Intraoperative intercostal nerve blockade for postthoracotomy pain

BACKGROUND: Epidural analgesia is widely employed as a means to control postthoracotomy pain, but is sometimes inadequate. The purpose of this study is to evaluate the effectiveness of intraoperative, temporary, intercostal nerve blockade in addition to epidural analgesia for control of postthoracotomy pain. METHODS: Forty patients undergoing elective lobectomy through antero-axillary thoracotomy were randomized to receive epidural analgesia only (group A, n = 20) or epidural analgesia plus temporary, intraoperative intercostal nerve blockade using 0.25% bupivacaine (group B, n = 20). Postoperative pain was assessed using a subjective analogue visual scale, and with the Prince Henry pain scale. Food intake and nonsteroidal analgesic consumption were also investigated. Serum ACTH and cortisol in each group were measured before and after the operation. RESULTS: The analogue visual scale scores were significantly higher in group A than group B (p < 0.001), and were significantly higher on the day of operation and postoperative days 1, 2, and 3 (p < 0.001, p < 0.005, p < 0.005, p < 0.05, respectively). Prince Henry pain scale scores were significantly higher on the day of operation and postoperative day 1 (p < 0.05, p < 0.005, respectively). Food intake was significantly lower in group A than in group B (p < 0.05), and nonsteroidal analgesic consumption was not significantly different between groups. There was no significant difference between group A and group B in serum ACTH or in cortisol levels. CONCLUSIONS: Additional intraoperative intercostal nerve blockade provides an additive benefit for postthoracotomy pain relief, especially early after operation.     

Thoracic epidural infusions for post thoracotomy pain relief: a clinical study to compare the efficacy of fentanyl — bupivicaine mixtures versus fentanyl alone

Background: Optimum pain relief following thoracotomy is essential for patient comfort and to reduce the incidence of postoperative pulmonary complications. Methods: A randomized clinical trial was conducted on 90 patients scheduled for pulmonary resection. The patients were randomly divided into three groups. Group 1 received 0.125% bupivicaine with fentanyl 10μg.ml⁻¹, Group 2 received 0.25% bupivicaine with fentanyl 10μg.ml⁻¹ and Group 3 received only fentanyl 10μg.ml⁻¹ in a calculated dose as a continuous thoracic epidural infusion. Adequacy of anglesia was assessed at rest and during movement over 24 hours. Analgesic efficacy was assessed using a visual analogue score and an observer verbal ranking scale. Results: Pain scores were significantly higher in Group 3 during the assessment period. (p<0.01) as compared to the other groups. The use of intraoperative vasopressors was significantly higher (p<0.05) in Group 2 as compared to the other groups. No neurological complications were encountered in any of the study groups. Conclusion: We conclude that in the early postoperative period, the use of 0.125% bupivicaine improves fentanyl epidural analgesia in patients undergoing lung resection.     

Cryoanalgesia for post-thoracotomy pain relief

A randomized study comparing the postoperative requirements of narcotics of three groups of patients (Group I: no analgesia; Group II: internal intercostal nerve block; Group III: cryoanalgesia) was conducted. This study was performed in order to assess the efficiency of cryoanalgesia versus internal intercostal nerve block to obtain pain relief after thoracotomy. Regarding post-operative narcotic requirements (Piritramide-Dipidolor), there was no significant difference between Group I and Group II patients, but patients from Group III required a significantly lower amount of narcotics during the first 36 postoperative hours (p less than 0.01). We conclude that, although cryoanalgesia does not provide complete post-thoracotomy pain relief, it is however an easy and safe method and is more efficient than internal intercostal nerve block for pain relief after thoracotomy.     

Management of pain after thoracotomy: experience of intercostal nerve block with alcohol during operation

Post-thoracotomy wound pain in 11 patients who underwent thoracic operation was controlled by intercostal nerve block with alcohol and thoracic epidural anesthesia. The intercostal nerve block was performed just before the closure of the thoracotomy wound. Epidural anesthesia was employed from the 1st to 5th post operative day. This method alleviated post-thoracotomy pain and obviated postoperative pulmonary complication in all patients in early post operative periods. In late post operative periods after discharge, intercostal nerve block could maintain excellent analgesia in 9 of 11 patients, only 2 patients required analgesic drugs or re-block of the intercostal nerve. Thus, intercostal nerve block with alcohol is an effective and simple option to control recalcitrant post-thoracotomy wound pain in thoracic surgery.     

