Schmerztherapie in der Thoraxchirurgie – Schmerzpathophysiologie und -epidemiologie bei thorakalen Eingriffen

Zusammenfassung

Akute und chronische Schmerzen sind ein relevantes Problem nach thoraxchirurgischen Eingriffen mit einer multifaktoriellen Genese. Einerseits beeinflussen iatrogene Prozeduren, wie der chirurgische Zugangsweg und die Komplexität der Behandlungen, und andererseits konstitutionelle Faktoren wie psychosoziale Komorbiditäten die individuelle Schmerzschwelle und die Entwicklung eines Postthorakotomie-Schmerzsyndroms (PTPS). Spezielle Phänomene, die mit thoraxchirurgischen Eingriffen in Verbindung gebracht werden - wie der ipsilaterale Schulterschmerz und neuropathische Schmerzen - werden diskutiert. Über die Beschreibung pathophysiologischer Mechanismen soll auf Behandlungsoptionen hingewiesen werden. Schlussfolgernd lässt sich feststellen, dass nur unter Anwendung gut organisierter, multimodaler schmerztherapeutischer Konzepte das Risiko perioperativer und chronischer Schmerzen vermindert werden kann.

Abstract

Acute and chronic pain are significant problems after thoracic surgery with a multifactorial pathogenesis. On the one hand iatrogenic procedures as surgical access and complexity of treatment procedures, and on the other hand constitutional factors as psychosocial comorbidities affect individual pain threshold and the development of a Postthoracic Pain Syndrome (PTPS). Special phenomena associated with thoracic surgery like ipsitateral shoulder pain and neuropathic pain are discussed. The characterization of pathophysiological pathways wants to point out treatment options. In conclusion there is a need for well organized, multimodal pain therapy concepts to minimize the risk of perioperative and chronic pain.

Kernaussagen

• Das PTPS tritt nach thoraxchirurgischen Eingriffen bei bis zu 91% der Patienten auf.

• Das PTPS tritt gehäuft als Folge einer insuffizienten perioperativen Schmerztherapie auf.

• Eine suffiziente perioperative Schmerztherapie kann die Mortalität hinsichtlich des Grundleidens positiv beeinflussen.

• Ca. 50 % der Patienten mit PTPS weisen neuropathische Schmerzen auf.

• Eine intraoperative Schonung der Interkostalnerven verringert die Morbidität neuropathischer Schmerzen.

• Der nach thoraxchirurgischen Eingriffen häufig auftretende ISP chronifiziert selten.

• Eine Ursache für den ISP ist eine Affektion des N. phrenicus.

• Pathophysiologische Zusammenhänge sprechen für den Einsatz multimodaler Analgesieregime entsprechend des WHO-Stufenschemas, regionalanästhesiologischer Methoden und Koanalgetika.

Schlüsselwörter:

Postthorakotomie-Schmerzsyndrom - Thorakotomie - chronischer Schmerz - ipsilateraler Schulterschmerz

Key words:

Postthoracic Pain Syndrome - thoracotomy - chronic pain - ipsitateral shoulder pain

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