Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints. Women Suffer More Short and Long-term Pain Than Men After Major Thoracotomy Impact of Pregabalin on the Occurrence of Postthoracotomy Pain Syndrome: A Randomized Trial Can chronic neuropathic pain following thoracic surgery be predicted during the postoperative period? Automated symptom alerts reduce postoperative symptom severity after cancer surgery: a randomized controlled clinical trial. A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery. Has postoperative pain been eradicated? Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-Related Quality of Life After Modified Radical Mastectomy Chronic postthoracotomy pain and health-related quality of life. Long-term Pain and Activity during Recovery from Major Thoracotomy Using Thoracic Epidural Analgesia From acute to chronic pain after laparoscopic cholecystectomy: A prospective follow-up analysis Risk factors for chronic pain following breast cancer surgery: a prospective study. Pain and physical function are similar following axillary, muscle-sparing vs posterolateral thoracotomy. Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: A population-based cohort study A Randomized Controlled Trial of Postthoracotomy Pulmonary Rehabilitation in Patients with Resectable Lung Cancer A prospective, double-blinded, randomized trial evaluating the use of preemptive analgesia of the skin before thoracotomy.
OBJECTIVE Long-term pain is a common sequela of thoracotomy , occurring in approximately 50 % of patients 2 years after thoracic surgery . Despite this alarming statistic , little is known about the factors responsible for the transition of acute to chronic pain . The aim of the present study is to identify predictors of long-term post-thoracotomy pain . DESIGN Follow-up was for 1.5 years for patients who had participated in a prospect i ve , r and omized , controlled trial of preemptive , multimodal analgesia .  SETTING Subjects were recruited from a tertiary care center . PATIENTS Thirty patients who had undergone lateral thoracotomy  were followed up by telephone , administered a structured interview , and classified according to long-term pain status . MAIN OUTCOME MEASURES Present pain status was measured by a verbal rating scale ( VAS ) . Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later . These include VAS pain scores at rest and after movement , McGill Pain Question naire data , patient-controlled morphine consumption ( mg ) , and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision . RESULTS Fifty-two percent of patients reported long-term pain . Early postoperative pain was the only factor that significantly predicted long-term pain . Pain intensity 24 h after surgery , at rest , and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients . A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Question naire . Cumulative morphine was comparable for the two groups . Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups . CONCLUSION Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain OBJECTIVE Two different surgical accesses combined with st and ard pain management procedures are compared regarding early and intermediate pulmonary function and pain relief . METHODS In a prospect i ve study , 15 consecutive patients undergoing video-thoracoscopy for pulmonary wedge resection ( group 1 ) were matched to 15 patients undergoing st and ard postero-lateral thoracotomy for lobectomy ( group 2 ) according to age , gender and preoperative pulmonary function . Postoperative pain control consisted of patient controlled analgesia in group 1 and epidural analgesia in group 2 .  Pain intensity was scored from 0 - 4 . The predicted postoperative pulmonary function ( FVC and FEV 1 ) after lobectomies was calculated from the preoperative value according to the extent of resection . A clinical measurement was obtained after a mean follow-up time of 4.2 months . RESULTS The ratios of postoperative measured to predicted values of FVC and FEV1 for group 1 compared with group 2 were 0.64 + /- 0.15 and 0.65 + /- 0.14 compared with 0.60 + /- 0.19 and 0.59 + /- 0.13 , resp . ( both n.s . ) at the first day postoperative ; 0.92 + /- 0.18 and 0.95 /- 0.17 compared with 0.76 + /- 0.20 ( P < 0.05 ) and 0.83 + /- 0.23 ( n.s . ) , resp . at hospital discharge ; 0.98 + /- 0.10 and 0.94 + /- 0.14 compared with 1.01 + /- 0.17 ( n.s . ) and 1.10 + /- 0.17 ( P < 0.05 ) , resp . at follow-up . Pain intensity score one day after surgery ranged from 0.4 ( resting position ) to 1.6 ( coughing ) for group 1 , and from 0.3 to 1.2 for group 2 . Thirty-six percent of the