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Effect of Cryoanalgesia on Post-Thoracotomy Pain


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We prepared this study to determine the effect of cryoanalgesia on post-thoracotomy pain. In this double-blinded randomized clinical trial, 60 patients who underwent thoracotomy were divided into two groups (control and cryoanalgesia). Visual Analogue Scale (VAS, 0-10) was used for the measurement of severity of post-thoracotomy pain. It was classified into three categories: 0-1 (mild), 2-3 (moderate), and 4-10 (severe). Pethidine (0.5-1 mg/kg) was administered in case of need for both groups. Patients were visited at the hospital a week later, and were contacted by phone at the first, second, and third months post-operatively. Intensity of pain in the control group was higher than the cryoanalgesia group in all visits the follow-up period. On the second day, the frequencies of severe pain (4-10) were 33.3% and 0 in the control and cryoanalgesia groups, respectively. The mild pain on the seventh day was 13.3% and 83.3% in the control and cryoanalgesia groups, respectively (P < 0.01). Pethidine consumption was 151.6 ± 27 mg in the control group and 87.5 ±48 mg in the cryoanalgesia group on the first day post-operation (P < 0.001). Cryoanalgesia is a useful technique with not serious side effects in order to alleviate post-thoracotomy pain and reduce the need for opiate consumption.
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Corresponding Author: Hossein Mohammadinasab
Research Center of Anesthesiology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Tel: +98 912 3615382, +98 912 1767087, Fax: +98 21 444056051, E-mail:
Effect of Cryoanalgesia on Post-Thoracotomy Pain
Sirous Momenzadeh1, Hedayatollah Elyasi2, Naser Valaie3, Badiozaman Radpey4,
Azizollah Abbasi5, Fatemeh Nematollahi1, and Hossein Mohammadinasab2
1 Department of Anesthesiology & Pain, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Research Center of Anesthesiology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 Department of Anesthesiology, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
5 Department of Thoracocic Surgery, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
6 Department of Obstetrics & Gynecology, Mothers Hospital, Tehran, Iran
Received: 14 Dec. 2009; Received in revised form: 28 Jan. 2010; Accepted: 12 Mar. 2010
Abstract- We prepared this study to determine the effect of cryoanalgesia on post-thoracotomy pain. In this
double-blinded randomized clinical trial, 60 patients who underwent thoracotomy were divided into two
groups (control and cryoanalgesia). Visual Analogue Scale (VAS, 0-10) was used for the measurement of
severity of post-thoracotomy pain. It was classified into three categories: 0-1 (mild), 2-3 (moderate), and 4-10
(severe). Pethidine (0.5-1 mg/kg) was administered in case of need for both groups. Patients were visited at
the hospital a week later, and were contacted by phone at the first, second, and third months post-operatively.
Intensity of pain in the control group was higher than the cryoanalgesia group in all visits the follow-up
period. On the second day, the frequencies of severe pain (4-10) were 33.3% and 0 in the control and
cryoanalgesia groups, respectively. The mild pain on the seventh day was 13.3% and 83.3% in the control and
cryoanalgesia groups, respectively (P < 0.01). Pethidine consumption was 151.6 ± 27 mg in the control group
and 87.5 ±48 mg in the cryoanalgesia group on the first day post-operation (P < 0.001). Cryoanalgesia is a
useful technique with not serious side effects in order to alleviate post-thoracotomy pain and reduce the need
for opiate consumption.
© 2011 Tehran University of Medical Sciences. All rights reserved.
Acta Medica Iranica 2011; 49(4): 241-245.
Keywords: Cryoanalgesia; Pain; Thoracotomy
In spite of recent progressive achievements in
anesthesiology, postoperative pain management and
treatment in patients is still one of the most complicated
problems among anesthesiologists. Thoracotomy is one
of the most painful surgical incisions currently used (1-
2). Inadequate control of post-thoracotomy pain is
associated with increased postoperative morbidity (3).
This association causes a significant relationship
between effective postoperative analgesia and the rate of
postoperative pulmonary complications such as
atelectasis, infections, etc after thoracotomies (4). The
true incidence of post-thoracotomy pain is difficult to
determine, with a reported range from 5% to 80% (5-8).
