Chronic post-thoracotomy pain syndrome

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Three-dimensional reconstruction of a chest computed tomography scan of a 60-year-old woman with acute and chronic chest pain localized to the region of a 10-year-old thoracotomy scar.

The 3-dimensional reconstruction of the computed tomography scan was obtained at the time of admission to exclude pulmonary embolus and aortic dissection. It confirmed a narrowing of the fifth intercostal space (Figure 1) where the thoracotomy had taken place. Pain was believed to be related to an entrapment of the fifth intercostal nerve or chronic periostitis due to bone-on-bone contact between the fifth and sixth ribs, or both. Lasting pain relief followed selective neurolysis of the fifth intercostal nerve.

Figure 1: Three-dimensional reconstruction of helical chest computed tomography scan shows close contact between fifth and sixth ribs (arrows).

Chronic post-thoracotomy pain syndrome is defined as pain that recurs or persists along a thoracotomy incision for at least 2 months following surgery. It can occur in more than 50% of cases.¹ Multiple mechanisms leading to chronic post-thoracotomy pain syndrome have been proposed, including poorly repositioned rib fractures, costochondritis, costochondral dislocation, intercostal neuroma, nerve entrapment and local infection.² Treatment is guided by the underlying cause, which in many cases is not clear.

Bruno M. Strebel MD Department of Internal Medicine Steffen Ross MD Institute of Radiology Cantonal Hospital of Munsterlingen Munsterlingen, Switzerland