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Clinical course of pain in a patient with neuropathic pain induced by ligation of an intercostal nerve
Journal of Clinical Anesthesia (2010) 22, 50–51
Case report
Clinical course of pain in a patient with neuropathic pain induced by ligation of an intercostal nerve Jitsu Kato MD, PhD (Associate Professor)⁎, Dai Gokan MD, PhD (Staff Anesthesiologist), Noriya Hirose DDS, PhD (Staff Anesthesiologist), Miyako Baba MD (Staff Anesthesiologist), Toru Ehara MD (Staff Anesthesiologist), Setsuro Ogawa MD, PhD (Professor and Chairman) Department of Anesthesiology, Nihon University Itabashi Hospital, Tokyo 173-8610, Japan Received 15 September 2007; revised 6 January 2009; accepted 8 January 2009
Keywords: Neuropathic pain; Chest drainage tube; Allodynia
Abstract A patient with severe right chest pain and mechanical allodynia induced by an intercostal drainage tube to his chest is presented. It was not relieved by treatment with diclofenac sodium and was worsened by movement and touch to the right chest wall. Mechanical allodynia was also present. The patient's wrenching pain disappeared immediately after stitch removal, but the dull pain and mechanical allodynia persisted, gradually decreasing to zero in 7 days. © 2010 Elsevier Inc. All rights reserved.
1. Introduction
2. Case report
Peripheral nerve ligation can cause severe pain with allodynia which reflects central sensitization, as shown in Bennett's rat model of peripheral mononeuropathy [1]. This phenomenon is also seen in certain clinical situations resulting from peripheral nerve compression or ligation, such as during surgery, inguinal hernioplasty [2,3], etc. Recently postherniotomy pain was considered as neuropathic pain caused by nerve injury or nerve injury by an inflammatory mesh response [2]. A patient with severe right chest pain and mechanical allodynia induced by ligation of an intercostal drainage tube to his chest skin is presented.
A 66-year-old man underwent surgical removal of a hemangiosarcoma of the scalp during general anesthesia. Bilateral pneumothorax, seemingly due to metastatic lung cancer, occurred 5 days after surgery. A left chest drainage tube was inserted at this time, the right one being inserted 7 days after surgery. Accidental dislodgement of the tube on the right side occurred 2 days later. Reinsertion and fixation was immediately done during local anesthesia. The patient experienced severe anterior chest wall pain that persisted despite treatment with 30 mg pentazocine intramuscularly and 50 mg diclofenac sodium by suppository. The severity of pain was such that the patient was unable to walk. The physician in charge suspected the cause of his pain to be metastatic lung cancer. He was referred to our pain clinic for appropriate pain management 10 days after the onset of his pain. The pain in his right chest at the time of initial clinical interviews and examination was continuous and wrenching, and had an intensity of 10 on the 11-point
⁎ Corresponding author. Tel.: +81 3 3972 8111x3284; fax: +81 3 5917 4766. E-mail address: [email protected] (J. Kato). 0952-8180/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2009.01.009
Neuropathic pain induced by ligation of an intercostal nerve numerical rating pain scale. It was worsened by movement and touching the right chest wall, and was sufficiently severe to interfere with his sleep. Mechanical allodynia was present over an area about 20 cm in diameter around the chest drainage tube on his right anterior chest. In addition, redness and tenderness were recognized at the drainage tube insertion site. After analyzing the patient's clinical course, quality of pain, resistance to pentazocine and diclofenac sodium, spread of the area of pain beyond the cutaneous distribution of the damaged nerve, and mechanical allodynia, it was concluded that the patient suffered from neuropathic pain with central sensitization, which probably occurred due to compression of an intercostal nerve branch by sutures used to fix the intercostal drainage tube. Immediately after removing the stitches at his first visit to our pain clinic, the wrenching pain disappeared completely, to the patient's great relief, although the dull pain and mechanical allodynia still persisted. Fresh sutures inserted to fix the drainage tube, while avoiding ligation and compression of the intercostal nerve branch, did not result in recurrence of the wrenching pain. The dull pain was adequately controlled with oral loxoprofen 180 mg per day. Mechanical allodynia decreased gradually over several days, disappearing completely after 7 days.
