Characteristics of the neuropathy induced by thoracotomy: a 4-month follow-up study with psychophysical examination.

OBJECTIVES: To explore the role of neuropathy in persistent pain after thoracotomy, combining a clinical follow-up and a psychophysical examination of the operated area. METHODS: Seventy-three patients were followed and examined at their discharge from hospital, 6 weeks and 4 months after pneumonectomy under thoracotomy. Spontaneous and evoked pain was assessed by clinical examination, a 7-day pain score, and the Neuropathic Pain Symptom Inventory. At the fourth month follow-up, pain and tolerance thresholds to pinprick, heat, and warm sensation threshold were measured on both sides of the thorax. RESULTS: The rate of spontaneous pain was 40% at discharge and went up to 59% at the sixth week follow-up. Evoked pain was rare at discharge (11%), most cases appearing at the sixth week follow-up (47%). The evolution profiles of pain between the sixth week and the fourth month follow-up were heterogeneous with a tendency to decrease. Young age, female sex, and spontaneous pain observed at discharge from hospital were identified as early predictive factors of spontaneous pain persisting at the fourth month follow-up. On the side of operation, thresholds tended to increase for warm and hot stimuli, and to decrease for mechanical stimuli. At the fourth month follow-up, spontaneous pain and evoked pain were associated to static hyperalgesia, persisting hypoesthesia, low mechanical thresholds, altered sensation of heat, and impaired quality of life. DISCUSSION: Peripheral neuropathy is common after thoracotomy, with variant characteristics, ranging from subclinical disturbances to severe pain. The process seems to develop between the discharge from hospital and the sixth week after thoracotomy.

A prospective study of neuropathic pain induced by thoracotomy: incidence, clinical description, and diagnosis.

This study evaluated prospectively the incidence of neuropathic pain after thoracotomy, described its clinical characteristics, and delineated landmarks for its diagnosis in daily practice. We evaluated clinically painful symptoms and sensory deficits in 54 patients after lateral/posterolateral thoracotomy for broncho-pulmonary carcinoma with standardized surgical and analgesic procedures. At 2months, 49 patients suffered from non malignant thoracic pain, and at 6months 38 patients (loss to follow-up for 7) reported persisting pain. In 35 patients, painful symptoms and sensory deficits could be evaluated using a standardized clinical bedside procedure. According to the grading system proposed by Treede et al. [41], neuropathic pain was considered probable in 21 patients, while use of the DN4 questionnaire concluded that neuropathic pain was probable in 17 patients. The two diagnostic procedures provided similar conclusions in 16 patients. Morphine consumption during the early post-operative period (mean 111.3±30.8mg/day) and pain intensity (VAS: mean 5.71±2.1) were significantly higher in patients suffering from neuropathic pain than in other patients with pain (mean 80±21.4mg/day; VAS: mean 3.9±2.4). The clinical picture in most patients with neuropathic pain included electric shocks and severe multimodal hypoesthesia in the sensory area of 5th/6th intercostal nerves. Thus, our results indicate a minimal incidence of chronic post-thoracotomy pain at 70% and that of neuropathic pain at 29%, this latter being clinically suggested by a combination of certain symptoms and reinforced by the DN4 questionnaire when sensory deficit at scar is present.

Anatomical bases of the surgical dissection of the interatrial septum: a morphological and histological study.

BACKGROUND: The interatrial septum (IAS) can be dissected to resect pulmonary tumors invading the left atrium. The aim of this study was to describe the dissected structures, and to expose the benefits, the limits, and the embryologic reasons of such dissection. METHODS: We dissected the IAS of 11 fresh, non-embalmed human hearts. The dissected structures were described and the length and depth of the dissection were measured. A histological study was performed in four other fresh hearts to identify and differentiate between dissectible and non-dissectible structures. RESULTS: The dissection was performed through a fatty tissue located between two muscular walls. The depth limit of the IAS dissection was identified as the limbus of the fossa ovalis and the muscular roof of the atria. The section of the latter doubles the depth of the dissection at the level of the upper pulmonary veins. Mean length of the dissected IAS was 77 mm (55-90). Mean depths of the IAS were 41 mm (35-50) at the level of the left upper pulmonary vein, 27 mm (12-35) between the upper and lower pulmonary veins, and 14 mm (8-20) at the level of the left inferior pulmonary vein CONCLUSION: The surgical dissection of the IAS is performed through the septum secundum that appears as an infold of the atrial wall. The length of the resectable left atrial cuff reaches a mean of 40 mm at the level of the upper pulmonary vein.