Pain management after open thoracotomy 2025: procedure‐specific postoperative pain management ( PROSPECT ) recommendations

INTRODUCTION: Adequate postoperative pain control is crucial for rehabilitation after open thoracotomy. The aim of this systematic review was to update the previous procedure-specific postoperative pain management recommendations for patients undergoing open thoracotomy. METHODS: Using previously reported PROSPECT methodology, we performed a systematic review of randomised controlled trials, systematic reviews and meta-analyses evaluating pain interventions for open thoracotomy published between 2015 and 2024. Data extracted from the included studies were evaluated by an expert subgroup that considered the relevance of the studied interventions in clinical practice and their risk/benefit profile. Recommendations were finalised after review and comments by all members of the PROSPECT working group using a modified Delphi approach. The Cochrane Risk of bias tool 2 was used to grade the quality of evidence. RESULTS: Overall, 100 studies were included. Based on the available evidence, either thoracic epidural analgesia or paravertebral blockade should be provided as a first-line analgesic intervention for open thoracotomy. Erector spinae plane, rhomboid intercostal or intercostal nerve blockade could be used as a second-line regional analgesia intervention. In addition, patients should receive basic analgesia consisting of paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2 selective inhibitors. Acupuncture or cryoanalgesia is recommended when regional analgesia cannot be performed, albeit with a low level of supportive evidence. The choice of surgical technique, postoperative physiotherapy and approach to patient education should be based on outcomes other than pain control. DISCUSSION: In these updated guidelines on pain management after open thoracotomy, the main changes concern the recommendation of either thoracic epidural analgesia or paravertebral blockade as the first-line intervention according to patient and clinician preference, combined with basic systemic analgesia. The use of other regional blocks should be limited to patients who cannot receive thoracic epidural analgesia or paravertebral blockade.