thoracoscopy patients and 33 % of the thoracotomy group complained of persistent pain or discomfort on the site of the operation after 3 - 18 months . CONCLUSION Post-thoracotomy pain can be effectively controlled with epidural analgesia and pain intensity is no higher than in patients after thoracoscopy who are managed with patient controlled analgesia . FVC is slightly more decreased after thoracotomy during the early postoperative period . FVC and FEV 1 approach the predicted values after four months in both groups . The rate of persistent pain is similar after thoracoscopy and thoracotomy Objectives Prolonged activation of pain centers is a proposed cause of chronic pain syndromes . Women are at particular risk for chronic pain as they tend to more readily detect pain and to attenuate it less than men . We set out to determine whether sex affected pain and recovery after major surgery by analyzing data originally collected to determine the effect of the timing of epidural analgesia on long-term outcome after thoracotomy . Methods Patients presenting for lobectomy , segmentectomy , or bilobectomy , but not pneumonectomy or chest wall resection , were enrolled .  Pain , physical activity , and the extent that pain interfered with activities after surgery were prospect ively assessed with st and ard question naires ( Brief Pain Inventory and physical component score of SF-36 ) on postoperative days 1 to 5 , and at postoperative weeks 4 , 8 , 12 , 24 , 36 , and 48 by a blinded research assistant . Perioperative care was st and ardized and included patient-controlled thoracic epidural analgesia until thoracostomy tube removal . Results Fifty eight men and 62 women were enrolled . Women reported more pain than men throughout the entire study period , and they had a higher rate of nonsteroidal anti-inflammatory drug use , but not opioid use . This increased pain was not explained by incision type , surgeon , tumor type , or tumor stage . Older patients reported less pain after discharge than younger patients . Postoperative physical activity levels were significantly less than those reported preoperatively , but did not differ by sex . Discussion Women have a distinctly different pain experience than men after thoracic surgery and probably require novel and /or multimodal analgesic regimens to improve their comfort Background  Postthoracotomy pain syndrome ( PTPS )  is a frequent cause of chronic postoperative pain .  Pregabalin might reduce the incidence of chronic postoperative pain . The goal of this study was to evaluate the impact of perioperative pregabalin on the occurrence of PTPS , defined as any surgical site pain 3 months after surgery . Methods We conducted a r and omized , placebo-controlled , double-blind trial in patients undergoing elective thoracotomy . Patients received either pregabalin 150 mg orally twice a day initiated 1 hour before thoracotomy and continued until 4 days after thoracotomy ( 10 doses total ) or a placebo using the same protocol . All patients received preincision thoracic epidural analgesia .  Postthoracotomy pain syndrome was evaluated using the Brief Pain Inventory question naire through a telephone interview . Secondary outcomes included evaluation of neuropathic characteristics through the Leeds Assessment of Neuropathic Symptoms and Signs question naire , analgesic use 3 months after surgery , and evaluation of acute postoperative pain and opioid consumption . Results One hundred fourteen patients were r and omized , and 99 patients completed the study ( placebo , n = 49 ; pregabalin , n = 50 ) . Postthoracotomy pain syndrome occurred in 49 ( 49.5 % ) of 99 patients and more frequently in the pregabalin group ( 31/50 [ 62 % ] vs 18/49 [ 37 % ] in the placebo group , P = 0.01 ) . However , among patients with PTPS , those in the pregabalin group required significantly less analgesics , reported less moderate to severe average pain , and presented significantly less neuropathic characteristics than patients in the placebo group 3 months after surgery . Conclusions Pregabalin did not reduce the incidence of PTPS in this study . Future research on PTPS should focus on the impact of regional analgesia on central sensitization Chronic pain following thoracic surgery  is common and associated with neuropathic symptoms , however , the proportion of patients with neuropathic pain in the immediate postoperative period is unknown . We aim ed to determine the proportion of patients who have neuropathic symptoms and signs immediately after , and at three months following thoracic surgery .  