Background: Of all the postsurgical pain conditions, thoracotomy pain poses a particular therapeutic
challenge in terms of its prevalence, severity, and ensuing postoperative morbidity. Multiple pain
generators contribute to the severity of post-thoracotomy pain, and therefore a multimodal analgesic
therapy is considered to be a necessary strategy. Along with opioids, thoracic epidural analgesia, and
paravertebral blocks, N-Methyl-D-Aspartate (NMDA) receptor antagonists such as ketamine have been
used as adjuvants to improve analgesia.
Objective: We reviewed the evidence for the efficacy of intravenous and epidural administration of
ketamine in acute post-thoracotomy pain management, and its effectiveness in reducing chronic postthoracotomy pain.
Study Design: Systematic literature review and an analytic study of a data subset were performed.
Methods: We searched PubMed, Embase, and Cochrane reviews using the key terms “ketamine,”
“neuropathic pain,” “postoperative,” and “post-thoracotomy pain syndrome.” The search was limited to
human trials and included all studies published before January 2015. Data from animal studies, abstracts,
and letters were excluded. All studies not available in the English language were excluded. The manuscript
bibliographies were reviewed for additional related articles. We included randomized controlled trials and
retrospective studies, while excluding individual case reports.
Results: This systematic literature search yielded 15 randomized control trials evaluating the efficacy
of ketamine in the treatment of acute post-thoracotomy pain; fewer studies assessed its effect on
attenuating chronic post-thoracotomy pain. The majority of reviewed studies demonstrated that ketamine
has efficacy in reduction of acute pain, but the evidence is limited on the long-term benefits of ketamine
to prevent post-thoracotomy pain syndrome, regardless of the route of administration. A nested analytical
study found there is a statistically significant reduction in acute post-thoracotomy pain with IV or epidural
ketamine. However currently, the evidence for a role of ketamine as a preventative agent for chronic postthoracotomy pain is insufficient due to the heterogeneity of the studies reviewed with regard to the route
of administration, dosage, and outcome measures.
Limitations: The evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy
pain is insufficient due to the heterogeneity of the studies reviewed.
Conclusion: The majority of randomized controlled trials reviewed show no role for ketamine in
attenuating or preventing post-thoracotomy pain syndrome at variable follow-up lengths. Therefore,
additional research is warranted with consideration of risk factors and long-term follow-up for chronic
post-thoracotomy pain though the evidence for benefit appears clear for acute post-thoracotomy pain.
Key words: Ketamine, postoperative, thoracotomy pain, post thoracotomy pain syndrome, neuropathic
pain
Topical capsaicin (high concentration) for chronic neuropathic pain in adults