Evaluation of postoperative pain relief after video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax

BACKGROUND: We have investigated correlation between postoperative pain and chest tube insertion after video-assisted thoracoscopic surgery (VATS) for patients with spontaneous pneumothorax, and have evaluated preemptive analgesia by intercostal nerve block (ICB) using bupivacaine. METHODS: Thirty patients received VATS for spontaneous hemi-pneumothorax. There were two groups of the patients; Group CT received chest tube before the operation, and the Group NCT received no chest tube. Both groups received general anesthesia combined with ICB by 0.25% bupivacaine at the surgical region before operation. Postoperative pain was assessed using visual analogue scale (VAS scale: 0-10) and the need for additional supplemental analgesics before the operation, and at 6 and 24 hours after the operation, and at 3, 7, 14, and 30 days after the operation. RESULTS: Visual analogue scale in Group NCT before the operation, and at 24 hours, 3, 7, 14, and 30 days after the operation was significantly lower than that of Group CT. Analgesic requirements were significantly lower in the Group NCT than in the Group CT. CONCLUSIONS: We should avoid the insertion of a chest tube before the operation as much as possible. Furthermore early operation and intercostal nerve blockade before the operation were useful to prevent postoperative pain and its shift to chronic post thoracostomy pain.     

Early postoperative pain management after thoracic surgery; pre- and postoperative versus postoperative epidural analgesia: a randomised study.

OBJECTIVES: Effective analgesia and blockade of the perioperative stress response may improve outcome and epidural analgesia plays a role in the reduction of pulmonary complications following thoracic surgery. In this study, we assessed preoperative and postoperative thoracic epidural analgesia (Preop-TEA and Postop-TEA) techniques on post-thoracotomy pain in 61 patients undergoing posterolateral thoracotomy. METHODS: A thoracic epidural catheter was inserted into all the patients before surgery. In Group I, 8 mL of 0.25% bupivacaine plus fentanyl 50 microg in 2 mL was administered preoperatively. In Group II, no medication was administered via the epidural catheter preoperatively and intraoperatively. Postoperative analgesia was maintained with patient-controlled epidural analgesia with bupivacaine and fentanyl solution in both groups. Pain was evaluated at 2, 4, 8, 12, 24 and 48 h at rest and coughing. RESULTS: Preop-TEA Group was associated with decreased pain compared with the Postop-TEA Group. CONCLUSIONS: In conclusion, preoperative epidural analgesia is an appropriate method for post-thoracotomy pain and is more effective in preventing acute postoperative pain.     

不同镇痛方法对老年食管癌患者术后疼痛及早期认知功能的影响

目的探讨不同镇痛方法对老年食管癌患者术后疼痛及认知功能的影响。方法选择拟行左进胸食管癌根治术患者60例,男31例,女29例,年龄65~80岁,ASAⅠ或Ⅱ级,随机分为A、B两组,每组30例。A组:关胸前予以0.375%罗哌卡因行肋间神经阻滞后接静脉镇痛泵,配方为舒芬太尼3μg/kg+氟比洛芬酯100mg,泵速2ml/h,自控镇痛0.5ml/按压,锁定时间15min。B组:关胸前予以舒芬太尼10μg+氟比洛芬酯50mg为负荷量后接静脉镇痛泵,配方同A组。观察两组患者术前1d、术后3、5、7d内简易精神状态量表(MMSE)评分,术后苏醒时、苏醒后4、8、12、24、48h视觉模拟疼痛(静息及运动时VAS)评分、BCS舒适评分、术后镇痛泵有效按压次数及术后认知功能障碍(POCD)的发生率。结果与B组比较,A组术后苏醒时、苏醒后4、8、12、24、48h静息及运动时VAS评分均明显降低(P0.05或P0.01);苏醒后4、8、12、24、48h的BCS评分明显升高、有效按压次数明显降低(P0.05);术后3、5、7d的MMSE评分明显升高(P0.05);术后3、5、7d的POCD发生率降低,但差异无统计学意义。结论开胸手术围术期应用肋间神经阻滞复合静脉镇痛可有效缓解患者术后疼痛,降低术后POCD的发生率,提高术后患者舒适度,有利于术后患者的快速康复。     