Chronic post-thoracotomy pain consists of different
types of pain, both myofascial and neuropathic pain
Along with persistent characteristic, post-
thoracotomy pain has cardiopulmonary complications as
well as psychological adverse effects. Based on previous
studies, pain relief in patients undergoing thoracotomy
operation is a debatable issue among anesthesiologists
(10-11). There are different methods of pain
management in these patients (1,12). It has been
reported that the local analgesia is one of the most
efficient ways of pain relief (13). Of these, the
cryoanalgesia is a local pain controlling method that is
progressively applied because of the ease of handling,
low cost and accessibility. Cryoanalgesia (the use of
cold to provide anesthesia or analgesia) is an old
analgesic method but still is in current clinical use (14).
Its intraoperative use in providing postoperative
analgesia for acute thoracic pain problems via an open
thoracotomy is well described (15). However, there are
controversies about the use of this method in post-
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Effect of cryoanalgesia on post-thoracotomy pain
242 Acta Medica Iranica, Vol. 49, No. 4 (2011)
thoracotomy pain (13,16). As a result, we decided to
determine the effect of cryoanalgesia on post-
thoracotomy pain.
Materials and Methods
This double blind randomized clinical trial included 60
patients with the age range of 19-51 years and ASA
(American Society of Anesthesiologists) classes I-III for
whom thoracotomy via posterolateral incisions were
required. The exclusion criteria were consisted of:
opioids or any other illegal drug addicts and diabetics
who were suffering from the disease for more than 10
years. Midazolam (2 mg/kg BW) and fentanyl (3 mg/kg
BW) were administered, as pre-medications for patients
in the operation room. The monitoring was performed
by pulse oximeter, ECG (Electrocardiography), end tidal
carbon dioxide (CO2), arterial blood gas analysis (ABG),
and invasive blood pressure. The patients were
preoxygenated using 100% oxygen for three minutes.
Anesthesia was induced by thiopental (5 mg/kg BW)
and atracurium (0.5 mg/kg BW) with a bolus dose which
continued in 20-minute intervals. Three minutes later,
intubation was done and then thoracotomy by postero-
lateral incision was performed. The techniques of
thoracotomy and suture materials were the same in all
Before the operation, the patients were randomly
divided by simple randomization by random table into
two groups: control and cryoanalgesia. In cryoanalgesia
group, before closure of the thorax, the intercostal
nerves (one at the level of the incision, one cranial, and
one caudal) were identified and exposed to peeling off
the parietal pleura. The Kooland cryoanalgesiaprobe
(administering CO2 as the cooling agent, JP- 1, Kooland,
China) was placed on each nerve, under direct vision.
Each nerve received a 90-second application of cold (-
70o C). Patients received halothane 1 minimum alveolar
concentration (MAC), oxygen and nitrous oxide (N2O),
50% of each, and atracurium (0.2 mg/kg) as
maintenance drugs. Anesthesia was maintained with
fentanyl (2 µg/kg; every half an hour) during the
operation. Neuromuscular blockade was reversed by
atropine (1.25 mg) and neostigmine (2.5 mg). Pethidine
(0.5-1 mg/kg) was administered by a nurse in the case of
need in both the control and cryoanalgesia groups.
A visual analogue scale (VAS, on a scale of 0-10)
was used in order to measure pain after thoracotomy.
The VAS was classified into three groups as follows: 0-
1 (no pain to mild), 2-3 (moderate), 4-10 (severe) (18).
The VAS recording was done at different postoperative
times: 0 (start of the recovery period), 0-24 hr (every
two hours), 24-48 hr (every four hours) and the third to
7th day (every morning and evening) following surgery
by a trained nurse. Both the nurse and the patients were
unaware of patient group assignments.
Patients were visited at the hospital one week after
discharge and were contacted by telephone at the first,
second, and third month post-operatively. Information
about the side effects including dysesthesia, allodynia
and hypoesthesia were recorded as well.
Descriptive indices including frequency, percentage,
mean ± SD were used to express data. The Chi-Square
or Fischer’s exact tests were used to compare qualitative
variables between the control and cryoanalgesia groups.
All analyses were performed using SPSS software
for Windows (Ver. 13.0) (SPSS Inc., Chicago, IL).
