Background & Aims
Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique with a neuromodulatory effect.1,2 Effects of tDCS as a non-pharmacological component of postoperative pain management were studied on acute postoperative pain in orthopedic, spinal, and thoracic surgery.3-5 No studies explored the effects of tDCS on chronic postsurgical pain (CPSP) prevention. Thoracotomy is an incision with a complex pain origin, and breathing exacerbated pain. Chronic post-thoracotomy pain (CPTP) incidence ranges from 21% to 61% after 12 months.6,7 We explored tDCS effects as additional component to the multimodal analgesia (education, a regular total daily dosage of nonopioid analgesics, regional anesthesia, and pain monitoring) for post-thoracotomy pain.5 Morphine PCA-IV was used when pain interfered with patient functionality and comfort. Here we analyze effect of tDCS added as a non-pharmacological component to postoperative multimodal analgesia on CPTP incidence.
Methods
The single-center, prospective, randomized, double-blind, sham-controlled proof-of-concept trial was conducted in patients diagnosed with lung cancer who underwent thoracotomy for lobectomy or pneumonectomy under total intravenous anesthesia (TCI remifentanil and propofol). The perioperative pain management included 4 components with intercostal nerve blocks at the end of the surgery, the full daily dosage of nonopioid analgesics started intraoperatively, and patient-controlled intravenous analgesia (PCA-IV) of morphine. Anodal tDCS was applied over the left primary motor cortex (C3-Fp2) for 20 mins on 5 consecutive days (a-tDCS group, n=31), while the control C-group (n=31) received sham stimulation. The telephone interview was performed 1 year after surgery. It included information about the presence and characteristics of pain (SF-MPQ, DN-4), medications for pain treatment and localization, anxiety (VAS-anxiety), and depression (Beck depression scale) presence.
Results
We analyzed the data of 39 responders (a-tDCS group, n=16; C-group, n=23). Groups were similar in demographic factors, TNM cancer classification, surgery extent, adjuvant oncological treatment, anxiety and depression level. CPSP was present in 7 (44%) patients in a-tDCS group and 11 (48%) in control. Although without a statistical difference, the cumulative dose of morphine was higher in patients with CPSP in both groups. AUC analysis didn’t show a significant difference in acute postoperative pain intensity. CPSP among groups was similar in localization (along thoracotomy scar in 86% of patients in the a-tDCS group and 73% in control), intensity during cough, and movement. Neuropathic pain was present in 14% of the a-tDCS group and 27% of patients in the C-group. The affective component of pain was present in 3 patients in the C-group. CPTP interfered with intensive activities (weight lifting) but not with regular daily activities. No difference was detected in analgesics use (a-tDCS group 71% vs C-group 45%), predominantly nonopioid analgesics. The pain persisted from surgery in 57% of a-tDCS and 55% of patients in the C-group.
Conclusions
In patients undergoing lung resection due to cancer through thoracotomy, the addition of tDCS as a non-pharmacologic method to the perioperative pain management bundle did not influence the CPTP incidence. The difference between patients who had CPTP in a-tDCS vs control was a lack of an affective component of pain and less presence of a neuropathic component of pain. However, more studies are needed to evaluate the effects of tDCS on acute and chronic postoperative pain.
References
1.Stagg CJ, Nitsche MA. (2011). Physiological basis of transcranial direct current stimulation. Neuroscientist 2011; 17:37–53.
2.Antal, A., Alekseichuk, I., Bikson, M., Brockmoller, J., Brunoni, A. R., Chen, R.,et al. (2017). Low intensity transcranial electric stimulation: Safety, ethical, legal regulatory and application guidelines. Clin. Neurophysiol. 2017; 128: 1774–1809.
3. Borckardt JJ, Reeves ST, Robinson SM, May JT, Epperson TI, Gunselman RJ, et al. Transcranial direct current stimulation (tDCS) reduces postsurgical opioid consumption in total knee arthroplasty (TKA). Clin. J. Pain 2013; 29:925–928.
4. Glaser J, Reeves ST, Stoll WD, Epperson TI, Hilbert M, Madan A, George MS, Borckardt JJ. Motor/Prefrontal Transcranial Direct Current Stimulation (tDCS) Following Lumbar Surgery Reduces Postoperative Analgesia Use. Spine (Phila Pa 1976). 2016;41:835-9.
5. Stamenkovic DM, Mladenovic K, Rancic N, Cvijanovic V, Maric N, Neskovic V, Zeba S, Karanikolas M and IlicTV. Effect of Transcranial Direct Current Stimulation Combined With Patient-Controlled Intravenous Morphine Analgesia on Analgesic Use and Post-Thoracotomy Pain. A Prospective, Randomized, Double-Blind, Sham-Controlled, Proof-of-Concept Clinical Trial. Front. Pharmacol. 2020; 11:125.
6. Ochroch EA, Gottschalk A, Augostides J, Carson KA, Kent L, Malayaman N, Kaiser LR, Aukburg SJ.Long-term pain and activity during recovery from major thoracotomy using thoracic epidural analgesia.Anesthesiology. 2002 97:1234-44.
7. Perttunen K, Tasmuth T, Kalso E.Chronic pain after thoracic surgery: a follow-up study.Acta Anaesthesiol Scand. 1999;43:563-7.
Poster Authors
Dusica Stamenkovic
MD, PhD
Medical Faculty of Military Medical Academy, University of Defense Belgrade, SERBIA
Lead Author
Katarina Mladenovic MD
PhD
Medical Faculty of Military Medical Academy, University of Defense Belgrade, SERBIA
Lead Author
Katarina Vasiljevic
MD
Medical Faculty of Military Medical Academy, University of Defense, Belgrade, SERBIA
Lead Author
Nemanja Rancic MD,PhD
Medical Faculty of Military Medical Academy, University of Defense Belgrade, SERBIA
Lead Author
Rade Vukovic Md,PhD
Department of anesthesiology and intensive care, Military Medical Academy,Belgrade, SERBIA
Lead Author
Tihomir Ilic MD
PhD
Clinic INOVIUM NEURO, Belgrade, Serbia
Lead Author
Topics
- Specific Pain Conditions/Pain in Specific Populations: Post-surgical/Post-traumatic Chronic Pain