Chronic Poststernotomy Pain

Abstract

Chronic pain following median sternotomy is common after cardiac surgery. If left untreated, chronic sternal pain can reduce quality of life, affecting sleep, mood, activity level, and overall satisfaction. This has a significant societal effect given the large number of cardiac surgeries annually. Although a number of pathophysiologic processes and risk factors are assumed to contribute, the exact cause and major risk factors remain unknown. Moreover, the treatment of chronic poststernotomy pain is often inadequate, relying on opioids and other medications that provide minimal benefit to the patient and have significant adverse effects. Indeed, little is known regarding the prevention of chronic pain development following sternotomy. This review aims to present the current, limited data regarding the incidence, risk factors, treatment, and prevention of chronic poststernotomy pain and to identify areas of future research to improve management of this common complaint following cardiac surgery.

Transversus Thoracis Muscle Plane Block

“…The patient reported immediate and complete resolution of pain that was maintained for 3 months after the injections. Although parasternal intercostal blocks may reduce acute postoperative pain, there is currently no evidence for their efficacy in preventing chronic poststernotomy pain [25]. For acute sternal fracture analgesia, TTP blocks alone appear to be adequate.…”

Persistent Pain After Cardiac Surgery: Prevention and Management

“…40 In a subsequent review of postoperative chronic pain prevention, Reddi 41 similarly concluded that ketamine may reduce chronic pain after surgery while suggesting gabapentin and pregabalin as promising but requiring additional robust studies prior to recommendation. In a recent review of chronic poststernotomy pain, Kleiman and colleagues 27 similarly found no evidence to support the use of transdermal lidocaine, glucocorticoids, or dexmedetomidine in decreasing chronic pain. In contrast, the authors acknowledge the effectiveness of acetaminophen, gabapentinoids, and ketamine in providing opioid-sparing analgesia, but describe their utility in preventing chronic poststernotomypain as limited or not yet examined.…”

“…9,15,16,24 Acetaminophen, gabapentinoids, and ketamine have all been previously described as providing both effective analgesia and offering opioid-sparing benefit. 27,28 Rafiq and colleagues conducted a prospective randomized controlled trial (RCT) examining multimodal analgesics versus opioids following cardiac surgery through median sternotomy. 24 The authors found a combined regimen utilizing dexamethasone, gabapentin, ibuprofen, and acetaminophen provided superior analgesia (decreased numeric rating pain scores) through postoperative day 3 and decreased incidence of nausea and vomiting versus morphine and acetaminophen alone.…”

“…29 Further literature remains limited or not yet assessed regarding gabapentinoid use in the prevention of chronic poststernotomy pain. 27,30 A subsequent systematic review conducted by Bignami and colleagues examined perioperative pain management modalities and cardiac surgery including multimodal analgesics. 16 With regard to acetaminophen (paracetamol) administration, the authors found 2 of 4 RCTs demonstrating significantly decreased Visual Analogue Scale (VAS) scores and one of these publications demonstrating significantly decreased opioid consumption.…”

“…In contrast, the authors acknowledge the effectiveness of acetaminophen, gabapentinoids, and ketamine in providing opioid-sparing analgesia, but describe their utility in preventing chronic poststernotomypain as limited or not yet examined. 27 The application of regional anesthesia provides a diverse array of potentially opioid-sparing pain management methods in accordance with a multimodal analgesic strategy. The ability to administer local anesthetics through regional anesthesia may be particularly favorable in highrisk surgical candidates as these techniques may reduce or outright avoid adverse effects associated with opioid administration.…”