Cerfolio Robert James, Bryant Ayesha S, Maniscalco Lee M
Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
Ann Thorac Surg. 2008 Jun;85(6):1901-6; discussion 1906-7. doi: 10.1016/j.athoracsur.2008.01.041.
The pain of thoracotomy may be related to trauma to the intercostal nerves.
This was a prospective randomized study of 160 patients. All patients had a functioning epidural, similar type and size thoracotomy, an intercostal muscle flap (ICM) harvested before rib spreading, inferior rib drilling, and postoperative pain management. In one group, the ICM was left intact distally and it dangled (D group); the ICM in the other was cut distally (C group). Pain was assessed using multiple pain scores. Outcomes assessed were qualitative and quantitative pain scores, number of ribs broken, spirometric values, analgesic use, and return to baseline activity for postoperative days 1 to 5 and weeks 2, 3, 4, 8, and 12.
The D group had 85 patients and the C group, 75. The groups had similar demographics, types of procedures, and histology. Intrahospital pain scores were similar; however, at postoperative weeks 3, 4, 8, and 12, the D group had significantly lower mean numeric pain scores and was using fewer analgesics (p < 0.05 for all). At 12 weeks, patients in the D group were more likely to have returned to baseline activity (p = 0.002).
An ICM flap reduces pain. Harvesting and then leaving the ICM flap intact instead of cutting it before rib spreading further reduced thoracotomy pain. This technique, when added to rib drilling, leads to reduced pain on postoperative weeks 3 to 12, to quicker return to baseline activity, and lessens the need for analgesics.
开胸手术的疼痛可能与肋间神经损伤有关。
这是一项对160例患者进行的前瞻性随机研究。所有患者均有功能正常的硬膜外麻醉，接受相似类型和大小的开胸手术，在肋骨撑开前切取肋间肌瓣（ICM），进行肋骨钻孔，并进行术后疼痛管理。一组中，ICM远端保持完整并悬吊（D组）；另一组中，ICM在远端切断（C组）。使用多种疼痛评分评估疼痛。评估的结果包括定性和定量疼痛评分、肋骨骨折数量、肺功能测定值、镇痛药使用情况，以及术后第1至5天和第2、3、4、8和12周恢复至基线活动的情况。
D组有85例患者，C组有75例。两组在人口统计学、手术类型和组织学方面相似。院内疼痛评分相似；然而，在术后第3、4、8和12周，D组的平均数字疼痛评分显著更低，且使用的镇痛药更少（所有p值均<0.05）。在12周时，D组患者更有可能恢复至基线活动（p = 0.002）。
ICM瓣可减轻疼痛。切取ICM瓣后保持其完整而非在肋骨撑开前切断可进一步减轻开胸手术疼痛。该技术与肋骨钻孔相结合，可减轻术后第3至12周的疼痛，加快恢复至基线活动的速度，并减少镇痛药的使用需求。
