Postthoracotomy pain syndrome Manoj K. Karmakar, MD, FRCA, FHKCA, FHKAM*, Anthony M.H. Ho, MS, MD, FRCPC, FCCP, FHKCA, FHKAM Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China Thoracotomy not only causes severe pain in the immediate postoperative period but in a significant number of patients it also produces long term post- thoracotomy pain [1–3] that often lasts for months or even years after surgery. The International Associa- tion for the Study of Pain defines postthoracotomy pain syndrome (PTPS) as pain that recurs or persists along a thoracotomy incision for at least 2 months following the surgical procedure [4]. Pain in this condition is unrelated to infection or persistent or recurrent tumor. Postthoracotomy pain syndrome has also been referred to as chronic postthoracotomy pain [5–7], postthoracotomy intercostal neuralgia [8], or postthoracotomy neuralgia [3,5,9] in the literature. Although recognized as a sequela of thoracotomy since 1944 [10], when the first reference to this con- dition was made by two United States army surgeons, Blades and Dugan [10], a lack of data in the literature until the 1990s suggests that it had been overlooked or neglected as a clinical entity. In 1991 Dajczman et al [11] published the first report on the preva- lence, severity, and functional significance of PTPS. Since then there has been growing interest on this subject and postthoracotomy pain syndrome is now a well-recognized long-term morbidity of tho- racic surgery. Nevertheless, there is still a paucity of objective data in the literature on PTPS. This article presents the current understanding of postthoracot- omy pain syndrome. Incidence It is difficult to quote the true incidence of post- thoracotomy pain syndrome. Widely varying inci- dence rates have been reported (Table 1), ranging from 5% to 80% [2,3,9,11 – 19]. Different definitions used to describe and assess pain, lack of large, prospective studies, small sample size, varying sur- gical techniques, nonstandard perioperative manage- ment, varying periods of follow-up care, and so forth have made the estimation of the incidence of PTPS difficult. Nonetheless, published data suggest that PTPS is a fairly common condition and can affect more than 50% of patients who undergo thoracotomy. It is a chronic condition, and as many as 30% of patients might still experience pain 4 to 5 years after surgery [11]. There is a decrease in the severity of pain with time [2,13], although in the unfortunate few there might be worsening of pain [13]. Characteristics of pain in postthoracotomy pain syndrome Most patients experience pain along the general area of the thoracotomy scar [6,14], but pain can also occur elsewhere in the chest [6,14], in the back [6,14], or in more than one location [6,14]. Pain can occur spontaneously or can be evoked by a particular stimulus or activity. Allodynia, the sensation of pain in response to a normally nonpainful stimulus, is a frequent feature of PTPS [1]. The majority of patients report their pain as an aching sensation [3,6,14 – 16, 9] or tenderness [6,14], but it can also be described as a continuous dysesthetic burning and aching [3,6, 14 – 16,19], lancinating pain [6], or a combination of 1547-4127/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S1547-4127(04)00022-2 Financial support was entirely from departmental/ins- titutional resources. * Corresponding author. E-mail address: karmakar@cuhk.edu.hk (M.K. Karmakar) Thorac Surg Clin 14 (2004) 345 – 352