Postoperative pain management after VATS for spontaneous pneumothorax - a systematic review

Historically, thoracic epidural analgesia has been the standard for postoperative pain management after surgery for spontaneous pneumothorax. With the advent of enhanced recovery after thoracic surgery protocols, less invasive locoregional analgesic techniques are increasingly considered. Due to lack of high-quality evidence, current guidelines do not address optimal analgesic strategies in this population. This systematic review evaluated the effectiveness of various analgesic techniques following video-assisted thoracoscopic surgery for spontaneous pneumothorax.

Medline, Embase and Cochrane databases were searched until May 2025. Inclusion criteria were patients undergoing video-assisted thoracoscopic surgery for spontaneous pneumothorax, with clearly described postoperative analgesic management (e.g. epidural, locoregional, systemic) and pain scores (visual analgesic score or numeric pain rating score) within 48 h. The primary outcome was pain scores within 48 h postoperatively; secondary outcomes included adjunct analgesic use and complications. Risk of bias was assessed for the primary outcome.

Thirty studies comprising 3,203 patients were assessed: risk of bias was low in 3, moderate/some concerns in 24 and high in 3 studies. There were 10 comparative studies and 20 single-arm cohort studies applying solely systemic analgesia (n = 14) or locoregional analgesia (n = 6). No single-arm cohort study applied solely epidural analgesia. Postoperative pain scores within 48 h were higher after systemic analgesia only, compared to the addition of locoregional or epidural analgesia. No clear differences were observed in analgesia-related complications between the analgesic techniques.

Locoregional or epidural analgesia as part of a multimodal regimen was associated with the lowest postoperative pain scores, although differences were small. Substantial heterogeneity and low certainty of evidence precluded definitive recommendations. This review provides a foundation for future research investigating optimal analgesic strategies following surgery for spontaneous pneumothorax.