Reduction of post-thoracotomy pain by cryotherapy of intercostal nerves

In a prospective study, 144 patients undergoing thoracotomy were randomized to two groups: In 71 cases cryoanalgesia was applied intraoperatively to the intercostal nerves above and below the incision to relieve postoperative pain, and 73 (control group) received bupivacaine-adrenaline intercostal blockade at the end of the operation. The amount of administered narcotic and mild analgesics, the visual analogue pain scores, the need for further intercostal blockade and the number of postoperative bronchoscopies to clear retained secretion were significantly less in the cryoanalgesia group than in the controls. There were no late nerve complications after cryoanalgesia, which is recommended for routine use in thoracotomy.     

Analgesia after thoracotomy: epidural fentanyl/bupivacaine compared with intercostal nerve block plus intravenous morphine

OBJECTIVES: Intercostal nerve blockade plus intravenous (IV) patient-controlled analgesia (PCA) could be an easier and safer alternative to epidural analgesia for postthoracotomy pain, but information about the efficacy of this technique is scarce. The objective of this randomized study was to compare the quality of analgesia and lung function in 2 groups of patients undergoing pulmonary surgery through a posterolateral thoracotomy. METHODS: Two groups were studied: G1 (n = 16) patients received a 5-segment intercostal block plus IV PCA morphine, and G2 (n = 15) patients received a bupivacaine and fentanyl PCA infusion through a thoracic epidural catheter. Resting and dynamic visual analog pain scale (VAS) measurements, forced vital capacity, and forced expiratory volume in 1 second were measured basally, on arrival in the recovery room, then hourly up to 4 hours and then 12, 24 and 48 hours later. Results were analyzed with a 2-way analysis of variance, chi-square, or Fisher exact test. A p value < or =0.05 was considered significant. RESULTS: Resting and dynamic VAS scores were slightly lower in G2 patients, although only resting scores were significant. After the first hour, mean scores were below 4 in both groups. No significant difference was observed between groups in relation to respiratory parameters or side effects. CONCLUSION: The fact that the difference in pain scores is probably not clinically significant shows that an intercostal block with bupivacaine plus IV morphine PCA is a good alternative for postthoracotomy pain management.     

Analgesia for thoracic surgery

The pain of thoracic surgery is severe which if addressed correctly reduces morbidity and mortality. Pain arises from muscle dissection, rib retraction and intercostal nerve damage. Management is challenged by pre-existing respiratory and co-morbid disease. Thoracic epidural analgesia for thoracotomy is considered ideal, however paravertebral blockade as part of a multimodal approach increasingly offers a comparable solution. Post-thoracotomy pain syndrome is a significant issue and preventive analgesia is worthy of consideration.     

Pre-emptive effect of multimodal analgesia in thoracic surgery

Thirty subjects undergoing posterolateral thoracotomy were allocated randomly to receive one of two analgesic regimens: group Pre received i.v. morphine, i.m. diclofenac and intercostal nerve blocks from T2 to T11, 20 min before operation and placebo injections after operation. Group Post received placebo injections before operation, and i.v. morphine, i.m. diclofenac and intercostal nerve blocks from T2 to T11 at the end of surgery, before discontinuation of anaesthesia. Visual analogue pain scores, extent and duration of intercostal nerve block, analgesic consumption and complications were assessed during the postoperative period by a single blinded observer. Subjects were followed-up for a minimum of 12 months to determine the incidence of post-thoracotomy pain syndrome. During the first 48 h after operation there were lower pain scores in group Pre when taking a vital capacity breath but there were no significant differences between the groups in any other measure. The effects of pre-emptive analgesia given before surgery appeared to be relatively modest in terms of analgesia, analgesic consumption and long-term outcome and were of limited clinical significance.      