3. Discussion The pain was considered to be a combination of peripheral neuropathic pain with central sensitization and inflammatory pain, as suggested by the clinical course, quality of pain, resistance to pentazocine and diclofenac sodium. The spread beyond the area of the cutaneous distribution of the intercostal nerve, mechanical allodynia, the presence of redness and tenderness at the chest drainage tube insertion site, disappearance of wrenching pain after removing the stitches, and response to loxoprofen after stitch removal also support this theory. Recently, in a case of a patient with postherniotomy pain resistant to conservative treatment, peripheral nerve entrap-
51 ment was confirmed on surgery, and the pain was relieved by dissection of the entrapped nerve [4,5]. Delikoukos et al. [4] reported that ilioinguinal nerve entrapment and mesh fixation on the periostium of the pubic tubercle by a staple were observed during re-operation following anterior inguinal hernia repair with mesh. The pain resolved by entrapped nerve resection after surgery. Severe pain with mechanical allodynia reflects central sensitization induced by peripheral nerve ligation [1,6]. In this patient, intercostal branch nerve damage probably produced mechanical allodynia similar to that seen in Bennett and Seltzer's rat model. Interestingly, it took 7 days for the dull pain and mechanical allodynia to fade completely, while the wrenching pain disappeared immediately after stitch removal. This phenomenon suggests that the dull pain was inflammatory in origin, responding to treatment with loxoprofen, while the mechanical allodynia was due to central sensitization. The severe wrenching pain, on the other hand, was thought to be due to direct stimulation of the nerve branch, and hence disappeared immediately after removal of the stitch. Intercostal drainage tube insertion is a commonly performed surgical procedure. Neuropathic pain with central sensitization is possible after insertion and fixation of a chest drainage tube.
References [1] Bennett GJ, Xie YK. A peripheral mononeuropathy in rat that produces disorders of pain sensation like those seen in man. Pain 1988;33:87-107. [2] Aasvang EK, Brandsborg B, Christensen B, et al. Neurophysiological characterization of postherniotomy pain. Pain 2008;137:173-81. [3] Mikkelsen T, Werner MU, Lassen B, et al. Pain sensory dysfunction 6 to 12 months after inguinal herniotomy. Anesth Analg 2004;99:146-51. [4] Delikoukos S, Fafoulakis F, Christodoulidis G, et al. Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh. Hernia 2008;12:593-5. [5] Amid PK. A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord. Arch Surg 2002;137:100-4. [6] Seltzer Z, Dubner R, Shir Y. A novel behavioral model of neuropathic pain disorders produced in rats by partial sciatic nerve injury. Pain 1990;43:205-18.
Case report
Clinical course of pain in a patient with neuropathic pain induced by ligation of an intercostal nerve Jitsu Kato MD, PhD (Associate Professor)⁎, Dai Gokan MD, PhD (Staff Anesthesiologist), Noriya Hirose DDS, PhD (Staff Anesthesiologist), Miyako Baba MD (Staff Anesthesiologist), Toru Ehara MD (Staff Anesthesiologist), Setsuro Ogawa MD, PhD (Professor and Chairman) Department of Anesthesiology, Nihon University Itabashi Hospital, Tokyo 173-8610, Japan Received 15 September 2007; revised 6 January 2009; accepted 8 January 2009
Keywords: Neuropathic pain; Chest drainage tube; Allodynia
Abstract A patient with severe right chest pain and mechanical allodynia induced by an intercostal drainage tube to his chest is presented. It was not relieved by treatment with diclofenac sodium and was worsened by movement and touch to the right chest wall. Mechanical allodynia was also present. The patient's wrenching pain disappeared immediately after stitch removal, but the dull pain and mechanical allodynia persisted, gradually decreasing to zero in 7 days. © 2010 Elsevier Inc. All rights reserved.
1. Introduction
2. Case report
Peripheral nerve ligation can cause severe pain with allodynia which reflects central sensitization, as shown in Bennett's rat model of peripheral mononeuropathy [1]. This phenomenon is also seen in certain clinical situations resulting from peripheral nerve compression or ligation, such as during surgery, inguinal hernioplasty [2,3], etc. Recently postherniotomy pain was considered as neuropathic pain caused by nerve injury or nerve injury by an inflammatory mesh response [2]. A patient with severe right chest pain and mechanical allodynia induced by ligation of an intercostal drainage tube to his chest skin is presented.
