European Journal of Cardio-thoracic Surgery 29 (2006) 800805

www.elsevier.com/locate/ejcts

A questionnaire study investigating the prevalence of the neuropathic

component of chronic pain after thoracic surgery
Michael F. Maguire a,*, Andrew Ravenscroft b, David Beggs a, John P. Duffy a
a

Department of Thoracic Surgery, Nottingham City Hospital Trust, Hucknall Road, Nottingham NG5 1PB, UK
b
Department of Anaesthesia, Nottingham City Hospital, Nottingham, UK

Received 25 November 2005; received in revised form 1 February 2006; accepted 3 February 2006; Available online 3 April 2006

Abstract
Objective: Our questionnaire study set out to assess the prevalence of chronic pain after thoracic surgery, the contribution of the neuropathic
component of chronic pain and the impact of chronic pain on patients lives. Methods: A questionnaire was sent to 1152 patients who had
undergone thoracic surgery in our department between 7 months and 7 years ago. The questionnaire was designed specifically for the study and
included questions on neuropathic symptoms. Responses were correlated with data from our prospectively entered database for analysis.
Results: Nine hundred and forty-eight people were included in the study, of which 600 responded (63%). Prevalence of chronic pain is 57% at 712
months, 36% at 45 years and 21% at 67 years. Patient age, consultant and time since the operation all have significant effects. Surgical
approach (video-assisted thoracoscopic surgery, thoracotomy) and diagnosis are not significant. Thirty-nine percent of those with pain take
analgesia, 46% felt their pain is their worst medical problem and 40% reported it limits their daily activities. The prevalence of each neuropathic
symptom is between 35 and 83%. The presence of a neuropathic symptom is associated with significantly more severe pain, more analgesia use and
pain more likely to limit daily activity. Conclusions: Chronic pain has a significant prevalence and impact on patients lives for several years after
thoracic surgery. Nerve dysfunction is associated with more severe pain, a greater impact and tends to persist. The reason for the individual
consultant being an important factor in post-thoracotomy pain needs further investigation.
# 2006 Published by Elsevier B.V.
Keywords: Chronic pain; Neuropathic pain; Thoracotomy; VATS

1. Introduction
Reports in the literature find the prevalence of chronic
pain after thoracic surgery to be 980% for thoracotomies
and 533% for video-assisted thoracoscopic surgery (VATS),
although studies comparing the two approaches did not show
significant differences beyond 1 year post-operative [114].
This large variance may be caused by how the authors defined
chronic pain, how long after surgery it was assessed, how the
data were collected, operative technique and method of
analgesia used. Some studies have also reported the impact
the pain has on patients lives and how it limits their daily
activity [9,10,13]. What is clear is that it is a significant
problem that requires further investigation.
Studies have shown that high levels of immediate postoperative pain are associated with an increase in the
likelihood of chronic pain [12]. The cause of the chronic
pain has not been established. However, there is evidence to
suggest this pain has a neuropathic component resulting from
nerve damage at the time of surgery. Studies have shown
* Corresponding author. Tel.: +44 115 9691169; fax: +44 115 8402605.
E-mail address: mrmmaguire@hotmail.com (M.F. Maguire).
1010-7940/$ see front matter # 2006 Published by Elsevier B.V.
doi:10.1016/j.ejcts.2006.02.002

intercostal nerve damage by demonstrating loss of intercostal nerve conduction during surgery and the loss of
abdominal reflexes after thoracic surgery is associated with
pain [15,16]. Also, chronic pain is frequently accompanied by
abnormal cutaneous sensation and is often treated with
antidepressants and antipsychotics rather than opiates.
Our aim was to investigate the prevalence of the
neuropathic component of chronic pain after thoracic
surgery and whether the presence of neuropathic symptoms
influenced the severity and impact of chronic pain.

2. Material and methods

Patients were identified from our departmental thoracic
surgery database which has data recorded prospectively
since 1991. Selection criteria were all living patients who had
undergone thoracic surgery involving VATS or thoracotomy
performed in our unit between 7 years and 7 months prior to
the start of this study. Patients were excluded if they had
undergone more than one operation, if their death had not
been recorded on our database, if they had thoracic
operations other than a thoracotomy or VATS procedure or

