Postthoracotomy Pain
Conditions
Keywords
Paravertebral Block, Serratus Posterior Superior Intercostal Plane Block, Thoracotomy
Brief summary
Patients undergoing thoracic surgery via thoracotomy are required to remain in the lateral decubitus position for prolonged periods due to surgical access requirements. This positioning is considered one of the major contributors to postoperative shoulder pain, particularly because of the mechanical stress imposed on the dependent shoulder and scapulothoracic region. The resulting pain not only reduces patient comfort but may also delay early mobilization, thereby adversely affecting respiratory function and the recovery of postoperative pulmonary capacity . Therefore, in thoracic surgery, the ability of regional anesthesia techniques to provide sensory coverage extending beyond the incision site to include dermatomes associated with the shoulder girdle has emerged as a critical factor influencing analgesic efficacy. In this context, the present study aims to comprehensively compare Serratus Posterior Superior Intercostal Plane Block (SPSIPB) and Thoracic Paravertebral Block (PVB) with respect to both the management of post-thoracotomy postoperative shoulder pain and their overall analgesic effectiveness. Furthermore, the contribution of these two techniques to postoperative pain management will be thoroughly evaluated in terms of patient comfort and safety profiles.
Detailed description
Thoracotomy is a commonly performed approach in thoracic surgery and is associated with severe postoperative pain due to extensive tissue dissection and rib retraction. Inadequate control of postoperative pain may lead to serious complications, including impaired respiratory function, secretion retention, atelectasis, pneumonia, chronic post-thoracotomy pain syndrome, and reduced patient satisfaction . Therefore, identifying effective, safe, and sustainable analgesic strategies following thoracotomy is of critical importance for improving both patient comfort and clinical outcomes. Thoracic epidural analgesia (TEA) has long been considered one of the most widely used techniques for postoperative pain control in thoracic surgery. Although TEA provides effective bilateral somatic and visceral analgesia, its clinical use is limited by several factors, including hypotension, urinary retention, motor blockade, epidural hematoma, technical challenges, and the requirement for patient cooperation. Consequently, in addition to systemic analgesics, regional anesthesia techniques have become essential components of multimodal analgesia protocols in thoracic surgery . This has encouraged the development of alternative approaches that are less invasive, technically more feasible, and capable of providing comparable analgesic efficacy. Fascial plane blocks, such as paravertebral block (PVB), erector spinae plane block (ESPB), serratus anterior plane block, and serratus posterior plane blocks, have gained increasing attention because they can be performed within more superficial anatomical planes and are associated with a lower risk of complications . These techniques are particularly considered safe alternatives in patients for whom epidural analgesia is contraindicated or technically challenging . Thoracic paravertebral block (PVB), one of the techniques evaluated in the present study, provides effective control of both somatic and visceral pain through direct blockade of the thoracic spinal nerves. Despite its relatively deep anatomical location, PVB has demonstrated efficacy in numerous clinical settings and has been widely adopted in clinical practice. It has been successfully utilized in major thoracic procedures, including open thoracotomy, video-assisted thoracoscopic surgery (VATS), breast surgery, management of rib fractures, and extensive thoracic operations such as pneumonectomy and lobectomy. However, due to its deep anatomical location, PVB is associated with technical challenges and potential complications, including pneumothorax and vascular injury . As an alternative approach, the Serratus Posterior Superior Intercostal Plane Block (SPSIPB) has emerged as a novel regional anesthesia technique offering a technically simpler and anatomically safer profile owing to its more superficial site of administration. This block is performed by injecting local anesthetic between the serratus posterior superior muscle and