One possible surgical adverse effect is chronic pain. To develop appropriate strategies to avoid
this issue, it is essential to examine predictive and pathological factors. Patients with and without
persistent pain following surgery's natural history provides an opportunity to deepen knowledge
of chronic pain's anatomy and psychology. Researching constant pain transmission and
predictors helps us to understand and treat the problem at patient and community scales. The
genetic, emotional, socio-demographic, and lifestyle determinants and consequences of pain
must be taken into account by tailored and effective prevention and treatment approaches
(Buchheit, 2012). We propose a systematic analysis of these factors' current understanding.
Chronic pain remains a significant medical issue following surgery. Despite years of study, there
is still limited knowledge of the mechanisms of chronic postoperative pain and the agents that
are effective in preventing it. Marginal factors, like the factor of nerve production, endothelin,
and other cytokines released from damaged tissue, have established the significance of inducing
full post incisional pain (Buchheit, 2012). The importance of vertebral nicotinic receptors,
transient receptor potential (TRP) V1,4, and other mitogen-activated protein neurotransmitter
receptors (MAPKs), such as those in lymphocytes and neurons, has shown to induce acute post
incisional pain and sustained retraction-induced soreness.
Nevertheless, there have also been hardly any studies of mechanisms essential to the pain which
remain for months or longer following the operation, while clinical evidence suggests that
relatively young age, female gender, and sustained preoperative agony all predict chronic
postoperative pain. For more than six months, as many as 40 to 50 percent of post-thoracotomy
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 3
patients have been experiencing persistent pain. During stretching or twisting, pain occurs at rest
(i.e., with shallow breathing) and also has a pronounced movement-related component, an
instance of mechanohyperalgesia. The intensity with which this pain can be categorized as
neuropathic is discussed, and chronic post-thoracotomy pain (CPTP) neurophysiological tests
find evidence of microvascular damage (Kelsheimer, 2019). Nonetheless, the fact that
perioperative epidural blocks significantly reduce the incidence of long-term post-thoracotomy
pain contributes to the central nervous system's important role in this syndrome.
Work on the mechanisms underlying CPTP has gained from the creation of a rat model using
surgical procedures and making postoperative symptoms closely parallel to clinical signs. In the
present study, we used this design to study the potential of different resolving to prevent or
reverse CPTP, naturally occurring lipid mediators that promote inflammation resolution and are
known to have antihyperalgesic effects on peripheral neuropathy and inflammatory pain
(Kelsheimer, 2019). The research uses pain behavior measures that go beyond the stimulation
threshold to produce an essential nocifensive response and include a more nuanced behavior
Resolvins, natural pro-inflammatory, and pro-resolving mediators, after peripheral nerve damage
or inflammation of the tissue, have been shown to have strong antihyperalgesic properties. These
result from activities on responsive neutrophils, monocytes, and lipid peroxidation immune cell
generation, as well as direct action on spinal neurons and glia, including effects on neuronal
glutamatergic transmission pre-and post-synaptic elements as well as MAPK activation in glia.
Chronic pain has many physical, psychological, and social factors associated with it. Previously,
risk factors have indeed been categorized as' controllable' and' un-modifiable,' though, this
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 4
micro-medical-centered mindset to pathology often does not take into consideration the complex
interaction of each risk factor between modifiable and non-modifiable elements (Kelsheimer,
2019). For instance, the experience of violence or abuse is sometimes deemed' un-modifiable'
because the incident or incidents have already happened, and the history of the person cannot be
altered. Nevertheless, the understanding of these events by the person and their effect on their
life and health is constantly evolving and will have an impact on their future health and
wellbeing. Besides, interventions that improve biopsychosocial health determinants that prevent
or decrease future population exposure to risk factors involved in chronic pain genesis.
