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Post Thoracotomy Pain Management: Time to spread the gospel!


Every year the International Association for the Study of Pain (IASP) chose a particular chronic pain area to highlight its clinical importance.  This year it is the turn of post-operative pain to take center stage and post thoracotomy pain is one area that certainly warrants attention. The incidence of post thoracotomy pain syndrome (PTPS) 3 months after surgery ranges between 22% and 67% making it one of the highest reported causes of post-operative pain demolishing the suffers quality of life.  

Ironically as a population we are now expected to live longer and combined with improved cancer survival rates it is likely that more individuals will require thoracotomy surgery. Therefore, we will face the challenge of dealing with a significant chronic pain issue for many years to come.

This is an area that Dr. Dominic Hegarty (Clinical Director Pain Relief Ireland) has recently written an extensive review on how best to manage this difficult condition using the evidence in the literature and his experience in the area. Dr. Hegarty was also invited as a keynote speaker at the international Pain Management Conference held in London this week. The meeting was jointly supported by the European League Against Pain (EuLAP) and Pain Concern.

This is an area that Dr. Dominic Hegarty (Clinical Director Pain Relief Ireland) has recently written an extensive review on how best to manage this difficult condition using the evidence in the literature and his experience in the area.

Dr. Hegarty was also invited as a keynote speaker at the international Pain Management Conference held in London this week. The meeting was jointly supported by the European League Against Pain (EuLAP) and Pain Concern.

Management of PTPS is complicated by the limited evidence based clinical guidelines to help plan treatment. What has improved is the awareness surrounding acute pain management. “There are many perioperative analgesic regimes and surgical techniques aimed at reducing the occurrence and severity of acute postoperative pain. This is very important in controlling the cascade of biochemical events associated with the development of chronic pain.” According to Dr. Hegarty it has proven very useful in the short term and sets the bar for future developments. 

Dr. Stephen Humble (Consultant at London Pain Clinic, Harley Street London & Imperial College London) chaired the session in London and asked Dr. Hegarty about the possibility of using analgesic in advance in these cases. Dr. Hegarty gave examples of how this strategy was proving to be useful in other conditions and what was being done to limit the development of chronicity using regional, neuroaxial and other analgesic techniques.

Unfortunately, what concerned Dr. Hegarty most was that once these patients head home they are often left in analgesic limbo, where they struggle to deal with significant surgery due to inappropriate or sometimes no analgesics planning. At follow up in the thoracic clinics the focus of care is centered on the surgical outcome. More often than not patients are so relieved to hear the results of the surgery the fear of persistent pain seems fictitious. In fact, many feel as it is their “obligation” to suffer, as they are “lucky to be alive”. This is an area that Pain Relief Ireland is trying to improve by extending the treatment planning into the 4-6 weeks following discharge.

As clinicians’ we must strive to deliver the best treatment options for our patients. We must be aware of the high probability of PTPS, including the physical and psychological impact it will have on those concerned. Pain physicians must be familiar with the range of conservative and interventional options from the simple trigger point injection, intercostal nerve blocks, advanced radiofrequency denervation and neuromodulation. Modern medicine means we have more specialist areas than ever before, however, the art of communication between these specialists is sometimes lost. While pain management is a relatively new discipline there are many treatment options to deal with PTPS. The problem is spreading the gospel!  

Dr Hegarty has also been invited to write an editorial for The Journal of Surgery & Transplantation Science entitled “Time to spread the gospel” where he underlines the issues and highlighting the research and clinical needs surrounding pros. The editorial seeks to spread the “good news” among surgeons and pain physicians worldwide and it is hoped that individuals who are not familiar with PTPS will recognize the condition sooner and appreciate that there are several treatment options. The value of a multidisciplinary team (MDT) that includes a pain management specialist may offer hope to those unfortunate to be inflicted with this chronic pain condition. Inviting a member of the pain team to join your MDT may be the best thing you can do for your patient. We all need to play our part.

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