Multimodal analgesia strategies for optimized pain management in thoracic surgery

Background: Thoracic surgery often causes severe postoperative pain, even when minimally invasive techniques are employed. Effective pain management is essential for optimizing recovery and improving patients' quality of life. Traditional opioid-based strategies effectively alleviate pain, but often lead to significant adverse effects. Multimodal analgesia (MMA) is a comprehensive approach combining pharmacologic and non-pharmacologic methods. This strategy aims to minimize opioid use, target multiple pain pathways, and improve recovery outcomes. Current Concepts: MMA covers the entire perioperative period and utilizes non-opioid agents such as acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, dexmedetomidine, lidocaine, and ketamine-used either individually or in combination. Regional anesthesia techniques, such as thoracic epidural anesthesia, paravertebral blocks, and fascial plane blocks (including erector spinae and serratus anterior plane blocks), have been shown to effectively reduce pain scores, opioid use, and complications. Enhanced recovery after surgery (ERAS) protocols support these multimodal strategies, highlighting the importance of regimens tailored to each patient's characteristics and the specific surgical procedure. Integrating MMA into ERAS programs has been associated with enhanced recovery, reduced length of hospital stays, and improved quality of life. Discussion and Conclusion: MMA provides comprehensive pain control by targeting both nociceptive and neuropathic pain mechanisms, thereby reducing opioid-related side effects. Nevertheless, evidence gaps remain concerning the best therapeutic combinations and long-term outcomes. Large-scale clinical trials should be conducted to confirm the efficacy of advanced nerve blocks and tailored analgesic strategies. Evidence-based, patient-specific pain management protocols are needed to improve surgical outcomes, accelerate recovery, and enhance patient satisfaction in thoracic surgery.