Current understanding of incidence and risk factors
Finding and handling such risk factors and aspects of modifiable risk factors can enable both the
avoidance and decrease of chronic pain entire length and intensity. It is still important to discuss
factors that are not suitable for medical interventions in the therapeutic context. Many are
meaningful to chronic pain projections, evaluations, management, and prognoses, and others will
be valuable in trying to determine new goals for therapeutic intervention. A pharmacologically
wise interdisciplinary and patient-centered strategy is essential to proper chronic pain
management (Kelsheimer, 2019). Known risk factors for chronic pain include; Demographic
factors, Lifestyle and behavior, Clinical factors, and others.
1. Demographic Risk Factors
While there is a lack of evidence to investigate chronic pain in children and adolescents, the
existing data suggest that elderly patients have a high incidence of chronic pain than young
patient groups. Advanced age and chronic pain (and its reporting) have a dynamic
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 5
interrelationship whereby multi-morbidity is separately correlated with chronic pain (Levy,
2019). For example, those aged 50 to 54 years have an 8% likelihood of developing postherpetic
neuralgia in people with shingles, while those aged 80 to 84 years have a 21% chance of
developing it. Evaluating pain in older patients can be complicated, mainly as older adults are
often reluctant to discuss or expose their pain level.
Processes of age-related diseases, such as cognitive impairment and Alzheimer's, can make it
harder for people to recognize and manage chronic pain. Pain symptoms, including length and
severity, body area affected, and the number of pain sites, was found to suggest ongoing pain in
older women, and these were less significant in older men. Nevertheless, chronic pain is not
limited to older age groups (Levy, 2019). Research from 42 countries found that self-reported
chronic pain of many teenage populaces was prevalent: 20.6 percent of young individuals
encountered headache, stomach, and backache pain in at least two sites. Chronic pain affects
close to 30% of those aged between 18 and 39 years.
Men tend not to report or encounter chronic pain than females, and in multiple sites, girls are
more likely than boys to report pain. Several studies have explored how variations between
gender (role) and sex (biological) are linked to how men and women feel pain. A new systematic
review found that women with pain are much more probable to use maladaptive coping
mechanisms that predispose them to chronic pain and less functional capacity (Levy, 2019). It
has been shown that women have lower pain levels and sensitivity and are more likely to
experience pain with increased intensity and unpleasantness.
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 6
The proof as well shows that women are sensitive to analgesia in different ways. Women are
more likely to seek treatment for their suffering, while suggestions are made for the severity of
pain in the different genders. There have been twice as many women as men in a recent study by
one specialist pain clinic. Women have experienced a higher intensity of pain and higher
impairment due to illness than men (Mills, 2019). Whereas the mechanisms behind these sex-
specific differences in pain perception and pain prevalence are insufficient, there is some
evidence of the role of estrogens and genetic factors, such as gender-specific differences in the
input of discomfort-related genes.
Ethnicity and cultural background
The prevalence and outcomes of pain-related conditions are significant and complex ethnic
variations, even though the processes underneath them continue to exist widely misunderstood.
White patients were shown to have less discomfort and less pain-related impairment than black
patients. A study of people in the United Kingdom revealed that those who self-identified as
white are much less likely to experience chronic pain as those who recorded black, Asian, or
mixed ethnicity (Mills, 2019). However, when adjusted for income jobs and adverse events in
life, the correlation between black and Asian pain was less likely than those who reported.
Population studies efficiently reveal that the predominance of chronic pain is inversely correlated
to socio-economic factors. People with substantial socio-economic deprivation are not only more
likely to suffer chronic pain than those from more wealthy areas, but they are much more likely
to encounter more extreme pain and more discomfort-related handicap. People with low
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 7
educational levels regarded income inequalities, and high neighborhood deprivation levels are
more likely to battle chronic pain than people with better educational standards, less presumed
wealth inequality, and living in more affluent neighborhoods.
Employment status and occupational factors
People who aren't at work due to health problems or handicaps are much more likely to
experience chronic pain than those who are at work. Employment risk factors for chronic pain
include terrible job management, fears of returning to work (including fear of a recurring injury),
lack of work flexibility or ability to change jobs, job satisfaction, and a higher overall level of
job obligation complexity (Mills, 2019). Chronic pain in the shoulder and neck was reported to
be an independent indicator of chronic pain and employment-related stress. Non-manual workers
are much less likely to report chronic pain than manual workers.
