Successful management of multifocal chronic post-surgical pain following thoracotomy with pleural window and laparotomy

Introduction. CPSP is a common complication following surgery, characterized by pain at the surgical site or radiating to a nerve or dermatome, typically after injury to deep somatic or visceral tissues, persisting for at least three months. The median incidence ranges from 20% to 30%.
Case description. A 72 year old female with persistent paravertebral back pain at the T8–T12 level, radiating along the rib cage, and left-sided chest wall pain along the thoracotomy scar, rated 8/10 Numeric Rating Scale (NRS), persisting for two months after surgery. Two years prior, she underwent surgery for hiatal hernia, followed by worsening dysphagia. This led to a laparotomy 10 weeks ago and creation of an esophagogastric anastomosis. After surgery, the patient developed pleural empyema due to anastomosis insufficiency, requiring video-assisted thoracoscopic surgery, followed by left-sided thoracotomy with pleural window creation. Due to pain, the patient received epidural steroid injection at T12 level with 40 mg of Triamcinolone and reported a 25% pain reduction. Three weeks later, a left-sided 8th and 9th intercostal nerve block was performed using 40 mg of Triamcinolone, 5×3 ml 1% Lidocaine, and scar infiltration with 10 ml of 1% Lidocaine and 8 mg of Dexamethasone. At follow up, the patient reported significant pain relief 2/10 (NRS) and no further interventions were deemed necessary. The patient also took Gabapentin 300 mg and Amitriptyline 10 mg twice daily for 6 weeks.
Summary. CPSP and radicular pain were successfully treated with epidural steroid injection, intercostal nerve blocks, and scar trigger point injections, resulting in a 75% reduction in pain.
Conclusions. Combined interventional treatments targeting the source of pain have proven effective in managing CPSP. A precise selection of the relevant nerves enhances the therapeutic outcome.
Keywords. Chronic post surgical pain CPSP; Radicular pain; Epidural steroids; Intercostal nerve block; Scar trigger-point injections