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Year : 2021  |  Volume : 15  |  Issue : 3  |  Page : 341-347

Post-thoracotomy analgesia

Pain Center, Akron Children's Hospital, Department of Anesthesia and Pain Medicine, Akron, Ohio, USA

Correspondence Address:
Desimir Mijatovic
Akron Children's Hospital, Pain Center, 214 West Bowery Street, Akron, Ohio 44308
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_743_20

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Date of Submission10-Jul-2020
Date of Acceptance10-Jul-2020
Date of Web Publication19-Jun-2021


Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.

Keywords: Analgesia; pain; postthoracotomy; thoracotomy

How to cite this article:
Mijatovic D, Bhalla T, Farid I. Post-thoracotomy analgesia. Saudi J Anaesth 2021;15:341-7

How to cite this URL:
Mijatovic D, Bhalla T, Farid I. Post-thoracotomy analgesia. Saudi J Anaesth [serial online] 2021 [cited 2022 Nov 29];15:341-7. Available from:

  Introduction Top

Thoracotomy is normally considered one of the most painful operative procedures and postthoracotomy pain is often severe and can be difficult to manage.[1] Due to the anatomical distribution, the pain experienced by the patient is multifaceted and requires multimodal therapy to adequately manage. It is vital to control pain effectively in the perioperative setting (specifically considering preemptive analgesia) to ensure proper breathing, cough, and mobilization of the patient. Poor pain control can lead to poor recovery, infection, and respiratory failure. Proper pain control is also important to reduce the incidence of chronic post-thoracotomy pain syndrome (PTPS).[2] There are several strategies employed to control post-thoracotomy pain.

Management strategies include interventional techniques, like neuraxial injections and regional blocks, and conservative treatments, such as narcotic medications, nonsteroidal anti-inflammatory medications (NSAIDs), acetaminophen, gabapentinoids, and other adjunctive treatments including massage therapy, transcutaneous electrical nerve stimulation (TENS), respiratory therapy, and physical therapy.

  Interventional Techniques Top

Thoracic epidural analgesia

Thoracic epidural analgesia (TEA) is used to manage thoracotomy pain. TEA is often utilized with moderate to large incisions or bilateral instrumentation and due to medication spread, is typically inserted in the middle of the dermatomal distribution of the incision.[3],[4] Epidural analgesia is administered in the perioperative period through a single injection or catheter placement and infusion with patient-controlled epidural analgesia (PCEA) device. Placing the epidural catheter prior to general anesthesia allows assessment of its placement and efficacy.[4] Preemptive analgesia involves initiating analgesia preoperatively to prevent pain signal transmission during surgery.[5] Initiation of epidural analgesia prior to surgery is shown to improve pain control postoperatively and decrease the incidence of chronic pain.[1],[6],[7] Epidural infusions typically consist of either local anesthetics, opioids, epinephrine, or a combination of these medications depending on patient characteristics.[3]

TEA has multiple benefits, including providing sufficient analgesia with decreased need for systemic opioids, decreased cardiopulmonary complications, decreased mortality, and decreased incidence of PTPS.[3],[6],[8] It is important to consider that TEA is associated with some procedure-related complications including potential spinal cord injury, infection, hematoma, postdural puncture headache, and catheter migration; however multiple studies have shown these complications to be rare.[3],[9] Medication associated side effects can include nausea, vomiting, pruritis, bradycardia, hypotension, sedation, urinary retention, and respiratory depression.[1],[3],[9] TEA has shown superior pain control to parenteral opioids with less side effects.[1],[3],[10] TEA has similar analgesic efficacy to other interventional techniques including intrathecal analgesia (ITA) and paravertebral block (PVB).[3],[4],[11]

Limited data in the pediatric population has shown similar benefits of TEA in terms of pain control, safety, earlier mobilization and feeding, decreased postsurgical complications, and a similar side effect profile.[12],[13],[14]

Intrathecal analgesia

ITA is another common strategy to address thoracotomy associated pain. In thoracotomy, ITA is often used in combination with paravertebral catheters or second line if epidural is contraindicated.[4] ITA involves the administration of opioids typically directly into the cerebrospinal fluid (CSF) allowing the medication to directly bind opioid receptors in the spinal cord.[4],[15] The speed, extent, and distribution of this spread is based on the lipophilicity of the medication administered.[4] Preservative-free morphine (PFM) is commonly used, but other opioids including fentanyl and hydromorphone are utilized as well.[15] ITA can be administered in a single injection or catheter placement with similar efficacy in the short term.[4],[16] Intrathecal catheter placement has several possible complications including neurological injury, CSF leaks, infection risk.[17] Patients receiving single injection ITA typically require multimodal or combination analgesia with parenteral narcotics or regional block due to short duration of action of PFM.[4],[18]

