Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.

OBJECTIVES Thoracic ultrasound is superior to chest X-ray for the detection of a pneumothorax in trauma and intensive care medicine. Data regarding its use in non-cardiac thoracic surgery are scarce and contradictory. Previous studies are heterogeneous regarding sonographic methodology and patient selection. This study aimed to evaluate the accuracy of thoracic ultrasound for pneumothorax assessment after lung resecting surgery in unselected patients. METHODS SONOR (SONOgraphy vs x-Ray) is a prospective observational trial (registry-ID DRKS00014557). A total of 123 consecutive patients with lung resecting surgery received a standardized thoracic ultrasound the same day and in addition to routine chest X-rays in erect position after removal of the chest tube. The sonographer was blinded to radiological findings and vice versa. RESULTS Sensitivity, specificity, positive and negative predictive values of ultrasound after removing the chest tube were 0.32, 0.85, 0.54, 0.69 for any pneumothorax and 1.0, 0.82, 0.19, 1.0 for pneumothorax ≥3 cm. No clinically relevant pneumothorax was missed. The agreement between sonography- and routine-based therapeutic decisions was 97%. Lung pulse was the most frequently detected sign to sonographically rule out a pneumothorax. CONCLUSIONS Postoperative thoracic ultrasound in unselected patients has a low overall sensitivity to detect a residual pneumothorax; however, its sensitivity and negative predictive values regarding clinically relevant pneumothorax are high. Test quality depends on the distinct sonographic methodology and patient selection. Anatomic differences in postsurgical and medical patients may be responsible for the contradictory results of previous trials. Studies with a larger population size are required to validate the accuracy of relevant pneumothoraces and identify appropriate selection criteria. Clinical trial registration number DRKS—German Clinical Trials Register, www.drks.de, registry-ID DRKS00014557.

Background: Post-thoracotomy pain syndrome (PTPS) is reported with a prevalence ranging between 33% and 91% in literature. However, the difference between open (TT) and video-assisted thoracic surgery (VATS) concerning the prevalence and neuropathic character of PTPS has not yet been systematically investigated. Furthermore, knowledge on analgesic treatment and its efficacy is limited. Methods: Structured telephone interviews were conducted with 488 patients 6 to 30 months after TT and VATS. In case of pain, patients received a structured questionnaire including the Leeds Assessment of Neuropathic Symptoms and Signs and Brief Pain Inventory. Results: Prevalence of PTPS was 28.6%. 13.2% of patients had a pain intensity Numeric Rating Scale >3, and 4.6% of patients had a pain intensity Numeric Rating Scale >5. In case of PTPS, 63% of patients suffered from neuropathic pain. Post-thoracotomy pain syndrome was more frequent after TT than after VATS (38.0% vs 29.3%, P < 0.05) and in patients younger than 65 years (42.3% vs 26.4%; P < 0.05). TT resulted more often in neuropathic pain (67.7% vs 43.9%; P < 0.05). Forty six percent of PTPS patients received analgesics: 30.3% nonopioids, 25.2% opioids, 10.9% anticonvulsants, and 1.7% antidepressants. Antineuropathic agents were used in 17.4% of patients with neuropathic pain. In 36.7% of patients, the reported reduction of pain was less than 30.0%. Conclusions: Post-thoracotomy pain syndrome is not as common as estimated. In most cases, pain intensity is moderate, but patients suffering from severe pain require special attention. They are often heavily disabled due to pain. Tissue-protecting surgery like VATS is beneficial for the prevention of PTPS. Analgesic medications are often underdosed, unspecific for neuropathic pain, and insufficient.

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The danger to life and the likelihood of an accompanying pulmonary diagnosis are both low up to age 45. Treatment on an intensive care unit and computerized tomography of the chest should be performed only for strict indications in patients under age 45. The pathophysiological basis of the differing patterns of illness depending on age and sex requires further investigation.