Pain management after open thoracotomy 2025: procedure-specific postoperative pain management (PROSPECT) recommendations.

Researchers recently reviewed 100 studies published between 2015 and 2024 to determine the best ways to manage pain after open thoracotomy, a major surgery where the chest is opened to access the lungs or heart. This type of surgery typically causes significant pain, and effective pain control is essential for patients to breathe deeply, move comfortably, and recover properly.

The study found that two main approaches work best as first-line treatments: thoracic epidural analgesia, which delivers pain-blocking medication near the spinal cord, and paravertebral blockade, which numbs the nerves along the spine that carry pain signals from the chest. Doctors can choose between these based on what works best for each patient's situation.

If these primary methods cannot be used, other nerve-blocking techniques like erector spinae plane block, rhomboid intercostal block, or intercostal nerve block serve as effective alternatives. All patients should also receive basic pain medications including paracetamol and anti-inflammatory drugs to reduce pain and swelling.

Interestingly, the review found that acupuncture may be helpful for patients who cannot receive regional nerve blocks, though the scientific evidence supporting this option is limited compared to the primary treatments. Cryoanalgesia, which involves freezing nerves to stop pain signals, is another alternative when standard nerve blocks aren't possible.

For patients considering acupuncture as part of their post-surgical pain management plan, it's important to understand that it's recommended primarily when other, more established pain control methods cannot be used. While acupuncture shows promise, it should be viewed as a complementary option rather than a first-line treatment for thoracotomy pain. Patients interested in acupuncture should seek treatment from a licensed acupuncturist with experience in post-surgical care.

This PROSPECT systematic review analyzed 100 randomized controlled trials, systematic reviews, and meta-analyses published between 2015-2024 examining postoperative analgesia following open thoracotomy. Using modified Delphi methodology and Cochrane Risk of Bias tool 2, an expert panel developed evidence-based recommendations. Primary findings indicate thoracic epidural analgesia (TEA) or paravertebral blockade (PVB) as equally effective first-line interventions, representing a shift from previous guidelines that prioritized TEA alone. Second-line regional techniques include erector spinae plane, rhomboid intercostal, or intercostal nerve blocks when TEA/PVB are contraindicated. Multimodal baseline analgesia with paracetamol and NSAIDs/COX-2 inhibitors is recommended for all patients. Acupuncture and cryoanalgesia received conditional recommendations for use when regional analgesia is not feasible, though supporting evidence remains limited. Clinical takeaway: Practitioners should offer either TEA or PVB based on patient-specific factors and institutional expertise, combined with systemic analgesics, reserving alternative regional blocks and adjunctive therapies like acupuncture for cases where primary interventions are unsuitable.