ITA has also been shown to be effective for post-thoracotomy analgesia and allows decreased opioid requirements postoperatively compared to parenteral opioids.[19] Common side effects of intrathecal opioids include pruritis, respiratory depression, nausea, vomiting, postdural puncture headaches, and urinary retention with pruritis being the most common and respiratory depression being most life-threatening.[4],[15],[19],[20],[21] ITA is more effective than opioid PCA alone.[16],[22],[23] When compared to TEA, several studies show similar benefits and side effects except for a higher risk of respiratory depression with ITA.[11],[20]

In the pediatric population, ITA can be used safely and effectively in combination with a multimodal analgesic approach with similar benefits and risks as mentioned in the adult literature.[24],[25]

Paravertebral block

More recently, PVBs have gained popularity as another strategy to address thoracotomy pain. PVB involves administering an anesthetic agent in a single injection or catheter infusion into the paravertebral space, which is formed by the parietal pleura anterolaterally and costotransverse ligament posteriorly, through which the spinal nerves pass from the intervertebral foramen to the intercostal space.[4],[9],[26] Studies have shown dermatomal spread up to 10 dermatomes depending on anesthetic agent and volume injected with preferential caudal spread, but certain patients may require multiple injections.[9],[26] Typically, PVB is considered a unilateral block, but due to epidural spread, a small percentage of patients may experience bilateral analgesia or sympathetic blockade.[26] Most clinicians will use local anesthetic with or without epinephrine.[26] PVB is usually considered overall safer and easier than TEA and is often considered when thoracotomy is unilateral, however bilateral PVB can also be performed.[26] Drawbacks to the procedure include lack of familiarity for clinicians, variable anesthetic spread, anesthetic leak out of the space, and the necessity for opioid supplementation.[4],[26]

There is evidence that PVB is effective for pain control in thoracic surgery and is comparable to TEA for post-thoracotomy pain with a similar safety profile and less side effects.[1],[27],[28],[29] Common complications and side effects of PVB include nerve injury, vascular puncture, dural puncture, hypotension, pleural puncture, and pneumothorax.[26],[28],[29]

Due to anatomical differences in children compared to adults, ultrasound guidance is often utilized to ensure proper technique.[30] In the pediatric population, PVB has been shown to be an effective and safe option for post-thoracotomy analgesia.[31],[32]

Serratus anterior plane block

The serratus anterior plane block (SAPB) has also recently become more popular options for post-thoracotomy analgesia. This ultrasound-guided block is performed by administering a local anesthetic to the potential space between the serratus muscle and the intercostal nerves at the T4-T5 level resulting in unilateral anterior thorax analgesia potentially spanning T2-T9.[9],[33] These blocks are shown to be effective in managing post-thoracotomy pain and can decrease opioid requirements postoperatively.[9],[34],[35] However, SAPB is not as effective for post-thoracotomy analgesia as PVB, especially after 12 hours postoperatively.[34],[36] Overall, there seems to be a lower complication rate when compared to TEA and PVB, but common complications include hypotension, bradycardia, and pneumothorax.[34],[36]

In the pediatric population, SAPB can be used effectively to manage post-thoracotomy pain and is shown to be superior to intercostal nerve blocks.[37],[38]

Erector spinae block

Erector spinae block (ESB) is an ultrasound-guided peripheral nerve block where local anesthetic is injected between the erector spinae fascia and transverse process causing the medication to spread to the paravertebral space resulting in analgesia.[39],[40] Studies in cadavers and live patients have shown multidermatomal level spread up to seven levels cranially and caudally.[40],[41] ESB has several complications including pneumothorax, bowel injury, nerve damage, local anesthetic systemic toxicity (LAST), and block failure.[42] In pooled studies, ESB is shown to be an effective strategy for post-thoracotomy pain in combination with a multimodal analgesia regimen.[39],[41] When compared to traditional analgesia strategies, ESB has shown similar pain control to TEA and PVB with lower instances of bradycardia and hypotension, but higher rates of analgesic failure.[42],[43],[44]

Several case studies in the pediatric population have demonstrated tolerability, safety, and efficacy of ESB in managing post-thoracotomy pain and decreasing opioid demand.[41],[45],[46]