A 66-year-old man underwent surgical removal of a hemangiosarcoma of the scalp during general anesthesia. Bilateral pneumothorax, seemingly due to metastatic lung cancer, occurred 5 days after surgery. A left chest drainage tube was inserted at this time, the right one being inserted 7 days after surgery. Accidental dislodgement of the tube on the right side occurred 2 days later. Reinsertion and fixation was immediately done during local anesthesia. The patient experienced severe anterior chest wall pain that persisted despite treatment with 30 mg pentazocine intramuscularly and 50 mg diclofenac sodium by suppository. The severity of pain was such that the patient was unable to walk. The physician in charge suspected the cause of his pain to be metastatic lung cancer. He was referred to our pain clinic for appropriate pain management 10 days after the onset of his pain. The pain in his right chest at the time of initial clinical interviews and examination was continuous and wrenching, and had an intensity of 10 on the 11-point
⁎ Corresponding author. Tel.: +81 3 3972 8111x3284; fax: +81 3 5917 4766. E-mail address: [email protected] (J. Kato). 0952-8180/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2009.01.009
Neuropathic pain induced by ligation of an intercostal nerve numerical rating pain scale. It was worsened by movement and touching the right chest wall, and was sufficiently severe to interfere with his sleep. Mechanical allodynia was present over an area about 20 cm in diameter around the chest drainage tube on his right anterior chest. In addition, redness and tenderness were recognized at the drainage tube insertion site. After analyzing the patient's clinical course, quality of pain, resistance to pentazocine and diclofenac sodium, spread of the area of pain beyond the cutaneous distribution of the damaged nerve, and mechanical allodynia, it was concluded that the patient suffered from neuropathic pain with central sensitization, which probably occurred due to compression of an intercostal nerve branch by sutures used to fix the intercostal drainage tube. Immediately after removing the stitches at his first visit to our pain clinic, the wrenching pain disappeared completely, to the patient's great relief, although the dull pain and mechanical allodynia still persisted. Fresh sutures inserted to fix the drainage tube, while avoiding ligation and compression of the intercostal nerve branch, did not result in recurrence of the wrenching pain. The dull pain was adequately controlled with oral loxoprofen 180 mg per day. Mechanical allodynia decreased gradually over several days, disappearing completely after 7 days.
3. Discussion The pain was considered to be a combination of peripheral neuropathic pain with central sensitization and inflammatory pain, as suggested by the clinical course, quality of pain, resistance to pentazocine and diclofenac sodium. The spread beyond the area of the cutaneous distribution of the intercostal nerve, mechanical allodynia, the presence of redness and tenderness at the chest drainage tube insertion site, disappearance of wrenching pain after removing the stitches, and response to loxoprofen after stitch removal also support this theory. Recently, in a case of a patient with postherniotomy pain resistant to conservative treatment, peripheral nerve entrap-
51 ment was confirmed on surgery, and the pain was relieved by dissection of the entrapped nerve [4,5]. Delikoukos et al. [4] reported that ilioinguinal nerve entrapment and mesh fixation on the periostium of the pubic tubercle by a staple were observed during re-operation following anterior inguinal hernia repair with mesh. The pain resolved by entrapped nerve resection after surgery. Severe pain with mechanical allodynia reflects central sensitization induced by peripheral nerve ligation [1,6]. In this patient, intercostal branch nerve damage probably produced mechanical allodynia similar to that seen in Bennett and Seltzer's rat model. Interestingly, it took 7 days for the dull pain and mechanical allodynia to fade completely, while the wrenching pain disappeared immediately after stitch removal. This phenomenon suggests that the dull pain was inflammatory in origin, responding to treatment with loxoprofen, while the mechanical allodynia was due to central sensitization. The severe wrenching pain, on the other hand, was thought to be due to direct stimulation of the nerve branch, and hence disappeared immediately after removal of the stitch. Intercostal drainage tube insertion is a commonly performed surgical procedure. Neuropathic pain with central sensitization is possible after insertion and fixation of a chest drainage tube.
References [1] Bennett GJ, Xie YK. A peripheral mononeuropathy in rat that produces disorders of pain sensation like those seen in man. Pain 1988;33:87-107. [2] Aasvang EK, Brandsborg B, Christensen B, et al. Neurophysiological characterization of postherniotomy pain. Pain 2008;137:173-81. [3] Mikkelsen T, Werner MU, Lassen B, et al. Pain sensory dysfunction 6 to 12 months after inguinal herniotomy. Anesth Analg 2004;99:146-51. [4] Delikoukos S, Fafoulakis F, Christodoulidis G, et al. Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh. Hernia 2008;12:593-5. [5] Amid PK. A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord. Arch Surg 2002;137:100-4. [6] Seltzer Z, Dubner R, Shir Y. A novel behavioral model of neuropathic pain disorders produced in rats by partial sciatic nerve injury. Pain 1990;43:205-18.