Sixty patients were randomized into two equal groups
(n=30 each of them). There was no significant difference
between the two groups in terms of age, ASA class, and
the operation site (Table 1). As shown in Table 1, the
male population in the cryoanalgesia group (83.3%) was
significantly higher than the control group (50%), P <
Table 1. Comparison of basic characteristics between the two studied groups
Control (N = 30) Cryoanalgesia (N = 30) P value
Age, mean ± SD 41.3 ± 15 41.9 ± 16 NS
15 (50.0%)
15 (50.0%)
25 (83.3%)
5 (16.7%)
Weight, mean ± SD 64.7 ±10.6 64.1 ± 12.1 NS
Site of thoracotomy
22 (73.3%)
8 (26.7%)
19 (63.3%)
11 (36.7%)
ASA class
4 (13.3%)
25 (83.4%)
1 (3.3%)
3 (10.0%)
27 (90.0%)
Abbreviations: SD = standard deviation; NS = not significant; ASA = American Society of Anesthesiologists
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S. Momenzadeh, et al.
Acta Medica Iranica, Vol. 49, No. 4 (2011) 243
first day
second day
third day
fourth day
fifth day
sixth day
seventh day
fallow up days
pain score
Figure 1. Mean score of patient pain in both groups during the follow-up period
Postoperative pain scores, in both control and
cryoanalgesia groups, are presented in Figure 1. As
depicted, the intensity of pain in the control group was
higher than the cryoanalgesia group throughout the
follow-up period. On the second day after the operation,
the frequencies of severe pain score were 33.3% and 0 in
the control and cryoanalgesia groups, respectively.
Subsequently, the "no to mild pain" category on the
seventh day was observed in 13.3% and 83.3% of the
control and cryoanalgesia groups, respectively. In
general, the pain intensity was significantly higher in the
control group compared to the cryoanalgesia group (P<
0.001). Table 2 presents the severity of pain according to
VAS categories between the two studied groups from
days one to six.
Mean amount of pethidine administration during the
study period is presented in Figure 2. Mean ± SD
administration of pethidine was significantly higher in
the control group than the cryoanalgesia patients on day
one post-operatively (151.6 ± 27 mg vs. 87 ± 48 mg; P <
0.001). The usage of pethidine in the cryoanalgesia
group was ended on the forth day after operation;
however the control group subjects required pethidine
until the seventh day post-operatively.
The percentage of sensory dysfunction in the patients
who underwent cryoanalgesia surgery showed that the
hypoesthesia occurrence was in the following pattern:
90% at the end of the first postoperative week, 76.7% at
the end of the first month, and 16.6% at the end of the
second month. No hypoesthesia was recorded at the end
of the third month. In addition, both allodynia and
dysesthesia were diminished to 10% at the end of the
first month and no further one was observed at the end
of the second month.
first day
second day
third day
fourth day
fifth day
sixth day
seven day
fallow up days
Pethidine (mg)
Figure 2. Mean of patient consumption (mg) in both groups during the follow-up period
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Effect of cryoanalgesia on post-thoracotomy pain
244 Acta Medica Iranica, Vol. 49, No. 4 (2011)
This is the first study, as to our knowledge, to evaluate
the clinical efficacy of cryoanalgesia in controlling the
post-operative pain of a group of Iranian patients who
underwent thoracotomy. The present results demonstrate
that the severity of thoracotomy-induced pain was better
controlled using cryoanalgesia method. This finding is
in affirmity with previous reports about the application
of cryoanalgesia in thoracotomy patients. In Maiwand et
al. study (18) the successful effect of cryoanalgesia on
pain management after thoracotomy has been reported.
They also noted that the consumption of opiates was
diminished after using cryoanalgesia. It has been shown
that efficacy of cryoanalgesia on postoperative pain
relief as well as improvement in pulmonary function in
patients underwent the cryoanalgesia was more
prominent in comparison to intravenous opiates received
patients (19, 17). There are some controversial
evidences on effectiveness of cryoanalgesia; in other
words, in some previous investigations (20), the
analgesic efficacy of cryoanalgesia has been reported
with less effect on pain relief and long-term
postoperative side effects. These controversies might be
because of lack of appropriate cryoanalgesia probe and
insufficient nerve freezing, nerve freezing at a point
distal to the branches, long freezing time, and nerve
freezing with a blind technique and with an unsuitable
nerve locator. Although the mechanism of cryoanalgesia
in pain relief is still unknown, it is likely that when
cryoanalgesia probe contacts with peripheral nerves, it
causes a second-grade nerve lesion (Axonotmesis). The
effects of cryoanalgesia are directly related to the
formation of intra- and extracellular ice crystals, which
result in microvascular changes and alteration of cellular
osmolality and permeability, causing cell damage and
disruption of nerve conduction, and consequently cause
The obtained results about the need for pethidine
administration are in agreement with data reported by
Orr et al. (19) and Pastor et al. (17) which showed that
the opiate (pethidine) consumption in the control group
was higher than the patients with cryoanalgesia surgery.