Intercostal nerve block

Intercostal nerve block (ICB) is a simple and direct method to provide analgesia. Typically, local anesthetic is injected directly up to five intercostal nerves corresponding to the dermatomes affected by the incision.[1] These can be performed by the surgeon with direct visualization in the pleural or percutaneously by the anesthesiologist but are often limited by a short duration of action and often require repeat injections.[1],[4] ICB has been shown to decrease postoperative opioid requirements.[1] However, ICB have been shown to be inferior to TEA for post-thoracotomy analgesia.[47] Complications of ICB include pneumothorax, LAST, bleeding, nerve injury, and block failure.[1]

Small studies have shown ICB to be effective and safe in the pediatric population with similar complication rates.[48],[49],[50]


A related strategy to ICB is cryoablation where intercostal nerves are frozen to -60°C to interrupt pain signaling by damaging the myelin sheath but keeping the nerve axon intact.[9],[51] Cryoablation has been reported to provide improved pain control, decreased opioid requirements, and less pulmonary complications when compared to ICB or parenteral opioids.[51],[52],[53] Complications of the procedure are mostly related to nerve damage and there is some evidence that cryoablation may be associated with increased risk for chronic pain and PTPS months after ablation.[1],[51],[54],[55] When compared to epidural analgesia, cryoablation required more opioids and resulted in worse pain control.[51]

Recent small studies in the pediatric population have shown benefit in pain control, decreased length of stay, and lower risk of complications, chronic neuropathic pain, or PTPS when compared to the adult population.[56],[57],[58]

Interpleural block

Interpleural analgesia involves injecting local anesthetic between the parietal and visceral pleura of the lung.[59] There is little evidence showing this to be an effective analgesic technique in thoracotomy pain. It is believed that postoperative blood in the pleural cavity and systemic absorption of the medication decreases the effectiveness of the procedure.[4] The lack of benefit has been shown in multiple studies and this technique is not recommended for post-thoracotomy pain.[4],[60],[61],[62]

Shoulder pain and interscalene block

Despite a well-performed block, patients may still have referred shoulder pain related to thoracotomy or chest tube placement, typically called Kehr's Sign. This referred pain is mediated by the phrenic nerve (C3-5) and is not normally covered by any of the analgesic techniques described in this section. Due to the supraclavicular nerves that originate from the same nerve roots as the phrenic nerve, this pain may be addressed with an interscalene brachial plexus block.[9] Interscalene block is shown to reduce post-thoracotomy shoulder pain without impairment of pulmonary function.[63],[64]

  Conservative Techniques Top


As mentioned before, due to the complex etiology of post-thoracotomy pain, it is important to apply a multimodal strategy in post-thoracotomy analgesia. This strategy should include interventional and regional analgesia in combination with systemic medications.[4],[65] Medications most used include opioids, NSAIDs, acetaminophen, and more recently gabapentinoids. There is some recent evidence for ketamine as a part of a multimodal analgesia strategy.

Due to the high doses required using opioids as sole agents, they are typically used in conjunction with regional techniques and nonopioid analgesics to provide adequate analgesia to avoid postoperative complications of uncontrolled pain.[4] Several opioids are used including morphine, fentanyl, hydromorphone, methadone, and tramadol. The addition of methadone to a multimodal analgesia strategy has been shown to decrease opioid requirements and improve pain scores postoperatively.[66],[67] Opioids can be administered orally or parenterally through patient-controlled analgesia (PCA) or on-demand dosing. Intravenous opioid PCA has been shown to provide better analgesia with less total dosage than on-demand parenteral opioids.[68],[69],[70] If regional anesthesia techniques are contraindicated, there is evidence that pain can be adequately controlled using a combination of parenteral opioids in combination with nonopioid medications.[71] While in general, opioids are effective at controlling pain, this must be balanced with the potential side effects of respiratory depression, sedation, itching, nausea, vomiting, urinary retention, constipation, and ileus.[72]

Ketamine infusion has been recently studied as an adjunctive analgesic medication in the perioperative period.[73] Ketamine can be added to opioids to effectively decrease postoperative pain and opioid requirements without significant worse side effects.[74],[75],[76]

NSAIDS are commonly used postoperatively as they simultaneously decrease pain and inflammation.[4] NSAIDs are part of a multimodal strategy to control pain and have been shown to decrease total opioid consumption and improve pain scores.[72],[77] Selective cyclooxegenase-2 (COX-2) inhibitors are sometimes preferred to nonselective NSAIDs due to lower risk of bleeding and gastrointestinal side effects.[72] Acetaminophen is a commonly used analgesic for mild to moderate pain and can be administered orally, rectally, and parenterally.[72] When compared to oral, intravenous acetaminophen has the benefit of faster analgesic onset and lack of first-pass metabolism, but high cost and risks of intravenous administration must be considered.[78] Acetaminophen can be used in combination with other analgesics with an additive effect.[4] NSAIDs and acetaminophen can both target ipsilateral referred shoulder pain.[4],[73],[79]