Comparison of different methods of postoperative analgesia after thoracotomy

Fifty-one patients scheduled for thoracotomy were included in a study involving five different methods of postoperative analgesia. Forty patients were randomly divided into: Group C, receiving intramuscular oxycodone on request following an intraoperative intercostal block; Group IC, intercostal blocks with 0.5% bupivacaine performed prior to surgery, 6 h later and on the first postoperative morning: Group EB, epidural bupivacaine as a continuous infusion of 0.25% bupivacaine (5 ml h-1); Group EM4 epidural morphine 4 mg injected prior to surgery and on the first postoperative morning. In addition, a fifth group (Group EM6) of 11 patients received 6 mg of epidural morphine timed as in Group EM4, but these patients were automatically scheduled to be observed in the ICU. Additional intramuscular oxycodone was given on request to all patients. Group EB, EM4 and EM6 had lower numbers of requests than Group C. Pain intensity score was lowest (2.5 on a scale from 0 to 10, 3 h postoperatively) in Group EM6, and there was a statistically significant difference in pain intensity at 3 h between EM4 and EM6. The evaluation of cooperation and pain by the physical therapist revealed no differences between the groups. Postoperative blood-gas analyses contained slightly elevated PCO2 values (6.0-7.3 kPa) in all groups. Postoperatively, only Group EB was devoid of PCO2 values above 7.3 kPa. Urinary retention was a common complication in the patients receiving epidural analgesia, occurring most frequently in Group EM6; 10 of the 11 patients had to be catheterized.     

Sciatic nerve blockade improves early postoperative analgesia after open repair of calcaneus fractures

OBJECTIVE: To determine the effectiveness of analgesia, with or without sciatic nerve blockade, after open repair of calcaneus fracture. DESIGN: Randomized, prospective trial involving 30 patients divided into 3 groups of 10, all having open repair of calcaneus fractures. Group 1 used morphine patient-controlled analgesia alone. Groups 2 and 3 had morphine patient-controlled analgesia and a "one-shot" bupivacaine sciatic nerve blockade, either presurgically (group 2) or postsurgically (group 3). SETTING: Harborview Medical Center operating rooms and orthopedic floors. OUTCOME MEASURES: Morphine use over 24 hours, visual analogue scale pain scores, and sciatic nerve blockade duration. RESULTS: In the absence of sciatic nerve blockade, initial postoperative pain was marked, even with a mean recovery room dose of intravenous morphine more than 30 mg. Sciatic nerve blockade with bupivacaine had a mean duration of 14 hours and substantially reduced pain for the first 24 postoperative hours. Presurgical blockade confers no advantage over postsurgical blockade. CONCLUSION: Sciatic nerve blockade confers significant benefit over morphine alone for analgesia after open repair of calcaneus fractures. Postsurgical sciatic nerve blockade provides the longest possible postoperative block duration.     

The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty

Either epidural analgesia or femoral nerve blockade improves analgesia and rehabilitation after total knee arthroplasty. No study has evaluated the combination of femoral nerve blockade and epidural analgesia. In this prospective, randomized, blinded study we investigated combining femoral nerve blockade with epidural analgesia. Forty-one patients received a single-injection femoral nerve block with 0.375% bupivacaine and 5 microg/mL epinephrine; 39 patients served as controls. All patients received combined spinal-epidural anesthesia and patient-controlled epidural analgesia with 0.06% bupivacaine and 10 microg/mL hydromorphone. Average duration of epidural analgesia was 2 days. All patients received the same standardized physical therapy intervention. Median visual analog scale (VAS) scores with physical therapy were significantly lower for 2 days among patients who received a femoral nerve block versus controls: 3 versus 4 (day 1), 2.5 versus 4 (day 2); P < 0.05. Median VAS pain scores at rest were 0 in both groups on days 1 and 2. Flexion range of motion was improved on postoperative day 2 (70 degrees versus 63 degrees ; P < 0.05). No peripheral neuropathies occurred. We conclude that the addition of femoral nerve blockade to epidural analgesia significantly improved analgesia for the first 2 days after total knee arthroplasty.     

Role of cryoanalgesia in the control of pain after thoracotomy.

Thoracotomy causes severe postoperative pain, which is difficult to manage since the use of systemic analgesics often causes respiratory depression. Cryoanalgesia of the intercostal nerves has been advocated as an effective means of local analgesia without serious side effects. A prospective randomised blind trial to investigate the efficacy of the technique was carried out. A total of 53 patients undergoing thoracotomy were allocated to either the trial or a control group. At thoracotomy the surgeon was informed of the patient's trial allocation. The trial group received one minute of direct cryotherapy to at least five intercostal nerves related to the incision. All patients received methadone via the lumbar epidural route in a dose calculated according to their weight. A linear analogue assessment of postoperative pain was made by the patients as soon as they were sufficiently awake. An independent record of all postoperative analgesia was kept. After discharge from hospital further assessments were made at least six weeks after operation. Statistical analysis of the scores of postoperative pain and analgesic consumption showed that there was no significant difference between the trial and the control group. There was, however, a suggestion of an increase in the long term morbidity, although these figures were not amenable to statistical analysis. Thus is has not been possible to demonstrate a role for cryoanalgesia in the control of post thoracotomy pain.     

