Pain After Median Sternotomy: Collateral Damage or Mitigatable Byproduct?

Abstract

Background Postoperative acute pain can cause anxiety and decrease the quality of life in patients. Acute sternal bone pain after cardiac surgery can persist for long time.

Objective The aim of this study is to explore the relationships between the degree of sternal misalignment and the degree of acute sternal pain after coronary artery bypass grafting surgery (CABG).

Methods We retrospectively reviewed postoperative coronary computed tomographic (CT) angiography and medical records in 104 patients who received CABG between May 1, 2009 and January 31, 2011. CT scan was classified into five categories, and we compared the degree of misalignment and subjective pain via numerical rating scale (NRS) system.

Results Positive correlation was noted between NRS and the degree of sternal misalignment (Pearson correlation coefficient 0.660, p = 0.000).

Conclusion Postoperative sternal pain is related to the degree of misalignment of the sternal halves. It would be appropriate for surgeons to approximate the sternal halves accurately to decrease the postoperative sternal wound pain in the first place.

Keywords

coronary artery bypass grafts surgery CABG - surgery/incisions - sternum

• References

• 1 Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97 (2) 534-540
• 2 Breivik H. Postoperative pain management: why is it difficult to show that it improves outcome?. Eur J Anaesthesiol 1998; 15 (6) 748-751
• 3 Carr DB, Goudas LC. Acute pain. Lancet 1999; 353 (9169) 2051-2058
• 4 Kalso E, Mennander S, Tasmuth T, Nilsson E. Chronic post-sternotomy pain. Acta Anaesthesiol Scand 2001; 45 (8) 935-939
• 5 Morris NR, Sabapathy S, Adams L, Kingsley RA, Schneider DA, Stulbarg MS. Verbal numerical scales are as reliable and sensitive as visual analog scales for rating dyspnea in young and older subjects. Respir Physiol Neurobiol 2007; 157 (2–3) 360-365
• 6 Lahtinen P, Kokki H, Hynynen M. Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity. Anesthesiology 2006; 105 (4) 794-800
• 7 Bitkover CY, Cederlund K, Aberg B, Vaage J. Computed tomography of the sternum and mediastinum after median sternotomy. Ann Thorac Surg 1999; 68 (3) 858-863
• 8 Greenwald LV, Baisden CE, Symbas PN. Rib fractures in coronary bypass patients: radionuclide detection. Radiology 1983; 148 (2) 553-554
• 9 Mueller XM, Tinguely F, Tevaearai HT, Revelly JP, Chioléro R, von Segesser LK. Pain location, distribution, and intensity after cardiac surgery. Chest 2000; 118 (2) 391-396
• 10 Özalp G, Sarioglu R, Tuncel G, Aslan K, Kadiogullari N. Preoperative emotional states in patients with breast cancer and postoperative pain. Acta Anaesthesiol Scand 2003; 47 (1) 26-29
• 11 Werner MU, Mjöbo HN, Nielsen PR, Rudin A. Prediction of postoperative pain: a systematic review of predictive experimental pain studies. Anesthesiology 2010; 112 (6) 1494-1502
• 12 The management of postoperative pain working group. VHA/DoD clinical practice guideline for the management of postoperative pain, version 1.2; 2002. www.healthquality.va.gov/pop/pop_fulltext.pdf
• 13 Allen MR, Hock JM, Burr DB. Periosteum: biology, regulation, and response to osteoporosis therapies. Bone 2004; 35 (5) 1003-1012
• 14 Ledger M, Leeks N, Ackland T, Wang A. Short malunions of the clavicle: an anatomic and functional study. J Shoulder Elbow Surg 2005; 14 (4) 349-354
• 15 Xarchas KC, Yfandithis P, Kazakos K. Malunion of the ulnar styloid as a cause of ulnar wrist pain. Clin Anat 2004; 17 (5) 418-422
• 16 Templeton PA, Fishman EK. CT evaluation of poststernotomy complications. AJR 1992; 159: 45-50
• 17 Li AE, Fishman EK. Evaluation of complications after sternotomy using single- and multidetector CT with three dimensional volume rendering. AJR 2003; 181: 1065-1070
• 18 Augustin G, Antabak A, Davila S. The periosteum. Part 1: Anatomy, histology and molecular biology. Injury 2007; 38 (10) 1115-1130
• 19 Tamiya E, Asakawa M, Shibamoto M , et al. Correlation of wound pain following open heart surgery (median sternotomy) and sternum misalignment assessed using X ray computed tomography. Int J Angiol 2000; 9: 159-163
• 20 Moore R, Follette DM, Berkoff HA. Poststernotomy fractures and pain management in open cardiac surgery. Chest 1994; 106 (5) 1339-1342
• 21 Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 1996; 12 (1) 50-55
• 22 Meyerson J, Thelin S, Gordh T, Karlsten R. The incidence of chronic post-sternotomy pain after cardiac surgery—a prospective study. Acta Anaesthesiol Scand 2001; 45 (8) 940-944