Intercostal nerve loop as an original treatment for long-term post-thoracotomy pain

Up to now, the treatment for long-term post-thoracotomy pain has been problematic. Conservative methods, surgical, or percutaneous rhizotomies or implantation of a permanent nerve stimulator have failed in many patients, and were not without risk. Because of this, we looked for a fundamental physiologically based approach to manage this pain problem with minimal risks but long lasting effect. As most patients obtained complete temporary pain relief after an intercostal nerve block of serial dermatomes bordering the thoracotomy, nerve ischemia, nerve entrapment in scar tissue, nerve compression due to abnormal bone formation and neuroma function may all have been mechanisms resulting in pain. Subsequently, three intercostal nerve loops between the six intercostal nerves, belonging to the three ribs above and below the thoracotomy, were performed. This technique creates permanent anesthetic dermatomes, thus avoiding nociceptive afferent stimuli and preventing recurrence of aberrant nerve regeneration responsible for chronic pain. This technique was applied successfully in five cases with a mean follow-up of 13 months. As nerve regeneration has stopped at that time, neuroma formation is prevented and pain recurrence is not to be expected. We, therefore, propose that if an anatomical pain distribution pattern along the thoracotomy scar is found in patients with long-term post-thoracotomy pain, serial intercostal nerve loops might be indicated as primary treatment.