Thoracic epidural has become the accepted standard for the management of pain in the postoperative period. However, it is a flawed standard and there are times when alternatives need to be considered.

Phrenic nerve block reduces shoulder tip pain.

There are a number of alternatives to epidural analgesia which can be considered when epidural is contra-indicated or where it is not possible to insert an epidural cannula. 

  1. For many years we used the patient controlled analgesia (PCA) narcotic system.  This can be used either in conjunction with other loco-regional blocks. 

  2. Continuous wound infusion with local anaesthetic is also possible and is facilitated by using the commercially available “on-Q Pain Buster” system.  This system may be useful for both local infusion and for intercostal or phrenic fat pad infusion.

  3. For open procedures where an epidural is not possible or major VATS procedures we use a continuous intercostal infusion (also known as paravertebral or extra pleural infusion). This is administered using the Pain Buster device.

  4. We use a long acting intercostal nerve block for all other thoracoscopic procedures.

Intercostal neuralgia can be reduced by intraoperative protection of the intercostal nerve and avoidance of pressure imparted by the rib spreader.


The Surgeon’s Role in Reducing Post-operative Pain

Following thoracotomy there are two predictable pain issues which need to be addressed:

  1. Acute postoperative pain

  2. Chronic intercostal neuralgia - almost unique to thoracotomy

There are a number of measures that the Thoracic Surgeon can use to decrease both forms of pain.


Analgesia Policy


Phrenic block

Shoulder tip pain

Intercostal Block


paravertebral block

Intercostal nerve protection


Intercostal nerve protection


Other measures