It is likely concerning the disruption of the axonal
function and conduction, the pain perception and
sensation is being reduced in the patients; therefore,
fewer opiates will be demanded. Another considerable
finding of the present study is the significant decrease in
the incidence of dysesthesia, hypoesthesia and allodynia
during the follow-up period in patients who received
cyoanalgesia. Hypoesthesia was gradually disappeared
at the end of the third month as well as dysesthesia and
allodynia which were significantly reduced at the end of
the second month. In case of allodynia and dysesthesia it
could be questioned whether these abnormalities are
related to surgery-induced trauma or to the
cryoanalgesiagenic outcomes? One of the limitations in
the current investigation was that the incidence rate of
these abnormalities was not measured in the control
group. In previous studies, all kinds of abovementioned
side effects have been observed in the thoracotomy
patients without cryoanalgesia. So, we suggest that
comparative analyses of postoperative side effects in
cryoanalgesia-group versus non-cryoanalgesia-group
should not be underestimated in the future hypotheses. It
is suggested that comparative interaction of pain relief
due to narcotic analgesia and cryoanalgesia should be
considered in the upcoming studies. The current findings
propose that the effect of cryoanalgesia on the pain
alleviation of other kinds of surgical operations
collaborating with the moderate to sever neuropathic
pain should be explored.
In conclusion, cryoanalgesia is an advantageous
technique in order to relieve post-thoracotomy pain and
reduce the opiate consumption. Additionally,
cryoanalgesia-induced sensory abnormalities
disappeared during the time. In the current research, the
cryoanalgesia is recommended to thoracic surgeons and
anesthesiologists in order to relieve post-thoracotomy
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... Of the 24 trials, 20 were for thoracic surgeries, two for herniorrhaphy [19,20], one for nephrectomy [21] and one for tonsillectomy [22]. Interventions included cryoanalgesia alone [23], cryoanalgesia with opioid analgesia [19][20][21][22][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40], or cryoanalgesia with epidural and opioid analgesia [41,42]. These combinations are described for each study in Table 1. ...
... Cryoanalgesia was administered intraoperatively in all studies. Comparators included epidural analgesia [33][34][35][36][40][41][42], intercostal nerve blocks [37][38][39], opioid analgesia only [19][20][21][22][25][26][27][28][29][30][31][32], nonopioid analgesia only [23], and non-divided intercostal muscle flap [24]. Only one study reported using a sham cryoanalgesia treatment in the comparator arm [19]. ...
... Only one study reported using a sham cryoanalgesia treatment in the comparator arm [19]. Fourteen studies did not report whether pain scores were at rest or with movement [22][23][24][25]27,[29][30][31][33][34][35]37,39,40]. Narcotic use was reported predominantly in terms of analgesic consumption and frequency of use. ...
Full-text available
Background Despite advances in pain management, postoperative pain continues to be an important problem with significant burden. Many current therapies have dose-limiting adverse effects and are limited by their short duration of action. This review examines the evidence for the efficacy and safety of cryoanalgesia in postoperative pain. Materials and methods This review was registered in PROSPERO and prepared in accordance with PRISMA. MEDLINE, EMBASE, and Cochrane databases were searched until July 2020. We included randomized controlled trials (RCTs) of adults evaluating perioperatively administered cryoanalgesia for postoperative pain relief. Results Twenty-four RCTS were included. Twenty studies examined cryoanalgesia for thoracotomy, two for herniorrhaphy, one for nephrectomy and one for tonsillectomy. Meta-analysis was performed for thoracic studies. We found that cryoanalgesia with opioids was more efficacious than opioid analgesia alone for acute pain (mean difference [MD] 2.32 units, 95 % confidence interval [CI] −3.35 to −1.30) and persistent pain (MD 0.81 units, 95 % CI –1.10 to −0.53) after thoracotomy. Cryoanalgesia with opioids also resulted in less postoperative nausea compared to opioid analgesia alone (relative risk [RR] 0.23, 95 % CI 0.06 to 0.95), but there was no difference in atelectasis (RR 0.38, 95 % CI 0.07 to 2.17). Conclusion Heterogeneity in comparators and outcomes were important limitations. In general, reporting of adverse events was incomplete and inconsistent. Many studies were over two decades old, and most were limited in how they described their methodology. Considering the potential, larger RCTs should be performed to better understand the role of cryoanalgesia in postoperative pain management.