M.F. Maguire et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 800805

Table 1
Questionnaire sent to the patients

801

Table 1 (Continued )

if they had operation more than 7 years ago. Patients were

operated on by one of four consultants (AD) and their
teams. All the consultants had their own method of
explaining the procedure to the patient, worked with
different anaesthetic staff, performed posterolateral thoracotomies differently, closed their thoracotomies differently, used varying sizes of chest drain and relied on different
methods of post-operative analgesia. Consultant C particularly contrasts with the other three: he is the only one who
does not routinely resect a rib during thoracotomy; he closes
the thoracotomy with sutures that run over the upper border
of the rib above and under the lower border, but above the
intercostal bundle, of the rib below; and he relies more
heavily on pre-incisional blocks and paravertebral infusions
rather than epidurals.
2.1. Local ethics committee guidelines were followed
Patients were recruited by post and each was sent our
questionnaire (Table 1). Those patients who failed to respond
within 1 month were sent the questionnaire again. The study
closed 1 month after this. The questionnaire was devised
specifically for this study. Many of the questions are
commonly found in published validated questionnaires.
Questions 48 were included to identify symptoms associated with neuropathic pain. These have been validated in
the context of the Leeds Assessment of Neuropathic
Symptoms and Signs (LANSS) Pain Scale that identified those
symptoms that helped distinguish neuropathic pain from
nociceptive pain [17]. Patient demographics, the operation
performed and the diagnosis were obtained from the
department database and correlated with the responses to
the questionnaire.
The data were analysed using the SPSS statistics software
package. Chi-square test (x2) was used to compare groups
with categorical variables, independent T test for compar-

802

M.F. Maguire et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 800805

ison of age and body mass index (BMI) and MannWhitney Utest for time since the operation. For multiple interdependent factor analysis multivariate logistic regression was used
to compare groups.

3. Results
Questionnaires were sent to 1152 patients (Fig. 1). Two
hundred and four patients (18%) were excluded: 133 had
undergone more than one operation; 55 patients had died out
of hospital and had not been recorded on our database; 11
had thoracic operations other than a thoracotomy or VATS
procedure; and 5 had their operation more than 7 years ago.
Nine hundred and forty-eight patients were therefore
included in the study. Six hundred of these patients
responded giving a response rate of 63%. Two hundred and
sixty-seven patients (45% of responders) report suffering with
pain caused by their thoracic surgery with an overall
prevalence of 45.4% for thoracotomies and 40.7% for VATS.
The patient characteristics are shown in Table 2. This also
shows the characteristics of the group that failed to respond.
The responder group (n = 600) and the non-responder group
(n = 348) were compared to assess whether they were
comparable. Significance was taken as p < 0.05. The nonresponder group are significantly more likely to be male, to
be younger, to have a lower BMI, to have had their operation
less recently, to have had a benign pleural operation and less
likely to have had a malignant lung operation. The nonresponders are also more likely to have undergone a VATS
surgical procedure, though this is not significant. Therefore,
the responders do not appear to be representative of the
whole study population.
Within the responder group those who report pain
(n = 267) were compared to those who did not report pain
(n = 333). Multivariate logistic regression analyses were
performed adjusting for age, BMI, sex, consultant, time

Fig. 1. Flow diagram.

since the operation, diagnosis and surgical approach

(Table 3). Data are presented as odds ratio (OR), 95%
confidence intervals (CI) when appropriate and with pvalues. This analysis indicates for every year increase in age
the likelihood of pain decreases by 2%, the consultant has a
significant effect, and for every year increase in time since
the operation the likelihood of pain decreases by 17%.
Although the likelihood of pain is 18% higher for females and
32% lower for VATS, these are not statistically significant. The
relationship between the prevalence of pain and consultant
is shown in Fig. 2 and indicates that consultant C is associated
with less pain (35.2%) compared to consultant D (58.7%)and
this is significant ( p < 0.001). The trend for the prevalence of
pain to fall with time since the operation is shown in Fig. 3.
Further analysis comparing specific proportions of malignant
versus benign diagnoses and comparing lung versus pleural
versus oesophageal diagnoses shows no significant association
with pain ( p = 0.6 and p = 0.7, respectively).
Their responses to the questionnaire (Table 4) show 7.9%
reported their pain is severe and 60.3% felt improvement in
their pain over time. In assessment of the impact of their

Table 2
Patient characteristics of responders and non-responders
Responder Group (n = 600)

Non-responder Group (n = 348)

p value

56.5
55 (1485)
26.5

63.8
50 (1486)
25.4

0.03
<0.001
0.04
0.001

Consultant (%)
A
B
C
D

29.2
14.3
35.5
21.0

26.1
18.7
35.3
19.8

Surgical approach (%)

Thoracotomy
VATS

80.3
19.7

77.0
23.0

Diagnosis (%)
Malignant lung
Benign lung
Malignant oesophagus
Benign oesophagus
Trauma
Malignant pleural
Benign pleural
Other

35.5
19.0
4.0
14.0
3.2
1.2
22.0
1.7

24.4
15.5
6.0
14.4
1.4
2.0
34.5
1.7

Male sex (%)

Mean age (range) (years)
Body mass index
Time since the operation

0.3 (NS)

0.3 (NS)

<0.001

M.F. Maguire et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 800805

Table 3
Comparison of the pain group with the no pain group, adjusting for age, BMI,
sex, consultant, time since the operation, diagnosis and surgical approach
Factor

OR

95% CI

p value

Age
BMI
Sex (female)
Consultant
Time since the operation
Diagnosis
Approach (VATS)

0.98
0.99
1.18

0.97, 1.0
0.97, 1.01
0.82, 1.69

0.83

0.74, 0.95

0.68

0.40, 1.16

0.03
0.5
0.4
0.02
0.005
0.7
0.2

803

Table 4
Responses to the questionnaire
Question no.