Pain Amelioration after Thoracotomy: A Prospective,Randomized Study

Twenty patients undergoing a posterolateral thoracotomy for lung resection or a nonpulmonary procedure were divided into four groups. Group 1 was the control group. Patients in Group 2 had an intercostal nerve block at the time of closure. Those in Group 3 underwent a continuous intercostal nerve block for five days. Electronic pain control was used in Group 4. An additional group of patients underwent operation through an anterolateral thoracotomy (Group 5) and was compared with the control group. Breathing performance was evaluated daily for five days with bedside spirometry, and intergroup comparison was done utilizing the unpaired t test and analysis of variance. Forced expiratory volume in one second, expressed as percent of preoperative values, was significantly better in Group 3 (continuous intercostal nerve block) at 52.4 ± 9.2% (standard deviation; p < 0.05) and in Group 5 (anterolateral thoracotomy) at 52.0 ± 7.5% (p < 0.05) than in the control group (38.4 ± 8.8%) five days postoperatively. It is concluded that bedside spirometry is a simple and reliable technique to assess postoperative changes in ventilatory mechanics due to pain. The pain that follows posterolateral thoracotomy can be substantially decreased with a continuous intercostal nerve block. Anterolateral thoracotomy is notably less painful than posterolateral thoracotomy and should be considered the approach of choice for patients with decreased pulmonary reserve who undergo uncomplicated pulmonary resection.     

Postthoracotomy pain management

The following techniques appear efficacious in controlling postthoracotomy pain and reducing the amount of systemic opioids consumed: continuous intercostal blockade, paravertebral blockade, and epidural opioids and/or anesthetics. The combination of thoracic epidural opioid and local anesthetic is very effective at relieving postthoracotomy pain, however, considerable experience is required for insertion of the thoracic epidural catheter and postoperative respiratory monitoring. Intercostal and paravertebral catheters can be inserted intraoperatively under direct visualization, to reduce complications of insertion. One-time intraoperative intercostal blockade may effectively reduce postoperative pain in the first day, but is not a practical long-term method for postthoracotomy pain. The effectiveness of interpleural analgesia, even with proper technique, appears inferior to epidural and other regional techniques. We have incorporated the principles outlined in this review into our general thoracic surgery protocol, as detailed in Fig. 1. Every patient is assessed preoperatively for epidural catheter placement. Contraindications include low platelet count (< 100,000), abnormal coagulation profile, medicinal anticoagulation (aspirin and nonsteroidal anti-inflammatories are not contraindications), bony spinal abnormalities, or neurological disorders. The T5/6 interspace is our preferred level, but T10 can work well with an increased dose of bupivacaine. Upon completion of the muscle sparing, minimal-access thoracotomy, we close the wound and perform a percutaneous intercostal nerve block (two ribs above and three below the incision). We then use patient-controlled epidural analgesia, with a basal infusion of bupivacaine and hydromorphone. To supplement inadequate or nonfunctioning epidurals, intravenous patient-controlled opioids are added. When choosing an approach to postthoracotomy pain management, the thoracic surgeon and anesthesiologist must consider the following: (1) the physician's experience, familiarity and personal complication rate with specific techniques; (2) the desired extent of local and systemic pain control; (3) the presence of contraindications to specific analgesic techniques and medications; and (4) availability of appropriate facilities for patient assessment and monitoring postthoracotomy. Refinements in surgical technique including limited or muscle-sparing thoracotomy, video-assisted thoracoscopic surgery (VATS) and robotic surgery may lessen the magnitude of postthoracotomy pain. We encourage all thoracic surgeons to be knowledgeable of available techniques and maintain a protocol to generate a database for periodic assessment of safety and efficacy.     

