared with the patient having a thoracotomy.

I do not wish Dr. Landreneau to take umbrage with my remarks to say that his group is not working on an important topic, but I would encourage them to continue with more scientific refinement.

Dr. Walter Cannon (Palo Alto, Calif.).
Dr. Landreneau has been one of the leaders in this arena and should be complimented on all the work that he has done.

The problem here is trying to decide what is pain and what is not, because of all the problems that are associated with it. It is interesting to note that using the epidural catheters in thoracic operations these days has dramatically reduced the amount of analgesic that is needed in the early postoperative period. It does not say anything for the long-term use of analgesics, but certainly in that one area we can see that if the problem of early pain is solved, patients seem to do better and have less long-term pain.

This study is flawed because it is so difficult to measure pain. I certainly compliment the authors on making a major effort to try to resolve this issue. I also compliment them on having the honesty to say that despite our thoughts that VATS has to be less painful for patients, in the long-run it may not be very much different.

Dr. Richard Peters (Palo Alto, Calif.).
Although there are always problems evaluating pain, I think we should all remember that it is what the patient thinks that is most important. These authors have asked the patients whether they hurt or not, and that in the final analysis is the really significant clinical fact. I would differ with Dr. Fosburg a little and say that the authors have asked the important question.

It is extremely important that we recognize that it is late pain that is being discussed. I would refer you to some work by Brian Blades, a long time ago, following up soldiers with chest injuries after World War II. He found that the more intercostal nerves that were injured, the more chronic the pain. The more sites of access that are used for introduction of instruments, the more intercostal nerves are likely to be injured. The result may be some more risk of chronic pain and this possibility should be thought about in any procedure that we use. It is important that the authors are able to point out that there is not any dramatic difference in the late pain dependent on how the intercostal nerves are injured.

Dr. John Benfield (Sacramento, Calif.)
I have the clinical impression that the patients in whom we have tried needle localization of lesions in the lung, with methylene blue, have had more pain than other patients. I wonder if that has been your experience as well?

The second group of patients who have had more pain than others is the group in which we have coagulated the pleura with argon beam coagulation.

Would you comment on those two aspects as possible contributors to pain?

Dr. Landreneau.
To answer Dr. Benfield's questions, we really have not analyzed the contribution of the chemical effects or the inflammatory effects of methylene blue, so I cannot answer that. I agree that yttrium-aluminum-garnet laser electrocautery does appear to have a deeper penetration and more of a long-term effect. It seems to take longer for the patients to get over that than just mechanical abrasion or the standard chemical pleurodesis methods that we use to complement our open or VATS procedures.

With regard to Dr. Fosburg's comments, I appreciate them and I also heartily agree that this is a flawed study, but pain is a difficult area to examine.

I appreciate Dr. Peters' comments. It truly was eye-opening that we do have patients who continue to say they are having disability long after their operation.

Dr. Orringer, who taught me how to do thoracic surgery at the University of Michigan, always stressed that we not open the cavity excessively and that we avoid injury to the intercostal nerve bundle. He would slap our hands if we did otherwise. I think it is important that we avoid unnecessary trauma during open thoracotomy.

The important issue for us is that we have patients—as I am sure you do—who come saying, "I need to have this video-assisted thoracic surgery because there is less pain." I felt compelled to try to identify the true difference on a chronic basis so that we could be honest with our patients, and it appears in the long-run that there probably is not much difference between the two techniques in this setting. In the acute and the subacute situations, when we have a patient in very poor condition, I think we should consider this as an alternative to open thoracotomy to avoid pain-related morbidity.

Dr. James B. D. Mark (Stanford, Calif.).
I have a couple of comments and a question. We are enthusiastic about VATS. Nonetheless, the pain question should not be the most influential one when deciding what operation to do. A number of ways are available to control pain after thoracotomy and I would not want to gain something in the realm of short-term pain relief and lose long-term gain.

A couple of techniques are useful. In our older patients when we do thoracotomy we resect a rib. We believe we do less damage with the retractor and get better exposure that way and are less apt to fracture ribs and distract ligaments. Another technique that is certainly not unique but that I believe helps decrease the likelihood of long-term pain is punching holes in the lower rib and using pericostal sutures in the lower rib and around the upper rib. That way you do not put your suture around the intercostal bundle of the lower rib in the incision, and I think long-term pain problems have been considerably less with use of that technique. Do you want to comment on any of that?

Dr. Landreneau.
I agree with you.

Footnotes

From the Section of Thoracic Surgery, ^a University of Pittsburgh, Pittsburgh, Pa.; the Division of Cardiothoracic Surgery, ^b Humana Hospital, Dallas, Tex.; the Division of Cardiothoracic Surgery, ^c St. Luke's Medical Center, Milwaukee, Wis.; and the Division of Cardiothoracic Surgery, ^d Saint Louis University, St. Louis, Mo.

Read at the Nineteenth Annual Meeting of The Western Thoracic Surgical Association, Carlsbad, Calif., June 23-26, 1993.

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