Question (in brief)

Answered yes (%)

Operation side
Right
Left
Bilateral

41.6
55.3
3.1

4
5
6
7
8
10
11
13
14

Strange, unpleasant skin sensations?

Skin looks different?
Abnormally sensitive skin?
Pain in sudden bursts?
Skin temperature has changed?
Pain over the scar?
Pain on the same side as the operation?
Onset straight after surgery?
Improved with time?

72.2
35.2
82.8
67.0
36.4
60.7
89.8
74.0
60.3

15

Pain severity
Mild
Moderate
Severe

50.6
41.5
7.9

Taking analgesia?
Attended pain clinic?
Pain the worst problem?
Pain limits daily activities?

39.2
15.0
45.5
39.7

16
18
19
20
Fig. 2. The relationship between prevalence of pain and consultant.

pain: 39.2% take analgesia, 45.5% feel it is their worst

medical problem and 39.7% reported it limits their daily
activities. Fifteen percent have attended a specialist pain
clinic.
Analyses were performed to try to identify any patient
characteristic, diagnosis or operative factor that could
predict whether a patient is likely to have severe pain
(compared to mild or moderate pain), to take analgesia, that
their pain is their worst medical problem or that their daily
activities are limited by pain (questions 15, 16, 18 and 20,
respectively). Multivariate logistic regression analysis was
used adjusting for sex, age, consultant, time since the
operation, BMI, diagnosis and surgical approach. The only
significant finding is that analgesia users are more likely to be
younger by on average 3 years compared to non-users. x2
analyses comparing the specific proportions of pleural versus
lung versus oesophagus diagnoses and benign versus malignant diagnoses were also performed. Comparison of pleural
versus pulmonary versus oesophageal diagnoses shows no
significant association with any of the factors. Comparison of

Fig. 3. The relationship between prevalence of pain and time since the
operation.

malignant versus benign diagnoses does show that malignancy is associated with a significantly higher proportion of
analgesia use (51% vs 31%, p = 0.03), although there is no
significant association with pain severity, pain being the
worst problem or pain limiting daily activity. Increasing time
since the operation does not appear to be associated with
prevalence of analgesia use ( p = 0.3), the number of
different types of analgesia in use or the type of analgesia
in use ( p > 0.05). x2 analysis of the relationship between the
pain severity and time since the operation shows no
significant association ( p = 0.1), or do the relationships
between pain being the worst medical problem or pain
limiting daily activity and time ( p = 0.09 and p = 0.4,
respectively).
The prevalence of each neuropathic symptom is between
35.2 and 82.8%. For each neuropathic symptom, a multivariate logistic regression analysis was performed comparing
the presence of the neuropathic symptom with its absence.
This showed no significant association for sex, age,
consultant, time since the operation, BMI, diagnosis or
surgical approach for any of the symptoms. x2 analyses were
performed to investigate any association between the
presence of neuropathic symptoms (questions 4, 5, 6, 7
and 8) and pain severity, analgesia use, pain being the worst
medical problem and daily activities being limited by pain
(questions 15, 16, 18 and 20, respectively). This is shown in
Table 5, with p-values < 0.05 being significant. This demonstrates that, with the exception of affected skin being
abnormally sensitive to touch, the presence of a neuropathic
symptom is associated with significantly more severe pain,
more analgesia use and pain more likely to limit daily activity.
Skin looking different and abnormal skin temperature are
also associated with the likelihood of pain being the worst
medical problem. There is no association between prevalence of the neuropathic symptom groups and increasing time
since the operation. The relationship between the presence
of a neuropathic symptom and whether patients felt their

M.F. Maguire et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 800805

804

Table 5
Relationship between neuropathic symptoms and the responses to questions 15, 16, 19 and 20, showing p-values form analyses
Question

15
16
19
20

Question

p value

4
Strange sensation

5
Looks different

6
Abnormally sensitive

7
Sudden bursts

8
Skin temperature

Pain severity
Analgesia
Worst problem
Limits Activity

0.01
0.007
0.3 (NS)
0.004

<0.001
0.01
0.01
<0.001

0.1
0.7
0.2
0.2

0.02
0.001
0.3 (NS)
0.001

pain had improved over time was assessed and found not to
be significant for any of the symptoms. All symptoms, except
abnormally sensitive to touch, reduce the likelihood of
having improvement, though only skin looking different is
significant: 67% versus 49% ( p = 0.03).