A comparison of epidural bupivacaine, levobupivacaine, and ropivacaine on postoperative analgesia and motor blockade

In this prospective, randomized, observer-blinded clinical trial, we compared the incidence of unwanted lower extremity motor blockade and the analgesic efficacy between small-dose (0.125%; 0.2 mg x kg(-1) x h(-1)) postoperative epidural infusions of bupivacaine (Group B; n = 28), levobupivacaine (Group L; n = 27), and ropivacaine (Group R; n = 26) in children after hypospadias repair. Motor blockade and pain were assessed at predetermined time points during 48 h by using a modified Bromage scale and the Children's and Infant's Postoperative Pain Scale (CHIPPS). Postoperative analgesia was almost identical in all three study groups (CHIPPS range, 0-3), with no need for the administration of supplemental analgesia in any patient. However, significantly more patients in Group B (n = 6; P = 0.03) displayed signs of unwanted motor blockade during the observation period compared with Group L (n = 0) and Group R (n = 0). In conclusion, significantly less unwanted motor blockade was associated with postoperative epidural infusions of 0.125% levobupivacaine or ropivacaine in children after hypospadias repair as compared with a similar infusion of bupivacaine. However, no difference with regard to postoperative analgesia could be detected among the three different local anesthetics studied.     

Epidural administration of low-dose morphine combined with clonidine for postoperative analgesia after lumbar disc surgery.

This study evaluates the efficacy and side effects of a low dose of epidural morphine combined with clonidine for postoperative pain relief after lumbar disc surgery. In 36 of 51 patients who accepted the procedure, an epidural catheter was inserted (L1-L2 level). General anesthesia was induced with propofol and sufentanil, and maintained with sevoflurane in O2/N2O. After emergence from anesthesia, epidural analgesia was initiated according to two randomly assigned protocols: 1 mg of morphine with 75 microg of clonidine (Group M) or 12.5 mg of bupivacaine with 75 microg of clonidine (Group B), in 10 mL saline. Piritramide was administered during the first postoperative 24 hours using a patient-controlled analgesia device (PCA). The following parameters were recorded: piritramide consumption during the first 24 hours; pain at rest during the first postoperative hours (D0), during the first night (D1), and during the first mobilization; [visual analogue scale (VAS)]; and the occurrence of drowsiness, motor blockade, respiratory depression, nausea, vomiting, itching, micturition problems, and bladder catheterization during D0 and D1. Epidural administration of morphine-clonidine significantly improved postoperative pain relief and reduced piritramide consumption as compared to epidural bupivacaine-clonidine. Side effects did not differ between groups except for a higher incidence of micturition problems in Group M during D1. The occurrence of bladder catheterization was not significantly higher in that group. We conclude that a low dose of epidural morphine combined with clonidine offers a better postoperative analgesia than does bupivacaine-clonidine. The excellent analgesic conditions were obtained at the expense of a higher incidence of difficulties in initiating micturition.     

Post-thoracotomy pain and pulmonary function--comparison of intermittent intercostal bupivacaine vs intravenous pethidine

OBJECTIVE AND METHODS: In a prospective, observer-blind study, 50 patients scheduled for posterolateral thoracotomy were investigated to compare the effects of intermittent intercostal extrapleural bupivacaine (n = 25) and intravenous pethidine (n = 25) on post-thoracotomy pain and pulmonary function. The severity of chest pain (objectified by the use 5-point scale of Prince Henry) and changes in spirometric values [forced vital capacity (FVC), forced expired volume in 1 s (FEV1) and FEV1/FVC] were monitored during the first three postoperative days. Because intravenous pethidine was used to supplement pain relief in the patients who received intercostal analgesia, total pethidine used was compared to that administered to patients in the intravenous pethidine group. RESULTS: There were no statistical significant differences regarding patient demographics in both groups. No complications occurred. There was no significant difference between mean pain scores in the first postoperative day, but in the second and third postoperative days and also in the whole first 72 post-operative hours, pain scores were significantly higher in the intravenous group than the intercostal group. The postoperative decrease in FVC and FEV1 was significantly less with intercostal bupivacaine compared with the intravenous pethidine. There was no significant intergroup difference in the post- to pre-operative FEV1/FVC ratio. The total amount of the pethidine received by the patients was significantly higher in the intravenous group than the intercostal group. CONCLUSION: Intermittent intercostal nerve block with bupivacaine appears to be a promising, safe and reliable technique in the management of post-thoracotomy pain. Use of intercostal bupivacaine could significantly reduce or even eliminate the postoperative need for systemic narcotics.