Due to the significant neuropathic component to post-thoracotomy pain and subsequent chronic PTPS, gabapentinoids including gabapentin and pregabalin have been used to specifically target this type of pain. Studies of gabapentinoids in post-thoracotomy analgesia have shown improved pain control, refractory chest wall pain relief, decreased opioid use, and reduced risk of chronic PTPS.[55],[72],[80],[81],[82],[83] Unfortunately, due to the heterogeneity of studies, there is no clear recommended regimen.[72] Side effects of gabapentinoids include dizziness, somnolence, sedation, and blurry vision.[72]

  Adjunctive Treatments Top

In addition to regional anesthesia techniques and medication, there is some evidence that adjunctive treatment strategies can be beneficial. Massage therapy has been shown in one systematic review to decrease pain scores after thoracotomy.[84] In combination with traditional post-thoracotomy analgesia, TENS has been shown to decrease pain and analgesic consumption without significant side effects or prolongation of hospital stay.[85],[86],[87] However, these benefits seem to be short-lived and only last while the TENS is in use.[88] Similarly, cold therapy in the form of ice packs can be used to decrease incisional pain and inflammation and decrease opioid requirements.[89]

Physical and respiratory therapy is an important part of thoracotomy recovery. Patient positioning is important to consider and early upright sitting and ambulation can improve lung function and recovery.[89] Posture correction, shoulder and scapula mobilization, and thoracic mobilization will help return patients to normal functioning.[89],[90] Lung expansion and clearing techniques including deep breathing, incentive spirometry, coughing, huffing, and breath control can improve functional recovery, decrease atelectasis, and decrease postoperative complications.[89],[90]

  Conclusion Top

Adequate perioperative management of thoracotomy pain is important to ensure good outcomes, decreased postoperative complications, improve mobilization, and decrease the risks of chronic pain. There are multiple strategies that can be used depending on patient characteristics and clinician expertise. In general, due to the multifactorial nature of post-thoracotomy pain, it is important to employ a multimodal analgesia strategy that can include neuraxial or peripheral regional analgesia, opioids, gabapentinoids, NSAIDs, acetaminophen, and adjunctive mechanical treatments.