A study also showed that chronic pain relates to work designation: chronic pain was manifest in
78.9% of all those unemployed, and only 39.8% of everyone in paid work and 42.4% from those
in voluntary or unpaid labor. However, this relationship may be bidirectional in that, because of
their pain, people with chronic pain may be less likely to be at work. The magnitude of the
responsibility of healthcare from chronic pain was also related to the level of education and
socio-economic level of patients (Shaw, 2008). A tally to measure work impairment from pain
leading to missing days showed that higher levels of anxiety, smoking, less education, and
obesity were associated with higher levels in both sexes.
2. Lifestyle and behavior
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 8
It is more likely that people with chronic pain would smoke than those without pain. Patients
who seem to be regular smokers show higher scores of pain amplitude than non-smokers and
report more distressing locations. Smoking includes many conditions that cause chronic pain in
the etiology, and the association between smoking and chronic pain tends to be correlated with
dosage. Chronic pain-affected smokers are more likely to be reliant on nicotine, smoke more
cigarettes a day, and have more trouble quitting smoking than those without the disorder.
Alcohol's analgesic properties are short-lived; however, it is widely used by clinicians to' self-
medicate' for chronic pain. People with chronic pain may develop resistance to their minimal
analgesic effects when alcohol is used to excess. Besides, withdrawal of alcohol can increase
pain sensitivity, which might facilitate a cycle of growing alcohol abuse to seek consequences of
analgesia at high doses as sensitivity builds, and to avoid the pain associated with the drawdown
of alcohol (Shaw, 2008). There is confirmation that the same deregulation of the neurocircuitry
of pain and neurochemistry that causes chronic pain can trigger alcohol dependence.
Epidemiological studies agree that fitness and physical exercise have beneficial effects on
chronic pain, improving quality of life and sexual function, reducing the severity of pain, and a
few side effects, even though the quality of the evidence differs. Adherence with workout
procedures is part of their success; high compliance interventions have resulted in significantly
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 9
more significant pain reduction than those who have unpredictable or unsupervised accordance
(Shaw, 2008). Due to the heterogeneity of chronic pain and exercise regimes, and study
limitations, including limited follow-up periods and small sample sizes, it is difficult to
determine the specific effects of physical activity on chronic pain.
There is evidence of benefit for some types of physical activity, however, in particular, chronic
pain conditions: aquatic exercise can enhance chronic back pain and develop physical function,
supervised aerobics and strength training has been shown to reduce pain in patients with
fibromyalgia, and t' ai chi has a beneficial effect on arthritis pain reduction. It has also been
demonstrated that yoga is having a beneficial impact on those with chronic pain. Suggestions to
include physical activity in treatment plans for chronic pain management have begun to appear in
the guidelines for national and international care.
Nutrition's role in chronic pain production and avoidance is unclear. Management plans for
nutrition can be beneficial for patients with severe pain by improving pain management and
lowering risk factors associated with chronic pain. There have also been calls for chronic pain
patients to be offered personalized nutrition assessment and counseling aimed at improving diet
and supplement use, and emerging evidence that this can improve the quality of life and clinical
outcomes in chronic pain patients.
The latest literature review and sub-analysis of 23 papers discovered that nutrition-based
interventions, especially those testing an altered overall diet or a single nutrient, had a significant
effect on decreasing pain severity and intensity reported by participants. The medical and chronic
pain research, including those included in the meta-analysis, was of low quality, however, and
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 10
there is insufficient evidence to make specific dietary guidelines. To determine the role of
nutrition in chronic pain, more rigorous studies are needed to examine nutrition with chronic
pain as a primary outcome.
Clinical Risk Factors
Another location of acute or chronic pain within the body is the most significant medical risk
factor for chronic pain progression. The higher the severity and the more places, the more likely
it is to experience chronic pain. The existence of distressing sensory input affects neurochemistry
to the extent that individuals are predisposed to chronic pain. Within days of exposure to
continuous painful stimuli, this increased susceptibility to illness can develop and can persist for
up to a year after the pain has resolved. Both are associated with a more inferior quality of life
with more than one cause of chronic pain and longer-lasting pain.