... The initial report of postsurgical analgesia using cryoneurolysis involved intraoperative application to surgically exposed intercostal nerves during thoracotomy. 29 Subsequently, multiple randomized, controlled trials involving thoracotomy 58 demonstrated analgesic, opioid-sparing, and pulmonary function benefits, as well as a shortened length of hospitalization and fewer opioid-related adverse effects, 19,24,[30][31][32][33][34][35][36][37]39,40,43,48,58 some with superiority over other regional analgesic techniq ues. 24,31,32,35,48 In contrast, six randomized trials failed to identify cryoneurolysis benefits. ...
Full-text available
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
... Momenzadeh et al. [75] compared the effects of intercostal cryoneurolysis on post-thoracotomy pain. The postoperative pain was classified in three groups according to the intensity: 0-1 (mild), 2-3 (moderate), and 4-10 (severe). ...
Full-text available
... However, because the temperature resulting in irreversible degeneration-approximately −100°C-is colder than the boiling point of the gas (carbon dioxide: −79°C; nitrous oxide: −88°C), the remaining endoneurium, perineurium, and epineurium remain intact and the axon regenerates at a rate of approximately 1 to 2 mm/d. 356 Cryoneurolysis has been used via the surgical incision to treat acute pain after thoracotomy, [358][359][360][361][362][363][364][365][366][367][368][369][370][371][372][373][374] tonsillectomy, 375 and herniorrhaphy. 376,377 Alternatively, ultrasound may be used to guide 378,379 a percutaneously inserted probe to a peripheral nerve to provide analgesia and has been described for various chronic pain conditions. ...
Full-text available
A continuous peripheral nerve block (CPNB) consists of a percutaneously inserted catheter with its tip adjacent to a target nerve/plexus through which local anesthetic may be administered, providing a prolonged block that may be titrated to the desired effect. In the decades after its first report in 1946, a plethora of data relating to CPNB was published, much of which was examined in a 2011 Anesthesia & Analgesia article. The current update is an evidence-based review of the CPNB literature published in the interim. Novel insertion sites include the adductor canal, interpectoral, quadratus lumborum, lesser palatine, ulnar, superficial, and deep peroneal nerves. Noteworthy new indications include providing analgesia after traumatic rib/femur fracture, manipulation for adhesive capsulitis, and treating abdominal wall pain during pregnancy. The preponderance of recently published evidence suggests benefits nearly exclusively in favor of catheter insertion using ultrasound guidance compared with electrical stimulation, although little new data are available to help guide practitioners regarding the specifics of ultrasound-guided catheter insertion (eg, optimal needle-nerve orientation). After some previous suggestions that automated, repeated bolus doses could provide benefits over a basal infusion, there is a dearth of supporting data published in the past few years. An increasing number of disposable infusion pumps does now allow a similar ability to adjust basal rates, bolus volume, and lockout times compared with their electronic, programmable counterparts, and a promising area of research is communicating with and controlling pumps remotely via the Internet. Large, prospective studies now document the relatively few major complications during ambulatory CPNB, although randomized, controlled studies demonstrating an actual shortening of hospitalization duration are few. Recent evidence suggests that, compared with femoral infusion, adductor canal catheters both induce less quadriceps femoris weakness and improve mobilization/ambulation, although the relative analgesia afforded by each remains in dispute. Newly published data demonstrate that the incidence and/or severity of chronic, persistent postsurgical pain may, at times, be decreased with a short-term postoperative CPNB. Few new CPNB-related complications have been identified, although large, prospective trials provide additional data regarding the incidence of adverse events. Lastly, a number of novel, alternative analgesic modalities are under development/investigation. Four such techniques are described and contrasted with CPNB, including single-injection peripheral nerve blocks with newer adjuvants, liposome bupivacaine used in wound infiltration and peripheral nerve blocks, cryoanalgesia with cryoneurolysis, and percutaneous peripheral nerve stimulation.