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Conflicts of interest

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  References Top

Gerner P. Postthoracotomy pain management problems. Anesthesiol Clin 2008;26:355–vii.  Back to cited text no. 1
Gottschalk A, Cohen SP, Yang S, Ochroch EA. Preventing and treating pain after thoracic surgery. Anesthesiology 2006;104:594-600.  Back to cited text no. 2
Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology 2011;115:181-8.  Back to cited text no. 3
Mesbah A, Yeung J, Gao F. Pain after thoracotomy, BJA Education 2016;16:1-7.  Back to cited text no. 4
Gottschalk A, Smith DS. New concepts in acute pain therapy: Preemptive analgesia. Am Fam Physician 2001;63:1979-84.  Back to cited text no. 5
Şentürk M, Ázcan PE, Talu GK, Kiyan E, Camci E, Ozyalçin S, et al. The effects of three different analgesia techniques on long-term postthoracotomy pain. Anesth Analg 2002;94:11-5.  Back to cited text no. 6
Erturk E, Aydogdu Kaya F, Kutanis D, Besir A, Akdogan A, Geze S, et al. The effectiveness of preemptive thoracic epidural analgesia in thoracic surgery. Biomed Res Int 2014;2014:673682.  Back to cited text no. 7
Dango S, Offner K, Kirschbaum A, Loop T, Passlick B. Epidural analgesia in thoracic surgery--optimising postoperative rehabilitation. Zentralbl Chir 2008;133:491-7.  Back to cited text no. 8
Kelsheimer B, Williams C, Kelsheimer C. New emerging modalities to treat post-thoracotomy pain syndrome: A review. Mo Med 2019;116:41-4.  Back to cited text no. 9
Bialka S, Copik M, Daszkiewicz A, Rivas E, Ruetzler K, Szarpak L, et al. Comparison of different methods of postoperative analgesia after thoracotomy-a randomized controlled trial. J Thorac Dis 2018;10:4874-82.  Back to cited text no. 10
Madi-Jebara S, Adaimé C, Yazigi A, Haddad F, Hayek G, Sleilaty G, et al. [Thoracic epidural and intrathecal analgesia have similar effects on pain relief and respiratory function after thoracic surgery]. Can J Anaesth 2005;52:710-6.  Back to cited text no. 11
Tobias JD, Lowe S, O'Dell N, Holcomb GW 3rd. Thoracic epidural anaesthesia in infants and children. Can J Anaesth 1993;40:879.  Back to cited text no. 12
Di Pede A, Morini F, Lombardi MH, Sgrò S, Laviani R, Dotta A, et al. Comparison of regional vs. systemic analgesia for post-thoracotomy care in infants. Paediatr Anaesth 2014;24:569-73.  Back to cited text no. 13
Karnik PP, Dave NM, Garasia M. Comparison of analgesic efficacy and safety of continuous epidural infusion versus local infiltration and systemic opioids in video-assisted thoracoscopic surgery decortication in pediatric empyema patients. Saudi J Anaesth 2018;12:240-4.  Back to cited text no. 14
Rathmell JP, Lair TR, Nauman B. The role of intrathecal drugs in the treatment of acute pain. Anesth Analg 2005;101(Suppl 5):S30-43.  Back to cited text no. 15
Ward VD, McCrory CR. An assessment of intrathecal catheters in the perioperative period: An analysis of 84 cases. Ir J Med Sci 2014;183:293-6.  Back to cited text no. 16
Staats PS. Complications of Intrathecal Therapy. Pain Med 2008;9(Suppl 1):S102-7.  Back to cited text no. 17
Mason N, Gondret R, Junca A, Bonnet F. Intrathecal sufentanil and morphine for post-thoracotomy pain relief. Br J Anaesth 2001;86:236-40.  Back to cited text no. 18
Meylan N, Elia N, Lysakowski C, Tramèr MR. Benefit and risk of intrathecal morphine without local anaesthetic in patients undergoing major surgery: Meta-analysis of randomized trials. Br J Anaesth 2009;102:156-67.  Back to cited text no. 19
Gehling M, Tryba M. Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: A meta-analysis. Anaesthesia 2009;64:643-51.  Back to cited text no. 20
Gwirtz KH, Young JV, Byers RS, Alley C, Levin K, Walker SG, et al. The safety and efficacy of intrathecal opioid analgesia for acute postoperative pain: Seven years' experience with 5969 surgical patients at Indiana University Hospital. Anesth Analg 1999;88:599-604.  Back to cited text no. 21
Askar FZ, Kocabas S, Yucel S, Samancilar O, Cetin H, Uyar M. The efficacy of intrathecal morphine in post-thoracotomy pain management. J Int Med Res 2007;35:314-22.  Back to cited text no. 22
Liu N, Kuhlman G, Dalibon N, Moutafis M, Levron JC, Fischler M. A randomized, double-blinded comparison of intrathecal morphine, sufentanil and their combination versus iv morphine patient-controlled analgesia for postthoracotomy pain. Anesth Analg 2001;92:31-6.  Back to cited text no. 23
Ganesh A, Kim A, Casale P, Cucchiaro G. Low-dose intrathecal morphine for postoperative analgesia in children. Anesth Analg 2007;104:271-6.  Back to cited text no. 24