The study was design ed as a prospect i ve observational cohort study . We identified patients with pain of predominantly neuropathic origin using the  Leeds Assessment of Neuropathic Symptoms and Signs ( LANSS ) score in the immediate postoperative period and the self-report LANSS ( S-LANSS ) version three months after surgery . One hundred patients undergoing video assisted thoracic surgery ( VATS ) or thoracotomy  completed LANSS  scores  preoperatively and in the immediate postoperative period . Eighty-seven percent completed three months S-LANSS follow-up scores . Eight percent of patients had positive LANSS scores in the immediate postoperative period ; 22 % of patients had positive S-LANSS scores three months following surgery . There was a significant association between positive scores in the acute and chronic periods ( relative risk ( RR ) 3.5 , [ 95 % confidence interval ( CI ) 1.7 - 7.2 ] ) . Identifying pain of predominantly neuropathic origin in the postoperative period with a simple pain score can help identify those at risk of developing chronic pain with these features following thoracic surgery PURPOSE Patients receiving cancer-related thoracotomy  are highly symptomatic in the first weeks after surgery . This study examined whether at-home symptom monitoring plus feedback to clinicians about severe symptoms contributes to more effective postoperative symptom control . PATIENTS AND METHODS We enrolled 100 patients receiving thoracotomy for lung cancer or lung metastasis in a two-arm r and omized controlled trial ; 79 patients completed the study . After hospital discharge , patients rated symptoms twice weekly for 4 weeks via automated telephone calls . For intervention group patients , an e-mail alert was forwarded to the patient 's clinical team for response if any of a subset of symptoms ( pain , disturbed sleep , distress , shortness of breath , or constipation ) reached a predetermined severity threshold . No alerts were generated for controls . Group differences in symptom threshold events were examined by generalized estimating equation modeling . RESULTS The intervention group experienced greater reduction in symptom threshold events than did controls ( 19 % v 8 % , respectively ) and a more rapid decline in symptom threshold events . The difference in average reduction in symptom interference between groups was -0.36 ( SE , 0.078 ; P = .02 ) . Clinicians responded to 84 % of e-mail alerts . Both groups reported equally high satisfaction with the automated system and with postoperative symptom control . CONCLUSION Frequent symptom monitoring with alerts to clinicians when symptoms became moderate or severe reduced symptom severity during the 4 weeks after thoracic surgery . Methods of automated symptom monitoring and triage may improve symptom control after major cancer surgery . These results should be confirmed in a larger study OBJECTIVE Our question naire study set out to assess the prevalence of chronic pain after thoracic surgery , the contribution of the neuropathic component of chronic pain and the impact of chronic pain on patients ' lives . METHODS A question naire was sent to 1152 patients who had undergone thoracic surgery in our department between 7 months and 7 years ago . The question naire was design ed specifically for the study and included questions on neuropathic symptoms . Responses were correlated with data from our prospect ively entered data base for analysis . RESULTS Nine hundred and forty-eight people were included in the study , of which 600 responded ( 63 % ) . Prevalence of chronic pain is 57 % at 7 - 12 months , 36 % at 4 - 5 years and 21 % at 6 - 7 years . Patient age , consultant and time since the operation all have significant effects . Surgical approach ( video-assisted thoracoscopic surgery , thoracotomy ) and diagnosis are not significant . Thirty-nine percent of those with pain take analgesia , 46 % felt their pain is their worst medical problem and 40 % reported it limits their daily activities . The prevalence of each neuropathic symptom is between 35 and 83 % . The presence of a neuropathic symptom is associated with significantly more severe pain , more analgesia use and pain more likely to limit daily activity . CONCLUSIONS Chronic pain has a significant prevalence and impact on patients ' lives for several years after thoracic surgery . Nerve dysfunction is associated with more severe pain , a greater impact and tends to persist . The reason for the individual consultant being an important factor in post-thoracotomy pain needs further investigation Recent evidence suggests that surgical trauma induces a process of central nervous system sensitisation that contributes to and enhances postoperative pain . These changes are also thought to be the underlying cause of much chronic pain . Central sensitisation is generated not only during surgery , but also postoperatively as a result of the inflammatory response to the damaged tissue . This knowledge provides a rational basis for pro-active , pre-emptive and postoperative analgesic strategies to reduce the neuronal barrage associated with tissue damage . Reduction or elimination of postoperative pain is therefore possible . We advocate the use of continuous extrapleural intercostal nerve block for postoperative analgesia in patients undergoing thoracotomy .  