... Momenzadeh et al. [75] compared the effects of intercostal cryoneurolysis on post-thoracotomy pain. The postoperative pain was classified in three groups according to the intensity: 0-1 (mild), 2-3 (moderate), and 4-10 (severe). ...
Cryoneuroablation is a technique of peripheral, precise neurolysis. A probe is placed on the targeted nerve, using landmarks, fluoroscopy, ultrasound, and/or built-in peripheral nerve stimulator. When the probe is in the exact right place, a gas (usually nitrous oxide) travels down the center of the probe, where it passes through a tiny opening, which causes the gas to expand and cool the tissues, creating an ice ball. These cold temperatures cause ice crystals to form in the tissues, which kill the nerves but leave the myelin sheath intact, allowing the nerve to grow back without neuroma formation. Thus, cryoneuroablation is appropriate for the destruction of large, myelinated nerves such as the occipital, intercostal, pudendal, or superior gluteal nerves. The period of prolonged analgesia followed by return of function allows a window of rehabilitation that is unique among the neurolytic techniques.
The term “cryoanalgesia” was coined by Lloyd and his co‐workers for its use in pain management, and proposed that this technique, because it is not followed by neuritis or neuralgia, was superior to other methods of peripheral nerve destruction, e.g., alcohol, phenol, or surgical lesions. The technique has gone by many names, including cryoablation, cryoneuroablation, cryosurgery, cryo‐analgesia, and cryoneurolysis. Indications for cryoneuroablation include peripheral nerves, cancer pain, intercostal nerve and tumor mass or bone lesions. The skin is anesthetized using very small amounts of local anesthetic with special care not to anesthetize the nerve. Complications from cryoneuroablation are quite rare. Because of the size of the probe, bleeding can be a potentially serious complication. The temporary increase in pain can be expected due to the trauma for the probe placement, especially if difficulty in localizing the nerve leads to increased tissue manipulation.
Introduction The optimal approach to pain management after thoracic surgery remains poorly defined. The purpose of this study was to examine the association between intercostal nerve cryoanalgesia and postoperative opioid requirements after thoracic surgery. Methods We conducted a single-center retrospective review of all patients who underwent unilateral thoracic surgery for pulmonary pathology from June 2017 to August 2019. Patients receiving intercostal nerve cryoanalgesia were compared with standard analgesia. The primary outcome was total oral morphine equivalent consumption during hospitalization, at discharge, and 90 d postoperatively. Secondary outcomes included pain scores and pulmonary function measured on postoperative days 1 and 3, at discharge, and postoperative complications. Planned subgroup analysis by opioid exposure and surgical approach was performed. Results The Wilcoxon rank-sum test demonstrated significantly less inpatient opioid use for cryoanalgesia patients (45 versus 305 mg, P < 0.001), regardless of opioid history (naïve: 22.5 versus 209.8 mg, P < 0.001; tolerant: 159.5 versus 1043 mg, P < 0.001) and minimally invasive approach (opioid naïve: 26.2 versus 209.8 mg, P < 0.001; tolerant: 158.5 versus 1059 mg, P < 0.001). Opioid-naïve patients required fewer discharge opioids (50 versus 168 mg; P < 0.05). Cryoanalgesia lowered daily pain scores (P < 0.001) and showed a trend toward lower 90-d opioid prescriptions and higher pulmonary function scores. There was no difference in postoperative complications (P = 0.31). Conclusions Our results suggest an association between intercostal nerve cryoanalgesia and reduced inpatient opioid requirements and pain in opioid-naïve and tolerant patients. Pulmonary function, 90-d opioid prescriptions, and adverse events were no different between groups. It may serve as a useful adjunct for opioid-sparing pain management in thoracic surgery.