Nichols DG, Yaster M, Lynn AM, Helfaer MA, Deshpande JK, Manson PN, et al. Disposition and respiratory effects of intrathecal morphine in children. Anesthesiology 1993;79:733-8.  Back to cited text no. 25
Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001;95:771-80.  Back to cited text no. 26
D'Ercole F, Arora H, Kumar PA. Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth 2018;32:915-27.  Back to cited text no. 27
Yeung JHY, Gates S, Naidu BV, Wilson MJA, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016;2:CD009121.  Back to cited text no. 28
Ding X, Jin S, Niu X, Ren H, Fu S, Li Q. A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy: An updated meta-analysis. PLoS One 2014;9:e96233.  Back to cited text no. 29
Kendigelen P, Ázcan R, Emre Ş. Ultrasound-guided thoracic paravertebral block experience in a child. Turk J Anaesthesiol Reanim 2016;44:57-8.  Back to cited text no. 30
El-Morsy GZ, El-Deeb A, El-Desouky T, Elsharkawy AA, Elgamal MA. Can thoracic paravertebral block replace thoracic epidural block in pediatric cardiac surgery? A randomized blinded study. Ann Card Anaesth 2012;15:259-63.  Back to cited text no. 31
[PUBMED]  [Full text]  
Murphy T, McCheyne A, Karlsson J. Analgesic management after thoracotomy for decortication in children: A retrospective audit of 83 children managed with a paravertebral infusion-based regime. Paediatr Anaesth 2016;26:722-6.  Back to cited text no. 32
Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107-13.  Back to cited text no. 33
Singh PM, Borle A, Kaur M, Trikha A, Sinha A. Opioid-sparing effects of the thoracic interfascial plane blocks: A meta-analysis of randomized controlled trials. Saudi J Anaesth 2018;12:103-11.  Back to cited text no. 34
Ákmen K, Ákmen BM. The efficacy of serratus anterior plane block in analgesia for thoracotomy: A retrospective study. J Anesth 2017;31:579-585.  Back to cited text no. 35
Saad FS, El Baradie SY, Abdel Aliem MAW, Ali MM, Kotb TAM. Ultrasound-guided serratus anterior plane block versus thoracic paravertebral block for perioperative analgesia in thoracotomy. Saudi J Anaesth 2018;12:565-70.  Back to cited text no. 36
Kaushal B, Chauhan S, Saini K, Helfaer MA, Deshpande JK, Manson PN, et al. Comparison of the efficacy of ultrasound-guided serratus anterior plane block, pectoral nerves II block, and intercostal nerve block for the management of postoperative thoracotomy pain after pediatric cardiac surgery. J Cardiothorac Vasc Anesth 2019;33:418-25.  Back to cited text no. 37
Biswas A, Luginbuehl I, Szabo E, Caldeira-Kulbakas M, Crawford MW, Everett T, et al. Use of serratus plane block for repair of coarctation of aorta: A report of 3 cases. Reg Anesth Pain Med 2018;43:641-3.  Back to cited text no. 38
Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: A pooled review of 242 cases. J Clin Anesth 2019;53:29-34.  Back to cited text no. 39
Vidal E, Giménez H, Forero M, Fajardo M. Erector spinae plane block: A cadaver study to determine its mechanism of action. Rev Esp Anestesiol Reanim 2018;65:514-9.  Back to cited text no. 40
Adhikary SD, Pruett A, Forero M, Thiruvenkatarajan V. Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth 2018;62:75-8.  Back to cited text no. 41
[PUBMED]  [Full text]  
Tulgar S, Selvi O, Senturk O, Serifsoy TE, Thomas DT. Ultrasound-guided erector spinae plane block: Indications, complications, and effects on acute and chronic pain based on a single-center experience. Cureus 2019;11:e3815.  Back to cited text no. 42
Nagaraja PS, Ragavendran S, Singh NG, Asai O, Bhavya G, Manjunath N, et al. Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth 2018;21:323-7.  Back to cited text no. 43
[PUBMED]  [Full text]  
Fang B, Wang Z, Huang X. Ultrasound-guided preoperative single-dose erector spinae plane block provides comparable analgesia to thoracic paravertebral block following thoracotomy: A single center randomized controlled double-blind study. Ann Transl Med 2019;7:174.  Back to cited text no. 44
Hernandez MA, Palazzi L, Lapalma J, Forero M, Chin KJ. Erector spinae plane block for surgery of the posterior thoracic wall in a pediatric patient. Reg Anesth Pain Med 2018;43:217-9.  Back to cited text no. 45
Gaio-Lima C, Costa CC, Moreira JB, Lemos TS, Trindade HL. Continuous erector spinae plane block for analgesia in pediatric thoracic surgery: A case report. Rev Esp Anestesiol Reanim 2018;65:287-90.  Back to cited text no. 46
Debreceni G, Molnár Z, Szélig L, Molnár TF. Continuous epidural or intercostal analgesia following thoracotomy: A prospective randomized double-blind clinical trial. Acta Anaesthesiol Scand 2003;47:1091-5.  Back to cited text no. 47
