Cryoanalgesia increases neuropathic pain after minimally invasive thoracic surgery

1. Adults who received cryoanalgesia during minimally invasive thoracic surgery experienced higher neuropathic pain scores at three, six, and twelve months compared to those receiving standard intercostal nerve block alone.

2. Cryoanalgesia and younger age were both associated with increased neuropathic pain risk at one year.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Minimally invasive thoracic surgery is typically associated with less postoperative pain compared with thoracotomy. However, chronic pain and neuropathic symptoms remain important concerns after surgery. Cryoanalgesia has been utilized as an adjunctive pain control strategy via reversible intercostal nerve ablation, but its longer-term effects in adults undergoing minimally invasive thoracic surgery have remained unclear. This one-year follow-up of a randomized clinical trial evaluated neuropathic pain and pain severity among adults who underwent video-assisted thoracoscopic or robotic thoracic surgery. The patients were randomized to receive either the standard intercostal nerve block alone or intercostal nerve block plus cryoanalgesia. At three, six, and 12 months, patients treated with cryoanalgesia demonstrated significantly higher neuropathic pain scores compared with standard care. A greater proportion of patients in the cryoanalgesia group also met criteria for neuropathic pain at each follow-up time point. Pain severity scores were higher in the cryoanalgesia group at three and six months, although this difference lost statistical significance by 12 months. These findings suggest that cryoanalgesia may increase longer-term neuropathic pain in adults undergoing minimally invasive thoracic surgery. In practice, these results lend caution to the consideration of cryoanalgesia in this population. Strengths of this study included its randomized design, patient blinding, standardized perioperative pain protocols, and in-person follow-up using validated pain and neuropathy measures. Limitations included incomplete follow-up at each time point, potential unblinding due to chest wall numbness, and the use of post hoc power analysis for long-term neuropathic outcomes.

Click to read the study in Annals of Surgery

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In-Depth [randomized controlled trial]: This one-year follow-up of a randomized clinical trial evaluated adults undergoing elective minimally invasive thoracic surgery, including video-assisted thoracoscopic surgery and robotic surgery. Patients were randomized to the standard of care group, which consisted of bupivacaine and lidocaine-based intercostal nerve block alone, or to the experimental group, which featured intercostal nerve block plus cryoanalgesia of five to six intercostal nerves. Neuropathic pain was assessed using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), with scores of 12 or greater suggesting neuropathic pain. Pain severity was assessed using the Visual Analog Scale (VAS). Follow-up data were available for 76 patients at three months, 82 patients at six months, and 84 patients at 12 months. Median LANSS scores were significantly higher in the cryoanalgesia group compared to the standard care group at three months (10 vs. 0.5, P = .003), six months (8 vs. 0, P < .001), and 12 months (4.5 vs. 0, P < .001). Neuropathic pain was also more common with cryoanalgesia at three months (40% vs. 19%, P = .031), six months (33% vs. 10%, P = .010), and 12 months (30% vs. 5%, P = .002). Similarly, VAS pain scores were significantly higher among patients treated with cryoanalgesia at three months (P = .012) and six months (P = .028), but not at 12 months (P = .168). Multivariate analysis revealed that cryoanalgesia was independently associated with higher odds of neuropathic pain at 12 months (OR 8.28; 95% CI, 1.33-51.68; P = .024). Younger age was also associated with increased neuropathic pain risk. These findings demonstrated that cryoanalgesia increased long-term neuropathic pain after minimally invasive thoracic surgery, supporting more cautious use of this practice.

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