Review articlePoststernotomy Pain: A Clinical Review
Section snippets
Methodology for the Literature Review
To identify relevant articles for the review, the web site http://www.pubmed.gov was used to query the following phrases: sternotomy pain, acute sternotomy pain, chronic sternotomy pain, thoracic epidural and sternotomy pain, thoracic epidural and cardiac surgery, spinal anesthesia and sternotomy pain, spinal anesthesia and cardiac surgery, regional anesthesia and sternotomy, regional anesthesia and cardiac surgery, local anesthesia and cardiac surgery, and pain and cardiac surgery. The authors
Epidemiology of Acute Sternotomy Pain
The assessment and quantification of acute pain can be highly variable and dependent on the interval of assessment as well as the instrument used for quantification. A number of scales are used in clinical practice to quantify pain. These include the facial expressions scale, the visual analog scale (VAS), numeric rating scales, and verbal rating scales, among others. Certain scales are better suited than others for particular patient populations. For example, the facial expressions scale can
Pathophysiology of Acute Sternotomy Pain
The mechanisms of postsurgery pain are complex, but generally speaking, in addition to nociceptive input from direct tissue trauma, an inflammatory response leads to the sensitization of peripheral and central pathways resulting in the experience of pain. Most sternotomy pain occurs because of tissue injury in the skin, subcutaneous tissues, bone, and cartilage. Intercostal nerves arising from thoracic nerve roots innervate the sternum, ribs, and surrounding subcutaneous tissue. The principal
Prevention and Treatment of Acute Sternotomy Pain
As mentioned previously, optimal pain management mitigates the stress response to surgery and may improve clinical outcomes for patients although this has been difficult to definitively prove. Poorly controlled pain after surgery has been associated with numerous adverse outcomes, including pulmonary complications, cardiac ischemic events, cardiac arrhythmias, hypercoagulability, and increased rates of wound infection.1
A number of studies have shown that poorly controlled pain is associated
Preoperative Patient Education
In a randomized trial at a large cardiovascular center in Canada, patients were randomized to receive preoperative education on pain management or standard hospital care.115 Those patients who received preoperative pain education received significantly more pain medicine during their hospital stay and had fewer concerns about requesting or taking pain medications. The implication of this study is that patients may require education about postoperative pain control to achieve maximum benefit.
Program Implementation
The implementation of departmental or hospital-wide programs can have a significant impact on outcomes. Several studies have shown improved pain scores and patient satisfaction with the implementation of specific programs or algorithms for managing postoperative pain.116, 117, 118
Electroacupuncture
Electroacupuncture was used as an adjunct in managing poststernotomy pain as far back as the 1970s.119 Electroacupuncture is performed by inserting small needles into the skin at specific acupuncture points and stimulating them with electrical current. The mechanism by which this treatment alleviates pain is not understood fully but may involve the release of endogenous opioids. One small, randomized trial of 30 patients showed a benefit of electroacupuncture in reducing poststernotomy pain and
Surgical Technique
Several studies have evaluated surgical variables and their impact on postoperative pain after sternotomy. In particular, recent studies have examined the impact of performing surgery through a “mini” sternotomy as compared with a standard or “full-length” sternotomy. Results have varied, with some studies showing a decrease in postoperative pain and others showing no benefit.121, 122, 123, 124 Alternative minimally invasive techniques for surgery also may provide a pain benefit. These
Epidemiology of Chronic Poststernotomy Pain
Chronic chest wall pain after sternotomy is common, with an estimated prevalence between 11% and 56%.131, 132, 133, 134, 135, 136, 137, 138, 139, 140 Most studies evaluating chronic poststernotomy pain focused on CABG surgery patients between 2 months and 3 years after surgery. Factors that appear to be associated with persistent pain include a large chest circumference, obesity, internal mammary artery harvesting, young age, and an increased requirement for postoperative analgesics during the
Pathophysiology of Chronic Poststernotomy Pain
The pathophysiology of chronic pain after sternotomy is complex, and its mechanisms are described poorly in the literature. Possible etiologies include sternal malunion, retained pacing wire fragments, and chronic inflammation caused by the presence of sternal wires. Additionally, an allergic reaction to nickel in sternal wires has been implicated as a possible etiology.143
Neuropathic pain from intercostal nerve damage likely plays an important role in chronic poststernotomy pain as well.
Prevention and Treatment of Chronic Pain
Limited evidence suggests that the development of chronic pain may be reduced by the implementation of specific anesthetic techniques.153, 154, 155 In particular, pain thresholds and the area of hyperalgesia after surgery may be altered depending on the anesthetic technique.156, 157, 158, 159, 160 The rationale for this is that certain anesthetic drugs or techniques may limit central and peripheral sensitization, which may lower the incidence or decrease the severity of chronic pain.161 It
Conclusions
Cardiac surgery most commonly is performed via median sternotomy, which results in significant postoperative pain and a noninsignificant incidence of chronic pain. Effective pain management after surgery leads to improved patient satisfaction and, possibly, improved clinical outcomes. A number of approaches may be used in the treatment of acute poststernotomy pain, including TEA, spinal anesthesia, intercostal and paravertebral blocks, opioids delivered via intravenous PCA, adjuncts, TENS,
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