When this is begun pre-emptively ( by precutaneous , pre-incisional paravertebral block ) it is combined with an opiate and a non-steroidal anti-inflammatory drug premedication . In a r and omised study of 56 patients , pain scores of less than 0.5 cm on a 10 cm scale were produced , postoperative lung function was preserved and glucose and cortisol responses were significantly unchanged from preoperative values . Evidence that effective perioperative analgesia reduces the incidence of chronic post-thoracotomy chest wall pain was found in a retrospective study of 1000 consecutive thoracotomies . The endpoints of a zero pain score , complete preservation of preoperative lung function and prevention of the stress response to trauma are currently achievable and should be provided for virtually all patients undergoing chest surgery . Pre-empting pain must be the goal for all those involved in the postoperative care of patients Background and Objectives Patients undergoing breast cancer surgery frequently experience chronic postoperative pain . The primary objective of this r and omized study was to determine if thoracic paravertebral block ( TPVB ) reduced the incidence of chronic pain after a modified radical mastectomy ( MRM ) when compared with general anesthesia ( GA ) . Methods One hundred eighty women undergoing MRM were r and omized to 1 of 3 study groups : group 1 : st and ardized GA , group 2 : GA with a single-injection TPVB and placebo paravertebral infusion , and group 3 : GA with a continuous TPVB . Outcomes assessed postoperatively included acute postoperative pain and analgesic consumption and , at 3 and 6 months , the incidence and severity of chronic pain and physical and mental health-related quality of life ( HRQOL ) . Results There was no significant difference in the incidence of chronic pain at 3 months ( P = 0.13 ) and 6 months ( P = 0.79 ) after the MRM between the study groups . The relative risk of developing chronic pain ( P = 0.25 ) was also similar between the groups . There was no difference in acute pain ( P = 0.22 ) or postoperative analgesic consumption ( P = 0.67 ) between the groups . Nevertheless , differences were observed in chronic pain – related secondary outcome variables . The TPVB groups reported lower chronic pain scores ( P < 0.05 ) , exhibited fewer symptoms and signs of chronic pain ( P ⩽ 0.01 ) , and also experienced better physical and mental HRQOL than did the GA group . Chronic pain scores also decreased with time in all study groups ( P < 0.05 ) . Conclusions There is no significant difference in the incidence or relative risk of chronic pain at 3 and 6 months after an MRM when TPVB is used in conjunction with GA . Nevertheless , patients who receive a TPVB report less severe chronic pain , exhibit fewer symptoms and signs of chronic pain , and also experience better physical and mental HRQOL BACKGROUND Pain after thoracotomy  is common . The objective of this study was to assess whether pain 3 months postthoracotomy negatively impacts quality of life . METHODS One hundred ten patients were prospect ively assessed using the Medical Outcomes Study  36-Item Short Form Health Survey before and 3 months after elective thoracotomy .  Pain and medication use were evaluated by question naire . Patients experiencing pain at 3 months were compared with patients who did not have postthoracotomy pain . RESULTS Seventy-five patients ( 68 % ) had pain 3 months postthoracotomy ; 12 patients ( 11 % ) rated their average pain greater than 3 ( out of 10 ) . Eighteen ( 16 % ) patients required opioid analgesics . The pain group reported lower SF-36 scores in physical functioning ( p = 0.049 ) , bodily pain ( p = 0.0002 ) , and vitality ( p = 0.044 ) . There were no other significant differences in any SF-36 scale between the pain and non-pain groups . CONCLUSIONS Pain is commonly reported at 3 months after elective thoracotomy but is generally mild , shows improvement with time , and does not