From the Guidelines
Pain in the shoulder after a lobectomy can be effectively managed with a multimodal approach, including postoperative locoregional analgesia techniques, multimodal physiotherapy, and pain management education. To manage this pain, start with over-the-counter medications like acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or ibuprofen (400-600mg every 6-8 hours with food if not contraindicated) 1. Apply heat therapy using a heating pad for 15-20 minutes several times daily. Gentle stretching exercises, such as pendulum swings and wall crawls, can help maintain mobility once cleared by your surgeon, usually 2-4 weeks post-surgery.
The pain often stems from surgical positioning during the procedure, irritation of the phrenic nerve, chest tube placement, or referred pain from the diaphragm. Most shoulder pain resolves within 2-4 weeks, but persistent or worsening pain, especially with fever, redness, or swelling, warrants immediate medical attention. Some key points to consider in managing shoulder pain after lobectomy include:
- Using a postoperative locoregional analgesia technique after thoracotomy to improve pain control and enhance recovery after surgery 1
- Implementing a multimodal physiotherapy program combining early mobilization and walking, breathing exercises, and intensive management of postoperative pain 1
- Providing pain management education as part of the multimodal physiotherapy program 1
- Avoiding the use of isolated chest physiotherapy techniques, as they have been shown to have no impact on the pulmonary complication rate or length of stay 1
Gradually increasing activity as tolerated will help restore normal shoulder function while the surgical site heals. Physical therapy may be recommended for ongoing issues. It is essential to follow the guidelines on enhanced recovery after pulmonary lobectomy, which recommend the use of postoperative locoregional analgesia techniques and multimodal physiotherapy to improve pain control and enhance recovery after surgery 1.
From the Research
Postoperative Pain after Lobectomy
- Postoperative pain is a common issue after lobectomy, with studies showing that minimally invasive procedures like video-assisted thoracoscopic surgery (VATS) can result in less postoperative pain compared to open procedures 2, 3.
- A study published in 2014 found that VATS lobectomy resulted in a lower level of postoperative pain compared to open resection, with a significant difference in favor of VATS in 8 out of 21 values for mean NAS (numeric rating scale) 2.
- Another study published in 2017 found that robotic lobectomy resulted in mild postoperative pain, with a mean pain intensity score of 2.1 ± 1.4, and weak interference on daily activities 4.
Comparison of Surgical Approaches
- A randomized controlled trial published in 2016 found that VATS was associated with less postoperative pain and better quality of life compared to anterolateral thoracotomy for the first year after surgery 3.
- The study found that the proportion of patients with clinically relevant moderate-to-severe pain (NRS ≥3) was significantly lower during the first 24 hours after VATS than after anterolateral thoracotomy 3.
Pain Management
- A study published in 2022 found that an opioid-free multimodal pain regimen can decrease opioid exposure while maintaining adequate pain control after thoracic surgery 5.
- The study found that patients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points, and average pain scores were significantly lower in the opioid-free protocol patients 5.
- Another study published in 2016 found that celecoxib and loxoprofen were superior to acetaminophen in pain relief after arthroscopic knee surgery, although the superiority of loxoprofen over acetaminophen was modest 6.