the second or third intercostal muscles. Following injection, the spread of local anesthetic may extend to the dorsal rami, lateral cutaneous branches of the intercostal nerves, and the paravertebral space. Consequently, SPSIPB can provide extensive sensory blockade covering dermatomes from T2 to T9 . The potential of SPSIPB to achieve broad dermatomal coverage and provide segmental analgesia comparable to that of PVB has been supported by cadaveric studies and case series reported in the literature. Anatomical and technical descriptions have demonstrated that the sensory distribution of SPSIPB may extend from C3 to T10 dermatomes . Such extensive spread suggests that SPSIPB may provide effective analgesia for upper thoracic regions. The analgesic efficacy of SPSIPB has also been demonstrated in procedures involving anatomical regions similar to thoracic surgery, including video-assisted thoracoscopic surgery (VATS), reduction mammaplasty, cardiac surgery, and pectus excavatum repair, as reported in several case studies and clinical reports. However, prospective studies directly comparing SPSIPB and PVB in patients undergoing open thoracotomy remain limited. In this context, the primary objective of the present study is to compare the efficacy of SPSIPB and PVB in providing postoperative analgesia in patients undergoing thoracic surgical procedures performed via thoracotomy and to contribute to the optimization of postoperative pain management strategies in thoracic surgery. Patients undergoing thoracic surgery via thoracotomy are required to remain in the lateral decubitus position for prolonged periods to facilitate surgical exposure. This positioning is considered one of the major contributors to postoperative shoulder pain, primarily due to the mechanical stress imposed on the non-dependent shoulder and scapulothoracic region. The resulting pain not only compromises patient comfort but may also delay early mobilization, thereby adversely affecting respiratory function and the recovery of postoperative pulmonary capacity . Therefore, the ability of regional anesthesia techniques used in thoracic surgery to provide sensory blockade extending beyond the surgical incision site to include dermatomes associated with the shoulder girdle has emerged as an important determinant of analgesic success. Accordingly, the present study aims to comprehensively compare SPSIPB and PVB with regard to both the management of post-thoracotomy postoperative shoulder pain and their overall analgesic efficacy. Furthermore, the contribution of these two techniques to postoperative pain management will be thoroughly evaluated in terms of patient comfort and safety profiles.
Interventions
In this study, the Serratus Posterior Superior Intercostal Plane Block (SPSIPB) will be performed under ultrasound guidance using an in-plane technique at the level of the superomedial border of the scapula. The block will be administered by injecting local anesthetic into the interfascial plane between the serratus posterior superior muscle and the second or third intercostal muscle. Bupivacaine at a concentration of 0.25% will be used as the local anesthetic agent. The total dose administered will be calculated according to the patient's body weight and will not exceed the maximum recommended dose of 2 mg/kg. In routine clinical practice, an injection volume of 25-30 mL of bupivacaine is generally sufficient to achieve an effective block in most patients.
Thoracic Paravertebral Block (PVB) will be performed under ultrasound guidance using an in-plane technique at the T4-T6 thoracic vertebral levels. The needle tip will be advanced into the paravertebral space located between the transverse process and the parietal pleura. For PVB, 0.25% bupivacaine will be used as the local anesthetic agent. The total dose will be adjusted according to the patient's body weight and will not exceed the maximum recommended dose of 2 mg/kg. Based on evidence from the literature, an injection volume of 25-30 mL of bupivacaine generally provides adequate spread in the majority of patients. All block procedures will be performed by an experienced anesthesiologist and a resident physician involved in the study. Following block administration, all patients will undergo general anesthesia, and thoracic surgical procedures will subsequently be performed via thoracotomy by the thoracic surgery team.