Introduction: Conventional nerve blocks utilize local anesthetic drugs to provide pain relief for hours or days following surgery or trauma. However, postoperative and trauma pain can last weeks or months. Ultrasound-guided percutaneous cryoneurolysis is an anesthetic modality that offers substantially longer pain relief compared to local anesthetic-based nerve blocks. Areas covered: In this review, we discuss the history, mechanism of action, and use of ultrasound-guided percutaneous cryoneurolysis by anesthesiologists in the setting of acute pain management. Expert opinion: Ultrasound-guided percutaneous cryoneurolysis offers the potential to provide weeks or months of pain relief following surgery or trauma. Compared to continuous local anesthetic-based peripheral nerve blocks, currently the gold standard for providing long duration postoperative analgesia, cryoneurolysis has benefits that include: 1) longer duration measured in weeks or months rather than days; 2) no external reservoir of local anesthetic to be carried by the patient; 3) no risk of infection; and 4) no risk of catheter dislodgement. However, cryoneurolysis can induce a prolonged motor block in addition to the sensory block, decreasing the appropriate indications to those in which potential sensory and motor deficits are acceptable. Additionally, cryoneurolysis of multiple nerves can have a substantial time requirement relative to other regional analgesic options.
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Cryoanalgesia, also known as cryoneurolysis or cryoneuroablation, is one of the most effective interventional methods for pain management, which allows providing high-quality long-term analgesia by low-temperature destruction of the nerve membranes of sensory or mixed nerves. Our review is devoted to the history of the use of cold for medical purposes, a description of the physical basis of the method and equipment used for cryoanalgesia, various clinical aspects and technical features of the procedure, as well as indications and contraindications, with a clinical description of various conditions that can be treated using interventional methods of pain management.
This chapter will discuss the anesthetic considerations for those patients undergoing repair of chest wall lesions. This will include a description of the preoperative considerations for these patients, intraoperative management, and postoperative issues, including pain control.
Surgical intervention into a soft tissue may lead to unavoidable injury to muscle and fat masses, the development of scar tissues, local reactions to foreign bodies (as may be employed in reconstruction), and lesions of sensory afferents that traverse or terminate in the surgical region. These occurrences are characteristics of most surgical procedures but apply with particular clarity to interventions involving the breast and chest wall. Whether for reconstruction or for more aggressive interventions related to removing tumor in cancer therapy, there are documented insults to structure and innervation. In addition, the treatment for malignancy may involve chemotherapy, known to induce peripheral neuropathies, and the use of radiation. Such radiation, although targeted at the tumor, may often unavoidably injure the underlying brachial plexus, leading to an additional neuropathy. Despite this degree of intervention, it has not been widely appreciated that pain may be a sequela of these treatments. Typically the concern with tumor reoccurrence has left the problems related to the pain resulting from these interventions largely unappreciated.
In 1980, Cousins and Bridenbaugh edited a 749-page book on local anesthetics, nerve blockade, and pain control. It has become the standard textbook on the subject primarily because of its superior quality. It is also the only book that encompasses all three subjects. This second edition has 1171 pages; two new chapters have been added, and three chapters have been subdivided into two or three subchapters. This review attempts to answer several questions: Does the new edition contain current information, and does it discuss significant topics overlooked in the first edition? Do the added chapters continue the excellence of the first edition? Finally, for those who have the first edition, is it worth buying the second edition? The authors have succeeded in their difficult task of improving an exceptional book. The new chapters are well written, comprehensive, and uniformly upto-date. Recent developments such as the carbonation and alkalinization of local
We used a pain questionnaire to evaluate the prevalence and functional significance of long-term postthoracotomy pain. Data on 56 patients who were at least 2 months postsurgery were analyzed. Thirty patients (54 percent) with a median follow-up of 19.5 months had persistent pain; 26 others were pain free at a median of 30.5 months postthoracotomy. Pain was reported in 24 of 44 patients (55 percent) who were more than one year after surgery, 13 of 29 patients (45 percent) more than two years, six of 16 (38 percent) more than three years, and three of ten patients (30 percent) greater than four years postthoracotomy. Pain intensity was low, but 13 patients stated that pain "slightly" or "moderately" interfered with their lives. Five of 56 patients had sufficiently severe chronic pain to require either daily analgesic use, nerve blocks, relaxation therapy, acupuncture, or referral to a pain clinic. We conclude that long-term chest wall pain is common postthoracotomy. It is generally not severe, but a small proportion of patients may experience persistent, moderately disabling pain.
