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. 2026 Jan 12.
doi: 10.1111/anae.70123. Online ahead of print.

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

Adrien Lemoine  1 , Anna Alber  2 , Girish P Joshi  3 , Marc Van de Velde  4 , Geertrui Dewinter  4 , Esther Pogatzki-Zahn  5 , Marie-Pierre Bonnet  6 ; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy
Collaborators, Affiliations

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

Adrien Lemoine et al. Anaesthesia. .

Abstract

Introduction: Adequate postoperative pain control is crucial for rehabilitation after open thoracotomy. The aim of this systematic review was to update the previous procedure-specific postoperative pain management recommendations for patients undergoing open thoracotomy.

Methods: Using previously reported PROSPECT methodology, we performed a systematic review of randomised controlled trials, systematic reviews and meta-analyses evaluating pain interventions for open thoracotomy published between 2015 and 2024. Data extracted from the included studies were evaluated by an expert subgroup that considered the relevance of the studied interventions in clinical practice and their risk/benefit profile. Recommendations were finalised after review and comments by all members of the PROSPECT working group using a modified Delphi approach. The Cochrane Risk of bias tool 2 was used to grade the quality of evidence.

Results: Overall, 100 studies were included. Based on the available evidence, either thoracic epidural analgesia or paravertebral blockade should be provided as a first-line analgesic intervention for open thoracotomy. Erector spinae plane, rhomboid intercostal or intercostal nerve blockade could be used as a second-line regional analgesia intervention. In addition, patients should receive basic analgesia consisting of paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2 selective inhibitors. Acupuncture or cryoanalgesia is recommended when regional analgesia cannot be performed, albeit with a low level of supportive evidence. The choice of surgical technique, postoperative physiotherapy and approach to patient education should be based on outcomes other than pain control.

Discussion: In these updated guidelines on pain management after open thoracotomy, the main changes concern the recommendation of either thoracic epidural analgesia or paravertebral blockade as the first-line intervention according to patient and clinician preference, combined with basic systemic analgesia. The use of other regional blocks should be limited to patients who cannot receive thoracic epidural analgesia or paravertebral blockade.

Keywords: pain; postoperative; regional; thoracotomy.

Plain language summary

What we did: The researchers searched through many medical studies done between 2015 and 2024. They found and carefully studied 100 different research papers from trusted medical databases. Experts then worked together to decide which pain treatments were the safest and most effective.

Why we did it: When someone has an open thoracotomy, it means they have surgery where doctors open the chest to reach the lungs or heart. After this kind of surgery, people often have a lot of pain. Good pain control is very important so that patients can breathe deeply, move around and get better faster. This study looked at the best ways to manage pain after open thoracotomy.

What we found: They recommend two main ways to control pain: thoracic epidural analgesia, which delivers medicine near the spinal cord to block pain, and paravertebral blockade, which numbs the nerves next to the spine that send pain signals from the chest. These are the first‐choice treatments because they work best for most patients. If these cannot be used, doctors can try other methods like erector spinae plane block, rhomboid intercostal block or intercostal nerve block. These are called second‐line treatments. Patients should also take basic pain medicines, such as paracetamol and non‐steroidal anti‐inflammatory drugs, or cyclooxygenase‐2 inhibitors to help with general pain and swelling. If regional pain blocks cannot be done, acupuncture or cryoanalgesia (freezing the nerves to stop pain) might help, though there is less scientific proof for these options. The choice of operation, physiotherapy and patient education should focus on things other than pain alone, like recovery and movement.

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References

    1. Makkad B, Heinke TL, Sheriffdeen R, et al. Practice advisory for preoperative and intraoperative pain management of thoracic surgical patients: part 1. Anesth Analg 2023; 137: 2–25. https://doi.org/10.1213/ANE.0000000000006441.
    1. Romero A, Garcia JEL, Joshi GP. The state of the art in preventing postthoracotomy pain. Semin Thorac Cardiovasc Surg 2013; 25: 116–124. https://doi.org/10.1053/j.semtcvs.2013.04.002.
    1. Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008; 107: 1026–1040. https://doi.org/10.1213/01.ane.0000333274.63501.ff.
    1. Prospect Working Group. Thoracotomy 2015 Summary Recommendations. ESRA. https://esraeurope.org/wp‐content/uploads/2019/02/Summary‐recommendation... (accessed 29/04/2025).
    1. Rogers ML, Duffy JP. Surgical aspects of chronic post‐thoracotomy pain. Eur J Cardiothorac Surg 2000; 18: 711–716. https://doi.org/10.1016/S1010‐7940(00)00569‐8.

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