Skip to Main Content


  1. Without adequate analgesia, most patients would experience severe pain following thoracic surgery.

  2. Epidural analgesia is widely practiced and has been shown to provide superior pain relief compared with systemic opioids.

  3. Multimodal analgesic strategies improve overall outcomes including patient satisfaction.

  4. Chronic post-thoracotomy pain (CPTP) is common and remains a challenging condition to treat. Further investigation into prevention of this syndrome is needed.


The patient is a 64-year-old man who underwent a left thoracotomy and extrapleural pneumonectomy for mesothelioma. A mid-thoracic epidural catheter was placed preoperatively and used to deliver 0.6mg of hydromorphone prior to incision. Intraoperatively, no medications were administered through the epidural catheter to avoid sympathectomy and hemodynamic instability.


Upon the patient's arrival to the intensive care unit, an epidural infusion of bupivacaine 0.125% and hydromorphone 10 mcg/mL was initiated at 6 mL/h. The patient initially experienced 8/10 pain, requiring an epidural bolus of local anesthetic and an increase of the infusion rate. These adjustments resulted in reduction of his pain to 3/10. With improved analgesia, the patient was able to improve incentive spirometry performance, but he still continued to experience shoulder pain. He continued to do well with adequate pain control in the intensive care unit (pain score 3-5/10). His epidural was discontinued on postoperative day 3. He was discharged to home on postoperative day 5 with oral oxycodone as needed.


At his 2-month postoperative evaluation, the patient complained of significant chest wall pain localized to the thoracotomy incision. He described his pain as burning and aching.


The importance of postoperative pain management is well established.1 Postoperative pain following thoracic procedures causes a reversible restrictive pattern of ventilation with a decrease in vital capacity (VC) and functional residual capacity (FRC), impaired cough, rapid, shallow breathing, and often retention of secretions. These physiologic changes are particularly significant in thoracic surgery patients with preexisting pulmonary comorbidities, and may result in atelectasis, hypoxemia, and respiratory failure.2 Effective postoperative analgesia is of critical importance in these individuals. Nonetheless, effective treatment strategies for acute and chronic post-thoracotomy pain remain a significant challenge.3,4


The adverse effects of poor analgesia are not limited to the pulmonary system. Pain has been associated with increased myocardial oxygen demand, myocardial dysfunction, increased catecholamine release, poor glycemic control, deep vein thrombosis, and pulmonary embolism.5,6 These complications of inadequate pain control have been shown to lead to increased mortality and morbidity, prolonged length of hospitalization, and increased cost of patient care.7,8 In addition, several recent retrospective reviews suggest that a higher intensity of early (first week) postoperative pain is a risk factor for development of persistent pain.9,10


In this chapter, we will briefly review the mechanisms of thoracic pain. We will then discuss management strategies for acute postoperative pain and outline key concepts regarding chronic post-thoracotomy pain. The reader is referred to Chapter 6 for a more detailed discussion on ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.