Pain management in thoracic surgery: bridging evidence and practice

Pain following thoracic surgery is complex and remains difficult to manage. Thoracic epidural analgesia (TEA) was long regarded as the gold standard, but the transition to minimally invasive surgery and enhanced recovery protocols has prompted greater use of alternative regional techniques. This review outlines current challenges in thoracic pain management and considers future strategies to optimise individualised care.

Current guidelines no longer recommend TEA as the first-line regional technique for thoracic pain. The adoption of video-assisted thoracic surgery and robotic-assisted thoracic surgery has enabled the use of alternative regional blocks, such as paravertebral and fascial plane blocks (e.g. erector spinae, serratus anterior). The efficacy of these techniques, along with various pharmacological and nonpharmacological modalities, continues to be evaluated. Future research should move beyond isolated interventions and focus on comprehensive treatment protocols, incorporating patient-reported outcomes to guide clinical decision-making.

The complex nature of postthoracic surgery pain supports a multimodal approach, combining regional techniques with systemic analgesia. Variation in clinical practice reflects differences in resources, institutional protocols, clinician expertise, and the pace of enhanced recovery after surgery implementation. Despite a growing evidence base, a universally accepted standard of care remains to be defined.