ANAESTHESIOLOGY AND INTENSIVE CARE Ipsilateral shoulder pain after thoracic surgery procedures under general and regional anesthesia – a retrospective observational study

Abstract

BackgroundIpsilateral shoulder pain (ISP) is a common complication of mixed etiology after thoracic surgery (its prevalence is estimated in the literature at between 42% and 97%). It is severe and resistant to treatment (patients complain of pain despite effective epidural analgesia at the surgical site).Aim of the studyThe aim of this retrospective, observational study was to evaluate the prevalence of ISP in patients operated on in our facility and to determine the risk factors for ISP development.Material and methods68 patients after thoracotomy or videothoracoscopy (video-assisted thoracic surgery – VATS) conducted under general and regional anesthesia were enrolled in the study and divided into two groups: group I without ISP and group II with postoperative ISP. We recorded age, sex, BMI, duration of surgery, type of surgery, type of regional anesthesia, and, in patients with epidural anesthesia, level of catheter placement.ResultsStatistically significant differences between the groups were obtained for BMI (24.67 and 27.68, respectively; p = 0.049), type of surgery (24% for thoracotomy and 0% for VATS, p = 0.026), and level of epidural catheter placement (4.35% for catheters placed at the level of Th5 or higher and 40.47% for catheters placed below Th5; p = 0.003).ConclusionsThe prevalence of ISP in our medical center amounts to 24% of thoracotomy patients. The fact that the difference in ISP prevalence was significantly related to the level of epidural catheter placement is consistent with the theory that ISP is related to phrenic nerve innervation. Moreover, epidural catheter placement is a modifiable factor, which can be used to reduce the prevalence of post-thoracotomy ISP.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

“…Patients with a higher Body Mass Index (BMI) report an increased prevalence of postthoracotomy IPS, representing a possibly higher strain on the shoulder and thus supporting this hypothesis in another study [22]. Meanwhile, the distraction of the ipsilateral shoulder joint was suggested as a possible cause for the limited effect of an intrapleural block, the supraclavicular nerve block was ineffective in palliating ISP [13], which suggests it is not a common cause of ISP.…”

“…However, in a prospective observational study by Bunchungmongkol et al, the potential risk factors for developing ISP were surgery performed by a thoracotomy approach compared with Video-Assisted Thoracoscopic Surgeries (VATS) (risk ratio: 2.12, 95% confidence interval: 1.16–3.86, p = 0.014) and surgery duration >2 hours (risk ratio: 1.61, 95% confidence interval: 1.07–2.44, p = 0.023) [6]. In a retrospective study by Misiołek et al, higher Body Mass Index (BMI), thoracotomy versus VATS approaches, and epidural catheter level lower than T5 were found to be associated with a higher prevalence of IPS [22]. In this study 4.35% of patients with an epidural catheter placed at T5 or higher developed ISP while 40.47% of patients with epidural catheter placed lower than T5 developed it [22].…”

“…In a retrospective study by Misiołek et al, higher Body Mass Index (BMI), thoracotomy versus VATS approaches, and epidural catheter level lower than T5 were found to be associated with a higher prevalence of IPS [22]. In this study 4.35% of patients with an epidural catheter placed at T5 or higher developed ISP while 40.47% of patients with epidural catheter placed lower than T5 developed it [22]. However, coincidence of open thoracotomy, long duration of surgery, and high BMI could not be ignored.…”

“…ISP is often resistant to increases in the epidural infusion rate [5, 15]. However, in a recent study, epidural catheters located in spaces higher than T5 were effective in preventing postthoracotomy ISP [22]. …”

“…There is also a report of effective treatment of postthoracotomy ISP by direct blockade of the phrenic nerve, after its inadvertent identification during attempt to locate brachial plexus [17]. The lower prevalence of postthoracotomy ISP when an epidural catheter is inserted higher than T5 is considered as supportive of the role of phrenic nerve in treatment of ISP [22]. …”