How should I assess and manage persistent postoperative pain in a female patient who underwent left atrial myxoma resection via median sternotomy, presenting for follow‑up [DATE] after surgery?

Assessment and Management of Persistent Post-Sternotomy Pain After Cardiac Surgery

You must perform a comprehensive evaluation to exclude chronic post-surgical pain syndrome and serious complications, particularly if this patient is beyond 90 days post-surgery and still requiring opioids, as this mandates formal assessment and potential pain service referral. 1

Immediate Clinical Assessment

Determine the exact timeline: The specific number of days post-surgery is critical, as management differs dramatically based on whether the patient is within or beyond the 90-day threshold. 1

Key Clinical Features to Evaluate

• Assess for sternal complications: Palpate for sternal instability (gap >3 mm), which correlates with significantly higher pain intensity and indicates potential sternal nonunion or dehiscence requiring surgical consultation. 2

• Characterize the pain pattern: Post-sternotomy pain syndrome presents as discomfort persisting for at least 2 months without apparent cause, affecting 7-66% of patients, with higher prevalence in women during the first 3 months. 1, 2

• Exclude serious complications: Evaluate for signs of sternal wound infection (erythema, purulent drainage, warmth, fever), pericarditis, or cardiac ischemia from graft complications, as these require urgent intervention rather than analgesic escalation. 1, 2

• Review current medication regimen: Identify if the patient is still taking opioids (including tramadol) or gabapentinoids, as both require specific management protocols. 1

Diagnostic Imaging Strategy (If Indicated)

• Order CT chest with contrast if you have clinical suspicion of sternal wound infection, concern for sternal dehiscence/nonunion, or need to assess osseous healing and residual chest wall deformities. 2

• Consider FDG-PET/CT if deep sternal wound infection is suspected, as it has 91% sensitivity and 97% specificity for determining infection depth and costal cartilage involvement. 2

• Avoid premature CT imaging in the early postoperative period (first 17 days) due to high false-positive rates. 2

Management Algorithm Based on Timeline

If Within 90 Days Post-Surgery:

• Optimize multimodal analgesia: Use scheduled acetaminophen (first-line) plus NSAIDs (ibuprofen or naproxen) if not contraindicated for anti-inflammatory effect. 2

• Reserve opioids for breakthrough pain only: Use immediate-release formulations (not long-acting or transdermal patches) for severe pain uncontrolled by non-opioids. 1

• Ensure proper opioid prescribing: No more than 7 days supply should be provided, with explicit documentation of dose and duration in all communications. 1

• Focus on functional goals: Treat to improve function and mobility (drinking, eating, movement) rather than pain intensity scores alone. 1

If Beyond 90 Days Post-Surgery and Still on Opioids:

This scenario triggers mandatory further assessment. 1

• Refer to pain service: Persistent opioid use at >90 days in opioid-naive patients warrants medical evaluation and exclusion of chronic post-surgical pain, with potential referral to specialized pain services or, in some cases, substance misuse services. 1

• Evaluate gabapentinoid use: If the patient is on gabapentinoids, review indications and taper off if no longer indicated. 1

• Avoid repeat opioid prescriptions: Postoperative opioids must never be added to repeat prescribing templates and should only be documented as acute medications reviewed at each issue. 1

Critical Pitfalls to Avoid

• Never dismiss persistent pain as "normal": Pain persisting beyond 2 months requires thorough evaluation for post-sternotomy pain syndrome or other complications. 2

• Do not escalate opioids without excluding complications: A sudden increase in pain or persistent pain beyond expected timelines mandates evaluation for infection, dehiscence, or other surgical complications before simply increasing analgesics. 2, 3

• Recognize multiple pain mechanisms can coexist: Musculoskeletal pain, nerve entrapment, infection, and cardiac ischemia from graft complications may occur simultaneously in post-CABG patients, though this patient had myxoma resection rather than CABG. 1, 2

• Avoid long-acting opioid formulations: Modified-release opioids and transdermal patches should be avoided without specialist consultation due to increased risk of respiratory complications and long-term continuation. 1

Patient Education and Safety

• Provide explicit weaning instructions: Patients must receive clear guidance on safe self-administration, analgesic weaning schedules, and proper disposal of unused medications at community or hospital pharmacies. 1

• Document functional outcomes: Reassess pain and functional status within 24 hours of treatment changes, focusing on return to normal activities rather than pain scores alone. 1, 3