Multi-morbidity and mortality
We are more likely than those without to experience chronic pain. Other chronic diagnoses have
up to 88 percent of those with chronic pain. There is an increased co-occurrence of chronic pain
with depression and cardiovascular disease even after adjustment for identified socio-economic
and environmental confounders (e.g., age, race, smoking, malnutrition, and education). About a
third of chronic pulmonary and coronary heart disease patients experience chronic pain (Steyaert,
2018). Comorbidity also complicates the medical care of people with chronic pain by restricting
the applicability of clinical guidelines unique to illness and decreasing treatment.
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 11
Patients hospitalized with severe pain were significantly more likely to die 10 years later from
ischemic heart disease or respiratory disease as those who recorded moderate chronic pain or
were pain-free. Those who experienced high pain severity but registered low pain impairment
had an increased survival rate of 10 years compared to those who were not resilient.
Enhancements in treatments for cancer and care have resulted in enhanced mortality rates,
resulting in an increased incidence of chronic pain in those with the disease. The prevalence of
chronic pain is double that of the general population for those living with neurological
conditions, and those with spinal cord injury have the most significant pain and discomfort.
Chronic pain is associated with depression, and the mixture of these factors can overlap in
families. Depression, panic, and detrimental pain perceptions are all related not only to the
development of fibromyalgia but also to chronic pain. Anxiety is strongly associated with
chronic pain: 50% of chronic pain patients have comorbid anxiety, and patients suffering are
more likely to be depressed. Depression is always unnoticed in patients with severe pain and,
therefore, untreated. Even when depression has improved, people with depression history remain
at an increased risk of chronic pain.
Fear and anxiety of pain are related to a higher likelihood of developing chronic pain and a
poorer prognosis for constant pain recovery. Anxiety avoidance behaviors and associated lack of
movement are independent risk factors for chronic pain development. A large population study
showed that patients who had visited their primary care physician for' muscles, panic, pressure,
or distress' had a higher risk of chronic pain diagnosis than those who had not seen their
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 12
Physician in this way (52.2% vs. 38.0%). Chronic pain is normal in post-traumatic stress disorder
(PTSD), although the relationship intensity varies depending on the cause of PTSD.
Surgical and medical interventions
Postoperative chronic pain is a significant complication of many surgical procedures.118,
although postoperative pain rates vary, it was estimated that up to 80% of patients experience a
degree of severe postoperative pain. Chronic postoperative pain affects up to 10 percent of
patients and is especially common after amputations, 85 percent, 65 percent thoracotomies, 55
percent cardiac surgery, and 50 percent breast surgery (Steyaert, 2018). Although it has become
a more widely recognized pathophysiology, post-surgical pain diagnosis rates have remained
unchanged. The risk of developing chronic postoperative pain in patients with foot surgery was
not associated with the severity of the procedure.
One research shows that practically 40% of people who are overweight experience chronic pain,
and that those who are not obese are more likely to experience moderate to severe pain than
chronic pain. A large-scale demographic study showed that the possibility of reporting chronic
pain doubled correspondingly with BMI: compared to groups of people with a healthy BMI, pain
rates were 68% in people with a BMI of; relative rates of chronic pain were 136% for those with
a BMI of 35 and 254% for those with BMI of > 40,127 This increased prevalence of chronic
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 13
Nearly half of people reporting chronic pain are affected by sleep disorders, with a quarter of
patients who have clinical insomnia. The correlation is bidirectional, with poor sleep caused by
chronic pain and poor sleep, increasing constant pain intensity and duration. In a retrospective
study of women over 17 years, sleep deprivation was found to be a risk factor of chronic pain
(Steyaert, 2018). A further study found that having fibromyalgia made people more inclined to
suffer from sleep disturbances and depression, and suggested that chronic pain management
should include the treatment of sleep disorders.
