Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia?

Currently epidural anesthesia is the gold standard for postoperative pain management in thoracic surgery. In a prospective randomised study, the effect of an intercostal nerve block applied at the end of the operation was compared to that of epidural anesthesia.

Thirty patients undergoing thoracotomy were randomised to each group. Patients with resection of the parietal pleura, rib resection and rethoracotomy were excluded from the study. Both groups received non-steroidal anti-inflammatory drugs every 8h as a baseline analgesic medication and were allowed to ask for supplemental subcutaneous opiate injection, limited to four injections per day. The patients in the epidural catheter group (group I) were provided with a motor pump allowing continuous infusion of bupivacain 0.125% and 2mg fentanyl/ml at a dosage of 6-10 ml per hour, dependent on the pain level over a period of 5 days. The patients of the second group (group II) received an intercostal nerve block at the end of the operation reaching from the third to the ninth intercostal space with 20 ml 0.5% bubivacaine. Pain was evaluated with a pain score ranging from 1 (no pain) to 10 (worst pain) twice daily in relaxed position and during physical activity like coughing. On the fifth postoperative day, the patients were asked specific questions concerning the subjective pain experience. Costs of both treatments were calculated. Mean pain values and costs of both groups were compared by t-tests for independent samples. A P value of less than 0.05 was considered significant.

Eighteen male and 12 female patients, aged between 35 and 71 years (mean 59) were included in the study. Nineteen patients had lobectomy, five bilobectomy, two decortication and three wedge resection. There were 22 right sided and eight left sided procedures. In group I, the mean pain score on the operation day was 3.95 in relaxed position and 6.33 during physical activity like coughing. The mean pain score during the following 4 days was 2.19 in relaxed position and 4.28 with activity. Three patients required additional subcutaneous opiate injection. In group II, the mean score on the operation day was 2.0 in relaxed position and 3.5 during activity. The mean pain score during the next 4 days was 2.84 in relaxed position and 5.65 with activity. Twelve patients received subcutaneous opiates. In both groups, no complications were observed.

The costs for treatment of one patient was 105 in group I and 33 in group II. Patients' satisfaction was equal in both groups, there were no differences in terms of outcome and recovery.

Pain management by intercostal block was superior during the first 24h after surgery whereas on the second day after surgery pain control was significantly better achieved by the epidural catheter in relaxed position. A combination of both forms of anaesthesia seems to be an ideal pain management in patients undergoing thoracic surgery.