Downs CS, Cooper MG. Continuous extrapleural intercostal nerve block for post thoracotomy analgesia in children. Anaesth Intensive Care 1997;25:390-7.  Back to cited text no. 48
Fleming WH, Sarafian LB. Kindness pays dividends: The medical benefits of intercostal nerve block following thoracotomy. J Thorac Cardiovasc Surg 1977;74:273-4.  Back to cited text no. 49
Matsota P, Livanios S, Marinopoulou E. Intercostal nerve block with bupivacaine for post-thoracotomy pain relief in children. Eur J Pediatr Surg 2001;11:219-22.  Back to cited text no. 50
Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy. Ann Thorac Surg 2005:80:1550-9.  Back to cited text no. 51
Moorjani N, Zhao F, Tian Y, Liang C, Kaluba J, Maiwand MO. Effects of cryoanalgesia on post-thoracotomy pain and on the structure of intercostal nerves: A human prospective randomized trial and a histological study. Eur J Cardiothorac Surg 2001;20:502-7.  Back to cited text no. 52
Roberts D, Pizzarelli G, Lepore V, al-Khaja N, Belboul A, Dernevik L. Reduction of post-thoracotomy pain by cryotherapy of intercostal nerves. Scand J Thorac Cardiovasc Surg 1988;22:127-30.  Back to cited text no. 53
Mustola ST, Lempinen J, Saimanen E, Vilkko P. Efficacy of thoracic epidural analgesia with or without intercostal nerve cryoanalgesia for postthoracotomy pain. Ann Thorac Surg 2011;91:869-73.  Back to cited text no. 54
Humble SR, Dalton AJ, Li L. A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy. Eur J Pain 2015;19:451-65.  Back to cited text no. 55
Zobel MJ, Ewbank C, Mora R, Idowu O, Kim S, Padilla BE. The incidence of neuropathic pain after intercostal cryoablation during the Nuss procedure. Pediatr Surg Int 2020;36:317-24.  Back to cited text no. 56
Dekonenko C, Dorman RM, Duran Y, Juang D, Aguayo P, Fraser JD, et al. Postoperative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia. J Pediatr Surg 2019. doi: 10.1016/j.jpedsurg. 2019.09.021.  Back to cited text no. 57
Graves CE, Moyer J, Zobel MJ, Mora R, Smith D, O'Day M, et al. Intraoperative intercostal nerve cryoablation During the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr Surg 2019;54:2250-6.  Back to cited text no. 58
Dhanjal S, Shannon C. Interpleural analgesia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.  Back to cited text no. 59
Silomon M, Claus T, Huwer H, Biedler A, Larsen R, Molter G. Interpleural analgesia does not influence postthoracotomy pain. Anesth Analg 2000;91:44-50.  Back to cited text no. 60
Bachmann-Mennenga B, Biscoping J, Kuhn DF, Schürg R, Ryan B, Erkens U, et al. Intercostal nerve block, interpleural analgesia, thoracic epidural block or systemic opioid application for pain relief after thoracotomy? Eur J Cardiothorac Surg 1993;7:12-8.  Back to cited text no. 61
Dravid RM, Paul RE. Interpleural block – part 2. Anaesthesia 2007;62:1143-53.  Back to cited text no. 62
Saranteas T, Alevizou A, Sidiropoulou T, Mavrogenis A, Tomos P, Florou P, et al. Ultrasound-guided interscalene brachial plexus nerve block with an ultralow volume of local anesthetic for post-thoracotomy shoulder girdle pain. J Cardiothorac Vasc Anesth 2018;32:312-7.  Back to cited text no. 63
Woo JH, Kim YJ, Kim KC, Kim CH, Jun J. The effect of interscalene block on ipsilateral shoulder pain and pulmonary function in patients undergoing lung lobectomy: A randomized controlled trial. Medicine (Baltimore) 2018;97:e11034.  Back to cited text no. 64
Romero A, Garcia JEL, Joshi GP. The state of the art in preventing postthoracotomy pain. Semin Thorac Cardiovasc Surg 2013;25:116-24.  Back to cited text no. 65
Gourlay GK, Willis RJ, Lamberty J. A double-blind comparison of the efficacy of methadone and morphine in postoperative pain control. Anesthesiology 1986;64:322-7.  Back to cited text no. 66
Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Shear T, et al. Intraoperative methadone for the prevention of postoperative pain: A randomized, double-blinded clinical trial in cardiac surgical patients. Anesthesiology 2015;122:1112-22.  Back to cited text no. 67
Zhou Y, Huang JX, Lu XH, Zhang YF, Zhang W. Patient-controlled intravenous analgesia for non-small cell lung cancer patient after thoracotomy. J Cancer Res Ther 2015;11(Suppl 1):C128-30.  Back to cited text no. 68
Boulanger A, Choinière M, Roy D, Bouré B, Chartrand D, Choquette R, et al. Comparison between patient-controlled analgesia and intramuscular meperidine after thoracotomy. Can J Anaesth 1993;40(5 Pt 1):409-15.  Back to cited text no. 69