In a randomized study, 63 patients were investigated for the benefits of cryoanalgesia after thoracotomy. Analgesia and its dependent effects such as enhancement of mobility, respiratory function, and reduced need of narcotics were evaluated. No significant differences in these variables were observed between the cryoanalgesia group and the control group. However, moderate to severe neuralgia was found in a number of patients in the cryoanalgesia group in the late postoperative period. Cryoanalgesia for pain relief after thoracotomy is not recommended.
Postthoracotomy pain can be reduced by cryoanalgesia of intercostal nerves. The technique involves focal freezing of peripheral nerves to interrupt pain pathways, producing immediate functional changes that recover as the nerves regenerate. To assess the time-course of functional changes that follow nerve injury, unilateral freeze lesions of sciatic nerve were induced in rats with a cryosurgical unit. The contralateral nerves were used as sham-operated controls. Following nerve injury, behavioral and electrophysiologic tests were repeated to 90 days. The acute effect of nerve injury was a decrease in behavioral measures of hind limb function (P less than 0.05), an increase in electrical threshold to elicit hind limb contraction (P less than 0.005), and an absence of stimulus-evoked compound action potential (P less than 0.005). Morphologic changes included substantial endoneurial edema associated with Wallerian degeneration. Remyelination occurred subsequently during the following 35 days. Although all physiologic measures returned toward normal, nerve conduction velocities were still much slower in the experimental group. In a second study, the long-term effects of cryogenic injury were compared with neurolytic injury with 10% procaine HCl, both of which produced a conduction velocity deficit that persisted at least 90 days after the initial injury. These behavioral and electrophysiologic results complement previous reports of morphologic deficits in the nerves including incomplete recovery of nerve fiber diameter and increased thickness of the perineurial sheath.
The efficacy of cryoanalgesia for the control of post-thoracotomy pain has led to the acceptance of the technique as a routine procedure in this unit. A study of 600 consecutive patients in whom an improved technique was used is not reported. The freezing time for each intercostal nerve in this group was reduced to one 30 second exposure instead of the two 30 second exposures previously used. This reduced the duration of cutaneous numbness, with no loss of pain control. Freezing above the fifth intercostal nerve is no longer practiced in women. Modification to the probe has simplified the procedure. Pulmonary function studies and blood-gas analysis are also described.
In a randomised controlled trial carried out during the first to days after thoracotomy patients who had had intercostal nerves frozen with a cryoprobe or were given morphine by continuous intravenous infusion had significant less pain at rest than patients given intramuscular morphine. Differences between the groups with respect to pain on movement and during physiotherapy were not significant. Pain was estimated using visual analogue scales, and an arc sine transformation was carried out on values obtained from these scales before comparison using an analysis of variance. The trial did not distinguish between the cryoprobe and infusion treatment. The simplicity of the cryoprobe had much to commend it, but in units without access to this equipment a small infusion pump offers a satisfactory alternative.
A prospective study was carried out in 120 patients undergoing elective thoracotomy for parenchymal disease. Patients were randomized into three groups: A (control group), B (epidural analgesia), C (freezing of intercostal nerves). Subjective pain relief was assessed on a linear visual analog scale. Analgesic requirements were evaluated during the 12 days following surgery, or until discharge if earlier. The vital capacity (VC) and forced expiratory volume in 1 s (FEV1) were measured on the day before operation and on the 1st, 2nd, 3rd and 7th postoperative days (POD). Subjective pain relief was significantly better in Group B in comparison with Group A (P < 0.05) or C (P < 0.05). Group C had the lowest score on the 11th and 12th POD but differences were not statistically significant. Requirements for intravenous analgesics were lower in Group B than in the control group (P < 0.05) during the first 3 POD, and in group C than in the control group the day of operation (P < 0.05). Oral analgesic requirements, when compared with controls, were lower in group B during the first 5 POD, and lower in group C on the 3rd and the 4th POD (P < 0.05). Cryoanalgesia led to a slight but not significant increase in VC and FEV1. Epidural analgesia led to a significant increase when compared with controls in FEV1 during the first 3 POD, and in FVC on the 7th POD (P < 0.05). It is concluded that epidural analgesia led to the best pain relief and restoration of pulmonary function after thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)