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Technique | Efficacy in Ipsilateral Shoulder Pain (ISP) | Advantages | Disadvantages | Comments |
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Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) | Yes [3, 6–8] Partial effect [5] | Simplicity of use Cross-effectivity for other pain syndromes | Unwanted side effects and contraindications Limited level of efficacy | Considered as coanalgesia |
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Acetaminophen | Yes [15] | Simplicity of use Cross-effectivity for other pain syndromes May be effective as preemptive analgesia Well tolerated | Limited level of efficacy | Considered as coanalgesia |
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Gabapentin | Yes [27, 29, 30] No [19, 31]
| Simplicity of use Cross-effectivity for other pain syndromes
| More effective in ISP in abdominal surgeries May cause dizziness or sedation | Considered as coanalgesia |
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Systemic ketamine | There is no report(s) about ISP Several reports about efficacy thoracotomy pain management [32–37] or against it [32, 35, 36] | Simplicity of use Cross-effectivity for other pain syndromes May be effective in prevention of chronic post thoracotomy pain development | May cause dizziness, sedation, or other neurologic or cardiac side effects | More researches are required |
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Thoracic epidural | Optimal analgesia for incisional pain [38–41] At levels higher than T5 effective on ISP [22] Not effective for ISP [5, 6, 8, 15, 16] | Excellent pain relief for incisional pain
| Limited or no efficacy on ISP Hemodynamic effects Invasive method Needing further assessments
| Recommended for all thoracotomy patients More research about the efficacy of epidurals higher than T5 in management of ISP |
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Intraoperative local anesthetic infiltration of the phrenic nerve at the level of the diaphragm | Yes [5, 7, 9, 10] | Significant effect on prevention of ISP Simple and effective There are reports about its safety | Short duration of effect Impossibility to repeat Concerns about hemidiaphragmatic weakness Needing surgical access | Recommended as a preventive effective method in otherwise healthy patients Need more assessments of safety at least in special subgroups of patient Needs development of technique and medication selection |
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Stellate ganglion block | Yes [7, 16] | Possible to repeat | Invasive Unwanted effects and side effects of stellate ganglion block | To be considered as a possibility to treatment of ISP in special patient Needing development of technique and medication selection |
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Interscalene brachial plexus block | Yes [7, 17, 18, 24] | Possible to repeat | Invasive Unwanted effects and side effects of brachial plexus block | To be considered as a possibility to treatment of ISP in special patient including multiple trauma of shoulder or arm Needing development of technique and medication selection |
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Direct blockade of the phrenic nerve | Yes (inadvertent) [17] | Possible to repeat | Invasive Concerning about hemidiaphragmatic weakness
| Needing more assessments of safety and efficacy Needing development of technique and medication selection |
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Intrapleural block | Yes [42–50] No [11, 51–55] | Safe and easy Could be repeated as needed Could be perform via chest tubes
| Some systemic side effects of intrapleural medications No effect on incisional pain or epidural analgesia requirement Sometimes incomplete block
| Could be considered as the first option in early postoperative phase, when clots, secretions, and adhesion bonds are minimal and ISP have the highest severity Needing more studies for development of technique and medication selection |
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Suprascapular nerve block
| Yes [10, 12, 17, 56] No [13] | Possible to repeat | Invasive Unwanted effects and side effects of Less effectiveness in compare with phrenic nerve block | Needing more assessments of safety and efficacy To be considered as a possibility to treatment of ISP in special patient including multiple trauma of shoulder or arm
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