(Kiosk 5) Successful Multimodal Treatment of Post-thoracotomy Pain Syndrome: A Case Report

Case Diagnosis: Post-Thoracotomy Pain Syndrome

Case Description or Program Description: 69-year-old female with a history of recurrent papillary serous ovarian cancer, status post laparoscopic debulking surgery in 2018, who presents with abdominal and lower chest wall pain.

Setting: Outpatient Clinic

Assessment/Results: Exam was significant for tenderness of the right upper abdomen/lower chest over the right anterior 6-7th ribs, likely in the region of prior laparoscopy sites. CT scan of the chest was negative for significant bony retropulsion or suspicious lytic or blastic osseous lesion. Right anterior region serratus plane block was performed with depomedrol and bupivacaine under ultrasound guidance with over 50% pain relief of symptoms. Patient was then started on physical therapy and encouraged to do chest wall mobilization. She subsequently received an ultrasound-guided trigger point injection to the rectus abdominus, which gave her significant pain relief at 2-month follow-up.

Discussion (relevance): Post-thoracotomy pain syndrome (PTPS) is a common complication of thoracic surgery. Pain is primarily due to rib retraction and damage to the serratus, intercostal muscles, and intercostal nerves. While manifestations can vary, the most common form of PTPS is neuropathic pain unresponsive to opioid therapy. A less common cause of PTPS is non-neurologic in origin and can be myofascial in origin. Thoracic epidural anesthesia is considered the current gold standard, however, this carries a high risk of complications including bleeding into the neuraxial space and hypotension. In this case, the patient’s pain was likely multifactorial, due to intercostal nerve damage and myofascial pain. When treated with a multimodal approach including serratus plane nerve block, rectus abdominus trigger point injection, and physical therapy, the patient’s pain was significantly improved.

Conclusions: This case highlights the importance of a multimodal approach to treating PTPS. It is important for physicians to be aware that multiple pain generators can contribute to the syndrome, which should all be adequately addressed to improve patient satisfaction.