4. Discussion
The authors believe this is the largest study investigating
chronic pain after thoracic surgery and one of a very few
looking at the neuropathic aspect of this type of chronic pain.
Other strengths include the fact that the basis for the
questionnaire is an inquiry of current symptoms rather than
symptoms the patient may have experienced in the past that
are difficult to recall. By targeting patients over a considerable
time period since their operation it does allow us to build up a
sense of how symptoms change with time. This is important for
informing chronic pain sufferers, considering treatment
options and assessing treatment efficacy. Our prospectively
gathered thoracic surgery database is a powerful tool having
had data entered rigorously for 14 years. It has a large number
of parameters for each individual though we have only used
those we thought were relevant to chronic pain.
The specific questions we used on neuropathic symptoms
have only been validated in the LANSS Pain Scale. This tool also
involves the examination of the patient. We recognise these
questions have not been validated for use in our questionnaire.
Questionnaires are often hampered by poor response rates but
we believe 63% is sufficient to give this study credibility.
Although the responders make up the majority, they were not
representative of the study group as a whole. We expected the
non-responders would tend to be young males, who underwent
VATS procedures for benign disease, a long time ago, because
this group is more likely to have moved away, be too busy or are
less inclined to complete a questionnaire.
Overall prevalence of chronic pain found in the study for
thoracotomy (45%) and VATS (41%) is comparable with the
published studies. However, we realise our study may overreport pain since people with pain are more likely to respond
to our questionnaire than people without pain. A trend for
the prevalence of pain to fall with time since the operation is
expected (Fig. 3), and may be due to a resolution of the
painful process peripherally or because of gradual lessening
of pain perception centrally. This finding is useful for
explaining to chronic pain sufferers that symptom prevalence
does fall with time.
From the comparison of the pain with the no-pain groups
an average decrease in prevalence (of 17%) per year after the
operation is expected. The fall in prevalence with increasing

(NS)
(NS)
(NS)
(NS)

<0.001
<0.001
0.003
<0.001

age may be explained by the elderly having less intense

inflammatory responses to surgery that may trigger chronic
pain syndromes, they may be more tolerant of pain, have
lower expectations of pain control or be taking painmodifying drugs for other comorbidities. This is supported
by our finding that patients who take analgesia specifically
for their thoracic surgery pain tend to be younger. The
significant finding that consultants have an effect on
prevalence of chronic pain may be the result of differences
in intra-operative technique, anaesthesia, method of postoperative analgesia, influence of trainees and style of
explanation that prepares the patient for surgery. The
evidence that there is no significant difference between VATS
and thoracotomy supports previous studies [1,2]. There was
no difference between malignant and benign diagnoses,
although we were unable to exclude patients with recurrent
disease: a factor highlighted in the literature [14]. We also
found those patients with malignant diagnoses were more
likely to be analgesia users, which may be because they need
more pain control or because it is more acceptable to
prescribe long-term analgesia to patients with malignancy.
In the pain group, the proportions of mild, moderate and
severe pain were expected, but the absence of a trend of
pain severity lessening with time was surprising. Just 60%
reporting improvement in their pain over time was
unexpectedly low. The significant impact of pain on patients
lives is well illustrated by around 40% taking analgesia, having
pain as their worst problem and pain limiting their daily
activities, and this supports the need for further research
into the prevention and treatment of chronic pain following
thoracic surgery.
With the exception of skin being abnormally sensitive to
touch, the presence of neuropathic pain symptoms was
associated with pain that is more severe, less likely to
improve with time and has a greater impact on patients
lives: more analgesia use, pain limiting daily activities and
pain being their worst medical problem. As the overall
prevalence of chronic pain falls with time, the frequencies of
neuropathic symptoms within the pain group did not change
significantly. This suggests neuropathic symptoms tend to
persist but become less troublesome with time.

5. Conclusion
Chronic pain after thoracic surgery is a significant problem
that affects a considerable proportion of patients and can
impact upon patients lives for several years. Our study shows
that in our unit this is influenced by patient age, operating
consultant and time since the operation. The influence of

M.F. Maguire et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 800805

consultant requires particular emphasis as this is an area that

can be more closely investigated and techniques that reduce
chronic pain can be sought. Neuropathic symptoms representing nerve dysfunction and damage are associated with
more severe chronic pain and greater impact on patients
lives, and tend to persist.

[6]

[7]

[8]

Acknowledgements
[9]

Thanks to Linda Beggs in the Thoracic Surgery Department, Tom Knight in the Clinical Audit Department and Jo
Leonardi-Bee in the Statistics Department.

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