INTRODUCTION Postoperative analgesia for chest wall excision surgeries is important as it directly affects the respiratory mechanics of the patient. Inadequate analgesia usually results in inability to breathe deeply and cough forcefully, both of which hamper postoperative pulmonary rehabilitation with subsequent retention of secretions, atelectasis and pneumonia. In chest wall surgeries, ribs and intercostal nerves are resected. Logically, the area distal to the excised nerve should be insensitive and therefore painless. However cross innervation from intact adjoining intercostal nerves can contribute to pain sensation. The underlying pathophysiology of pain after excision of chest wall along with the rib and intercostal nerve can be both somatic and neuropathic. The severity of pain would also depend upon the extent of surgery and methods of postoperative analgesia. While there is abundant literature on post thoracotomy acute and chronic pain, studies on pain after chest wall excisions are lacking. Pain after rib resection is likely to be different from that after thoracotomy incisions. In thoracotomy procedures, during rib spreading, multiple intercostal nerves are injured. Typically, the nerves immediately above and below the incision may be injured completely or partially. The type of injury may be different as the nerve is not resected completely. Therefore, the severity and character of pain after rib and intercostal nerve excision may be different from that of thoracotomy incisions limiting the extrapolation of information regarding one to the other. We therefore plan to conduct this observational study to understand the character of acute and chronic pain in these cases and examine its association if any with the sensory deficits consequent to intercostal nerve excision. As chronic pain data will be difficult to obtain retrospectively, we will study chronic pain prospectively and acute pain both prospectively and retrospectively. AIM AND OBJECTIVES Aim: 1. To understand incidence and character of postoperative acute and chronic pain after chest wall excision involving rib and intercostal nerve excision 2. To understand management of postoperative acute and chronic pain in these patients. 3. To identify areas of sensory deficit after these surgeries and its association with the incidence and site of acute and chronic pain.
Primary objective: To evaluatea cute pain incidence and severity after rib and intercostal nerve excision and the pain management technique used METHODOLOGY: Single centre ambispective study conducted in a tertiary care cancer hospital. Study duration:Retrospective: 5 years: 1st January 2020 to 31st December 2024. Prospective: 2 years We expect to recruit around 80-100 patients in the retrospective study and around 50 patients prospectively The retrospective data will be collected from the patient’s electronic medical record (EMR), acute pain service (APS) database, physical forms and case file wherever available. The worst pain scores and pain scores at rest and on deep breathing will be recorded for 5 postoperative days. Retrospectively patients will be recruited from thoracic database, hospital OT register and OT logbook. Prospective study: The study will commence after IEC approval and CTRI registration. Patients undergoing chest wall excision surgery will be screened for inclusion and exclusion criteria. Eligible patients will be recruited after obtaining an informed consent. The patients’ demographic data and preoperative analgesic usage will be recorded. Details of intraoperative and postoperative analgesia including methods of pain relief and numerical pain scores at rest and deep breathing will be recorded. i At discharge, 3 and 6 months after surgery, the patient will be administered the painDETECTquestionnaire to diagnose neuropathic pain. Brief pain inventory (BPI) will also be administered to assess the severity of pain and impact of pain on daily functions at discharge and around 3 and 6 months postoperatively. Analgesics consumed by the patient will be recorded. Sensations at the surgical site will be recorded at discharge, 3 and 6 months after surgery. The patients will be examined at around 3 and 6 months when they visit the hospital as part of their standard postoperative follow up. If they do not visit the hospital at around 3 and 6 months, a member of the study team will contact the patient telephonically or by email to collect the relevant data. Chronic Pain Assessment PainDETECTquestionnaire : The PainDETECT Questionnaire (PDQ) will be used distinguish between neuropathic and nociceptive pain (NP). This PDQ will be explained and given to the patient at discharge, 3 and 6 months to diagnose neuropathic pain. The patients will be examined at discharge and at 3 and 6 months when they visit the hospital as part of their standard postoperative follow up. If they do not visit the hospital at 3 and 6 months, a member of the study team will contact the patient to collect the relevant data by telephone or email.The PDQ will be administered to the patients in the language they understand. Brief pain inventory ( BPI) The BPI is an instrument to assess the severity of pain and impact of pain on daily functions in patients with pain from chronic diseases. The short form comprises of nine questions related to the severity of pain, impact of pain on daily function, location of pain, pain medications and amount of pain relief in the past 24 hours or the past week. Statistics Data will be described as frequencies and percentages. Categorical data will be compared using the chisquare/Fisher’s test and numerical data will be compared using the unpaired t-test or the Mann Whitney Utest. p values less than 0.05 will be considered significant for all comparisons. Data will be entered into a statistical software (SPSS 22.0) for analysis.
|