Other Risk Factors
The likelihood of a person developing long-term pain or pain-related disability can be affected
by personal beliefs and attitudes. Patients who have adopted passive coping mechanisms such as'
resting and taking medicines' use three times the number of healthcare appointments and double
the level of pain impairment compared to those who have adopted active strategies. Early life
factors affect the intensity and duration of chronic pain experience: people who encounter
tragedy or emotional trauma or physical trauma in childhood have an increased risk of chronic
pain in their adult lives. Early life stress may alter the role of the hypothalamic-pituitary-adrenal
axis, influencing the response to stress.
Treatment with intravenous and oral medicines for postoperative thoracic surgical pain is the
most non-invasive method and has found its way into many enhanced postoperative recovery
(ERAS) protocols. However, without side effects, non-invasive does not necessarily mean that.
At our institution, PCAs with narcotics such as fentanyl, Dilaudid, and morphine are used in
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 14
conventional medication treatment. PCAs are price-effective, convenient to use, and usually have
higher dose-controlled patient satisfaction compared to general nursing.
Several opioid adjuncts such as ketorolac, ketamine, acetaminophen, and gabapentin have
synergistic effects. They may provide improved analgesia, but the availability of such
medications as well as provider inexperience and prejudice – restrict their usage. Ketamine is a
commonly used receptor antagonist of N-methyl-D-aspartate (NMDA) with anesthetic,
analgesic, and antihyperalgesic but also anti-inflammatory properties. In the pathophysiology of
central sensitization after surgery, NMDA receptors are critical, and their blockage by ketamine
has been shown to prevent their production and to minimize both acute postoperative pain
severity and opioid usage.
Ketamine tends to have a beneficial effect on the development of CPSP. Maybe, as McNicol et
al. have already indicated, patient subgroups (e.g., chronic pain or opioid-dependent patients)
might be the primary beneficiaries of their use. In the perioperative environment, memantine, an
oral antagonist of the NMDA receptor, was also reported. Nitrous oxide, one of the first
anesthetic agents, produces analgesia and decreases hyperalgesia through an inhibitory effect on
the NMDA receptor that is not competitive (Rogers, 2000). Nonetheless, for the prevention of
CPSP, nitrous oxide administration is not recommended, except perhaps in a subset of Asian
patients. Gabapentin and pregabalin anticonvulsants also minimize nociceptive
neurotransmission by blocking the sub-units of voltage-gated calcium channels, which vary in
bioavailability in particular.
Local anesthesia and analgesia, i.e., local anesthetic administration at the wound, peripheral
nerve, or spinal cord level, enhances early pain management and decreases opioid prerequisites
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 15
after surgical procedure. Numerous clinical trials have investigated the potential for CPSP
prevention, but the available studies do not show a consistently positive effect (Rogers, 2000).
Glucocorticoids inhibit the expression of pro-inflammatory cytokines, the secretion of which is
involved in developing and sustaining central sensitization at or near the site of a nerve injury.
Lidocaine is an analgesic, antihyperalgesic, and anti-inflammatory amide local anesthetic. It has
been extensively studied subcutaneously as part of a bidirectional analgesic regimen. The pillar
of perioperative analgesia has been opioids for decades (Rogers, 2000). Nonetheless, questions
about their use in that environment have been posed in recent years. While opioids have a
powerful brief-term antidepressant effect, they may also lead to rapid tolerance and opioid-
induced hyperalgesia (OIH), whose mechanisms include activation of NMDA receptors and
enhancement of secondary tissue injury glial inflammatory reaction.
OIVI results in acute opioid toxicity. Coadministration and comorbidity of other sedative drugs
(e.g., gabapentinoids, benzodiazepines, and other opioids) increases the risk of damage. Since
that awareness of the harm caused by OIVI and individual patients' unpredictable dosage
requirements, sedation scoring should now be compulsory for all patients receiving opioids, and
the concomitant use of different sedative agents should be prevented whenever possible.
Summary and Future Direction
Increasing evidence indicates that multimodal sedation reduces the risk of chronic post-surgical
pain by using a combination of catheter-based techniques and systemic analgesics. For patients
undergoing high-risk surgery, such as amputation and thoracotomy, extensive therapy is
particularly important (Perkins, 2000). With the latest demonstration that active acute pain
management, irrespective of the method used, decreases the prevalence of phantom limb pain at
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 16
six months, we now have the scientific justification and ethical obligation to use multiple tools to
treat these patients.