usually require opioid analgesics . Patients who experience postthoracotomy pain at 3 months are at risk for significantly decreased physical functioning and vitality , but are not at risk for significantly decreased social , emotional , or mental health functioning compared with patients who do not experience postthoracotomy pain at 3 months Background Pain  following thoracotomy  can persist for years with an undetermined impact on quality of life . Factors hypothesized to modulate this painful experience include analgesic regimen , gender , and type of incision . Methods A total of 157 generally healthy patients of both genders scheduled for segmentectomy , lobectomy , or bilobectomy through a posterolateral or muscle-sparing incision were r and omly assigned to receive thoracic epidural analgesia initiated prior to incision or at the time of rib approximation .  Pain and activity scores were obtained 4 , 8 , 12 , 24 , 36 , and 48 weeks after surgery . Results Overall , there were no differences in pain scores between the control and intervention groups during hospitalization ( P ≥ 0.165 ) or after discharge ( P ≥ 0.098 ) . The number of patients reporting pain 1 yr following surgery ( 18 of 85 ; 21.2 % ) was not significantly different ( P = 0.122 ) from the number reporting preoperative pain ( 15 of 120 ; 12.5 % ) . During hospitalization , women reported greater pain than men ( worst pain , P = 0.007 ; average pain , P = 0.016 ) . Women experienced fewer supraventricular tachydysrhythmias ( P = 0.013 ) and were thus discharged earlier ( P = 0.002 ) . After discharge women continued to report greater discomfort than men ( P ≤ 0.016 ) , but did not differ from men in their level of physical activity ( P = 0.241 ) . Conclusions Initiation of thoracic epidural analgesia prior to incision or the use of a muscle-sparing incision did not significantly impact pain or physical activity . Although women reported significantly greater pain during hospitalization and after discharge , they experienced fewer complications , were more likely to be discharged from the hospital sooner , and were just as active after discharge as men Objective . The pathogenesis and risk of chronic pain after cholecystectomy are unknown . In this prospect i ve study of 150 consecutive patients undergoing laparoscopic cholecystectomy  , the preoperative clinical data , cold pressor test , state of neuroticism and early postoperative pain intensity were assessed . Material and methods . Follow-up question naires were sent to all patients 1 year after surgery . Patients with moderate/severe chronic pain were interviewed and invited to participate in a structured examination programme . Results . The question naire response rate was 100 % . Twenty patients reported moderate or severe chronic pain . The 1-year in-office interview revealed that two patients without chronic pain had misinterpreted the question naire . Sixteen patients were enrolled for the examination programme . Demonstrable pathology explained the aetiology of chronic pain in 8 patients ( 5 % ) ; another 8 patients with moderate ( n=6 ) or severe ( n=2 ) chronic pain were without pathological findings . In total , 132 patients had no chronic pain . Chronic pain patients suffered significantly more intense acute postoperative pain compared with those without chronic pain ( p≤0.05 ) . The incidence of chronic pain patients was higher in the group of patients with intense acute postoperative pain than in patients with low acute postoperative pain ( p = 0.030–0.063 ) . Development of chronic pain was not statistically related to a preoperative cold pressor nociceptive stimulus , preoperative state of neuroticism or to any other variables examined . Conclusions . The risk of significant chronic pain after laparoscopic cholecystectomy for symptomatic cholecystolithiasis is low but was significantly associated with the intensity of acute postoperative pain . Patients should be carefully examined to exclude somatic causes of chronic pain after laparoscopic cholecystectomy UNLABELLED Chronic pain following breast cancer surgery is associated with decreased health-related quality of life and is a source of additional psychosocial distress in women who are already confronting the multiple stresses of cancer . Few prospect i ve studies have identified risk factors for chronic pain following breast cancer surgery . Putative demographic , clinical , and psychosocial risk factors for chronic pain were evaluated prospect ively in 95 women scheduled for breast cancer surgery . In a multivariate analysis of the presence of chronic pain , only younger age