Lange MP, Dahn MS, Jacobs LA. Patient-controlled analgesia versus intermittent analgesia dosing. Heart Lung 1988;17:495-8.  Back to cited text no. 70
Leger R, Ohlmer A, Scheiderer U, Dohrmann P, Böhle A, Wulf H. [Pain therapy after thoracoscopic interventions. Do regional analgesia techniques (intercostal block or interpleural analgesia) have advantages over intravenous patient-controlled opioid analgesia (PCA)?]. Chirurg 1999;70:682-9.  Back to cited text no. 71
Thompson C, French DG, Costache I. Pain management within an enhanced recovery program after thoracic surgery. J Thorac Dis 2018;10(Suppl 32):S3773-80.  Back to cited text no. 72
Kolettas A, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Kioumis I, et al. Postoperative pain management. J Thorac Dis 2015;7(Suppl 1):S62-72.  Back to cited text no. 73
Mathews TJ, Churchhouse AM, Housden T, Dunning J. Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain?. Interact Cardiovasc Thorac Surg 2012;14:194-9.  Back to cited text no. 74
Chazan S, Buda I, Nesher N, Paz J, Weinbroum AA. Low-dose ketamine via intravenous patient-controlled analgesia device after various transthoracic procedures improves analgesia and patient and family satisfaction. Pain Manag Nurs 2010;11:169-76.  Back to cited text no. 75
Tseng WC, Lin WL, Lai HC, Huang TW, Chen PH, Wu ZF. Fentanyl-based intravenous patient-controlled analgesia with low dose of ketamine is not inferior to thoracic epidural analgesia for acute post-thoracotomy pain following video-assisted thoracic surgery: A randomized controlled study. Medicine (Baltimore) 2019;98:e16403.  Back to cited text no. 76
Pavy T, Medley C, Murphy DF. Effect of indomethacin on pain relief after thoracotomy. Br J Anaesth 1990;65:624-7.  Back to cited text no. 77
Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus oral acetaminophen for pain: Systematic review of current evidence to support clinical decision-making. Can J Hosp Pharm 2015;68:238-47.  Back to cited text no. 78
Yousefshahi F, Predescu O, Colizza M, Asenjo JF. Postthoracotomy ipsilateral shoulder pain: A literature review on characteristics and treatment. Pain Res Manag 2016;2016:3652726.  Back to cited text no. 79
Sihoe AD, Lee TW, Wan IY, Thung KH, Yim AP. The use of gabapentin for post-operative and post-traumatic pain in thoracic surgery patients. Eur J Cardiothorac Surg 2006;29:795-9.  Back to cited text no. 80
Hah J, Mackey SC, Schmidt P, McCue R, Humphreys K, Trafton J, et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort: A randomized clinical trial [published correction appears in JAMA Surg 2018;153:396]. JAMA Surg 2018;153:303-11.  Back to cited text no. 81
Gaber S, Saleh E, Elshaikh S, Reyad R, Elramly M, Mourad I, et al. Role of perioperative pregabalin in the management of acute and chronic post-thoracotomy pain. Open Access Maced J Med Sci 2019;7:1974-8.  Back to cited text no. 82
Yu Y, Liu N, Zeng Q, Duan J, Bao Q, Lei M, et al. The efficacy of pregabalin for the management of acute and chronic postoperative pain in thoracotomy: A meta-analysis with trial sequential analysis of randomized-controlled trials. J Pain Res 2018;12:159-70.  Back to cited text no. 83
Boitor M, Gélinas C, Richard-Lalonde M, Thombs BD. The effect of massage on acute postoperative pain in critically and acutely Ill adults post-thoracic surgery: Systematic review and meta-analysis of randomized controlled trials. Heart Lung 2017;46:339-46.  Back to cited text no. 84
Erden S, Senol Celik S. The effect of transcutaneous electrical nerve stimulation on post-thoracotomy pain. Contemp Nurse 2015;51:163-70.  Back to cited text no. 85
Sezen CB, Akboga SA, Celik A, Kalafat CE, Tastepe AI. Transcutaneous electrical nerve stimulation effect on postoperative complications. Asian Cardiovasc Thorac Ann 2017;25:276-80.  Back to cited text no. 86
Freynet A, Falcoz PE. Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy? Interact Cardiovasc Thorac Surg 2010;10:283-8.  Back to cited text no. 87
Chandra A, Banavaliker JN, Das PK, Hasti S. Use of transcutaneous electrical nerve stimulation as an adjunctive to epidural analgesia in the management of acute thoracotomy pain. Indian J Anaesth 2010;54:116-20.  Back to cited text no. 88
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Ahmad AM. Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review. Korean J Thorac Cardiovasc Surg 2018;51:293-307.  Back to cited text no. 89
Baddeley RA. Physiotherapy for enhanced recovery in thoracic surgery. J Thorac Dis 2016;8(Suppl 1):S107-10.  Back to cited text no. 90

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