Sponsors
Ankara City Hospital Bilkent
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
OTHER
Masking
SINGLE (Subject)
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
* Patients scheduled to undergo elective thoracic surgery via thoracotomy * Patients aged between 18 and 75 years * Patients classified as American Society of Anesthesiologists (ASA) physical status I-III * Patients who provide written informed consent to participate in the study
Exclusion criteria
* Patients with a known allergy or hypersensitivity to local anesthetic agents * Patients with coagulation disorders or those receiving anticoagulant therapy * Pregnant or breastfeeding women * Patients with impaired consciousness or inability to communicate effectively * Patients in whom block administration is unsuccessful * Patients who decline regional block administration * Patients with mental or cognitive impairment precluding reliable preoperative pain assessment * Patients with intolerance to or contraindications for morphine or other opioid medications * Patients who voluntarily choose to withdraw from the study at any stage of the research process * Patients who develop intraoperative surgical complications * Patients who experience hemodynamic complications during the perioperative period * Patients who develop serious postoperative medical complications requiring intensive care unit admission, reoperation, or other major medical interventions * Patients with incomplete follow-up data or in whom opioid consumption cannot be accurately assessed due to technical malfunction of the patient-controlled analgesia (PCA) device will be excluded from the final analysis.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Assessment of Postoperative Pain Intensity | Postoperative pain evaluations will be performed and recorded at predefined intervals during the first 24 postoperative hours, namely at 0, 1, 6, 12, and 24 hours after surgery. | Pain severity will be evaluated using the Numeric Rating Scale (NRS; 0-10), with 0 indicating no pain and 10 indicating the worst imaginable pain. |
| Assessment of Postoperative Shoulder Pain | Postoperative shoulder pain evaluations will be recorded at predetermined intervals during the first 24 hours postoperatively, namely at 0, 1, 6, 12, and 24 hours.Furthermore, shoulder pain assessments will be repeated at the one-month postoperative foll | Postoperative shoulder pain will be evaluated based on its presence or absence and quantified using the Numeric Rating Scale (NRS).The occurrence, duration, and severity of shoulder pain will be documented throughout the study period. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Assessment of Respiratory Function Using the Triflow Device | The same assessment will be repeated at 0, 1, 6, 12, and 24 hours postoperatively, and changes in Triflow performance over time will be evaluated. Pain experienced during Triflow performance will be assessed and documented using the Numeric Rating Scale | The Triflow device is an incentive spirometer that is activated by the patient's inspiratory effort and is used for the objective assessment of pulmonary function following thoracic surgery. Preoperatively, patients will be instructed on the proper use of the Triflow device and will perform a practice breathing exercise. The maximum number of balls elevated during this maneuver will be recorded as the baseline measurement. The intensity of pain experienced during Triflow performance will be evaluated and documented using the Numeric Rating Scale (NRS). |
| Postoperative Analgesic Requirement | during the first 24 postoperative hours | All patients will receive intravenous patient-controlled analgesia (PCA) for postoperative pain management. The total opioid (morphine) consumption during the first 24 postoperative hours will be recorded and expressed in milligrams (mg). |
| Assessment of Additional Analgesic Use and Rescue Analgesia Requirements | during the first 24 postoperative hours | In addition to intravenous morphine patient-controlled analgesia (PCA) and the institution's routine postoperative analgesic protocol, the presence of any additional analgesic requirements will be recorded. |
| Assessment of Block-Related Complications and Adverse Events | during the first 24 postoperative hours | Patients will be monitored for potential block-related complications, including pneumothorax, hematoma formation, injection-site pain, block failure, and local anesthetic systemic toxicity (LAST). All adverse events will be systematically documented throughout the study period. |
| Assessment of Patient Satisfaction and Overall Comfort | at 24 hours postoperatively and at the first postoperative month | Patient satisfaction will be evaluated at 24 hours postoperatively and again during the 1-month follow-up assessment. Satisfaction levels will be assessed using a 5-point Likert scale. |
| Effects on Early Mobilization and Respiratory Function | during the first 24 postoperative hours | The time to first mobilization, defined as the time at which the patient first stands up following surgery, will be recorded.Patients will be assessed to determine whether pain had a limiting effect on mobilization. |
Countries
Turkey (Türkiye)
Contacts
PRINCIPAL_INVESTIGATORhülya yiğit
ankara bilkent şehir hastanesi
Outcome results
None listed