was associated with a significantly increased risk of developing chronic pain 3 months after surgery . In an analysis of the intensity of chronic pain , however , more invasive surgery , radiation therapy after surgery , and clinical ly meaningful acute postoperative pain each independently predicted more intense chronic pain 3 months after surgery . Preoperative emotional functioning variables did not independently contribute to the prediction of either the presence or the intensity of chronic pain after breast cancer surgery . These findings not only increase underst and ing of risk factors for chronic pain following breast cancer surgery and the processes that may contribute to its development but also provide a basis for the development of preventive interventions . PERSPECTIVE Clinical variables and severe acute pain were risk factors for chronic pain following breast cancer surgery , but psychosocial distress was not , which provides a basis for hypothesizing that aggressive management of acute postoperative pain may reduce chronic pain STUDY OBJECTIVES We set out to determine whether there is a difference in postoperative pain and recovery after the patient undergoes the axillary muscle-sparing incision ( ie  ,  muscle-sparing thoracotomy [ MT ] ) vs the modified posterolateral incision ( ie  ,  posterolateral thoracotomy [ PT ] ) .  DESIGN Analysis of a data base originally collected to determine the effect of the timing of epidural analgesia on long-term outcome after thoracotomy . SETTING The Hospital of the University of Pennsylvania . PATIENTS Patients presenting for lobectomy , segmentectomy , or bilobectomy . MEASUREMENTS Pain , physical activity , and the extent that pain interfered with activities following major thoracotomy were prospect ively assessed with st and ard question naires ( ie , the brief pain inventory and the Medical Outcomes Study 36-item short form ) on postoperative days 1 to 5 , and at postoperative weeks 4 , 8 , 12 , 24 , 36 , and 48 by a blinded research assistant . Perioperative care was st and ardized and included patient-controlled thoracic epidural analgesia until thoracostomy tube removal . RESULTS Eighty-two subjects underwent MT and 38 subjects underwent PT  during the 16-month accrual period . There were no significant differences in demographics . Pain reported during hospitalization and after hospital discharge did not differ with respect to incision type ( p > or = 0.17 ) . Postoperative physical activity levels were significantly less than those reported preoperatively , with a trend toward better functioning in the MT groups after 8 weeks . Incision type did not predict complications , morbidity , or mortality . CONCLUSIONS When comparing patients who had undergone vertical , axillary , wholly MT to those who had undergone modified serratus muscle-sparing PT , postoperative differences in pain were not apparent . One should not anticipate reduced pain or more rapid overall recovery following MT , at least when epidural analgesia is used aggressively for perioperative pain control Summary Risk factors for chronic pain up to 9 months after breast cancer surgery include younger age , psychological vulnerability , axillary clearance surgery , and severe acute postoperative pain . ABSTRACT Chronic postsurgical pain ( CPSP ) is a common postoperative adverse event affecting up to half of women undergoing breast cancer surgery , yet few epidemiological studies have prospect ively investigated the role of preoperative , intraoperative , and postoperative risk factors for pain onset and chronicity . We prospect ively investigated preoperative sociodemographic and psychological factors , intraoperative clinical factors , and acute postoperative pain in a prospect i ve cohort of 362 women undergoing surgery for primary breast cancer . Intraoperative nerve h and ling ( division or preservation ) of the intercostobrachial nerve was recorded . At 4 and 9 months after surgery , incidence of chronic painful symptoms not present preoperatively was 68 % and 63 % , respectively . Univariate analysis revealed that multiple psychological factors and nerve division was associated with chronic pain at 4 and 9 months . In a multivariate model , independent predictors of CPSP at 4 months included younger age and acute postoperative pain ( odds ratio [ OR ] 1.34 , 95 % confidence interval [ CI ] 1.12 to 1.60 ) , whereas preoperative psychological robustness ( OR 0.70 , 95 % CI 0.49 to 0.99 ) , a composite variable comprising high dispositional optimism , high positive affect , and low emotional distress , was protective . At 9 months , younger age , axillary node clearance ( OR 2.97 , 95 % CI 1.09 to 8.06 ) , and severity of acute postoperative pain ( OR 1.17 , 95 % CI 1.00 to 1.37 ) were predictive of pain persistence . Of those with CPSP , 25 % experienced moderate to severe pain and 40 % were positive on Douleur Neuropathique 4 and Self‐Complete Leeds Assessment of Neuropathic Symptoms and Signs pain scales . Overall , a high proportion of women report painful symptoms , altered sensations , and numbness in the upper body within the first 9 months after resectional breast surgery and cancer treatment Introduction : Little is known about the effects of rehabilitation for patients with lung cancer after thoracotomy . The primary objective of this study was to evaluate the effect of a multidisciplinary rehabilitation program on quality of life ( QOL ) and secondary objectives were to determine its effects on pain and exercise capacity and the feasibility of combining rehabilitation with adjuvant chemotherapy . Methods : Patients who had undergone a thoracotomy for lung cancer were r and omized between rehabilitation and usual care .  Rehabilitation consisted of twice-weekly training for 12 weeks starting 1 month after hospital discharge , scheduled visits to pain specialists , and medical social work . QOL and pain were measured with vali date d question naires at baseline and after 1 , 3 , 6 , and 12 months . Exercise tolerance was assessed at baseline and after 3 months with a 6-minute walking distance test . Results : The study closed prematurely because of the introduction of video-assisted thoracoscopic surgery .  Of 57 r and omized patients , 49 patients ( 23 active and 26 control ) were analyzed .  QOL was not significantly different between groups , although , the active group reported more pain after 3 and 6 months and more limitations because of physical problems after 3 months . In the active group , 6-minute walking distance improved by 35 m from preoperative baseline , as opposed to the control group that showed a decline by 59 m ( p = 0.024 for difference ) . Patients treated with adjuvant chemotherapy showed decreased attendance at training sessions . Conclusion : Rehabilitation did not result in a better QOL . Exercise tolerance improved at the cost of more pain and more limitations because of physical problems . We suggest that rehabilitation is better postponed for 3 to 4 months after hospital discharge BACKGROUND Thoracic surgeons spend a lot of time treating the pain of thoracotomy . METHODS A total of 119 consecutive patients underwent elective thoracotomy .  They were prospect ively r and omized into two groups . One group received an injection of 1 % lidocaine with epinephrine in the planned skin incision just before thoracotomy , and the other group received an equal amount of saline and epinephrine . All patients had a functioning preoperative epidural ; a skin incision the width of their latissimus dorsi muscle , which was cut ; sparing of the serratus anterior muscle ; undercutting of the sixth rib ; intercostal nerve blocks before rib spreading ; a similar number of chest tubes and pulmonary resections ; and comparable postoperative pain management . Pain was objectified by a numeric pain score , a visual pain score , and by the Modified McGill pain question naire each day in the hospital , and at 3 , 6 , and 12 months postoperatively . RESULTS There were 66 patients in the lidocaine group ( L group ) and 53 patients in the saline group ( S group ) . Although a trend was noted toward less pain in the L group during the first 3 postoperative days ( on the numeric pain scale only ) the difference was not statistically significant in overall pain in the hospital or at 3 , 6 , and 12 months after the operation . Other pain scores and descriptors were similar throughout . CONCLUSIONS The injection of lidocaine and epinephrine in the skin just before thoracotomy does not decrease the amount or type of pain during the hospital stay or at 3 , 6 , and 12 months after surgery
However , intercostal nerve injury seems to be the most important pathogenic factor .
Chronic pain complaints after thoracic surgery represent a significant clinical problem in 25 - 60 % of patients .
Results from thoracic and other surgical procedures suggest multiple pathogenic mechanisms that include pre- , intra- , and postoperative factors .
This review attempts to analyse the methodology and systematic s of the studies on the  post-thoracotomy pain syndrome ( PTPS ) after lung cancer surgery in adults , in order to clarify the relative role of possible pathogenic factors and to define future strategies for prevention .