Considerable potential future analytical research is required to establish the local history and
extent of the problem of chronic post-thoracotomy pain. The neuropathic characteristics and
objective evidence from surgical technique studies strongly suggest that intercostal nerve
damage is a significant factor in CPP cause. Though, until it is possible to determine the precise
mechanism of intercostal nerve injury, strategies can only be directed towards treating
established chronic post-thoracotomy pain (Perkins, 2000). It is necessary to carry out detailed
studies of surgical techniques. This could then reduce the incidence of chronic post-thoracotomy
discomfort by changing operating procedures.
Clinicians should be aware of the danger of these significant complications and change their
practice to minimize harm. Optimum pain relief for achieving functional goals and promoting
recovery should still be our primary objective, but this should not be at the expense of adverse
long-term outcomes, resulting in a significant impact on the quality of life of patients. Therefore,
we may need to consider prolonged therapies during the period of neurological plasticity rather
than several days of recovery. If this postoperative remodeling process can be altered, we will
have an additional tool to reduce the incidence of chronic postoperative pain.
An extreme and underestimated problem is chronic post-thoracotomy pain. It is present in about
50% of all post-thoracotomy patients, and in 5%, it is severe and disabled. There is no indication
of a significant decrease over time. Intercostal thoracotomy nerve damage is most likely a
significant factor in continued post-thoracotomy pain development, although the exact
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 17
mechanism is not known. Current guidelines for PTPS care are based on the prescription of
powerful opioid drugs combined with strategies for learning tolerance.
There has been little work to date, focusing on the causative mechanisms of PTPS and no
recognition of the role of genetic variation and susceptibility to PTPS despite success in other
chronic pain conditions. They agree that PTPS is a chronic condition of pain that can be
extremely susceptible to preventive treatment if it is possible to identify those at high risk in
advance of the discomfort it causes. It is necessary to address the significant global disease
burden of chronic pain by addressing the causes and effects of chronic pain, directed at patient
and population levels (Perkins, 2000). Modifiable risk factors (e.g., acute pain, Lifestyle, and
behavior) need to be discussed with the patient at the center of treatment to minimize and reduce
the impact of chronic pain.
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 18
Buchheit, T., & Pyati, S. (2012). Prevention of chronic pain after surgical nerve injury:
amputation and thoracotomy. Surgical Clinics, 92(2), 393-407.
Kelsheimer, B., Williams, C., & Kelsheimer, C. (2019). New Emerging Modalities to Treat Post-
Thoracotomy Pain Syndrome: A Review. Missouri medicine, 116(1), 41.
Levy, N., Mills, P., & Rockett, M. (2019). Post-surgical pain management: time for a paradigm
shift. British journal of anaesthesia.
Mills, S. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: a review of its epidemiology
and associated factors in population-based studies. British journal of anaesthesia.
Perkins, F. M., & Kehlet, H. (2000). Chronic pain as an outcome of surgeryA review of
predictive factors. Anesthesiology: The Journal of the American Society of
Anesthesiologists, 93(4), 1123-1133.
Rogers, M. L., & Duffy, J. P. (2000). Surgical aspects of chronic post-thoracotomy
pain. European Journal of Cardio-Thoracic Surgery, 18(6), 711-716.
Shaw, A., & Keefe, F. J. (2008). Genetic and environmental determinants of postthoracotomy
pain syndrome. Current Opinion in Anesthesiology, 21(1), 8-11.
Steyaert, A., & Lavand’homme, P. (2018). Prevention and treatment of chronic postsurgical
STRATEGIES TO PREVENT POST-THORACOTOMY PAIN 19
pain: a narrative review. Drugs, 78(3), 339-354.
Wang, J. C. F., & Strichartz, G. R. (2017). Prevention of chronic post-thoracotomy pain in rats
by intrathecal resolvin D1 and D2: effectiveness of perioperative and delayed drug
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