Osteopathic Manipulation for Post-Thoracotomy Patients
With a multi-disciplinary, team approach, OMT can play a positive role in minimizing post-operative morbidity following thoracotomy
By Austin L. Jones, OMSIV and Michael Lockwood, DO, FCA
ABSTRACT: The post-thoracotomy patient population is a group of challenging patients that can benefit from a well-rounded team approach that includes osteopathic examination and manipulative treatment. A case report of a 61-year-old white male, status post right thoracotomy and lung mass resection, provides an example of the use of osteopathic principles and practices in this patient population. The approach to the post-thoracotomy patient is examined with special emphasis on osteopathic considerations. Along with a multi-disciplinary, cooperative team approach, osteopathic manipulative treatment can play a positive role in minimizing post-operative morbidity following thoracotomy.
The thoracic surgical patient is well suited for osteopathic examination and treatment, as entry into the thoracic cavity has a great potential to disrupt the normal mechanical structure and function of the rib cage. Besides altered mechanics of the rib cage, the patient is also at risk for the commonly-observed post-surgical morbidities. Although the exact number of thoracotomies performed annually is difficult to identify, a conservative estimate of several hundred thousand procedures are performed each year.
In 2004 approximately 400,000 operations were performed on the respiratory system in which entry into the thoracic cavity, including the possibility of thoracotomy as an operative approach, was required.1 This figure may be an underestimation of the true thoracotomy incidence, as a number of pulmonary and cardiovascular procedures requiring thoracotomy are not included in this data set. With this large post-thoracotomy patient population, it is imperative that osteopathic physicians explore the structural and functional considerations of these patients in order to offer the well rounded, quality care that incorporating osteopathic principles and practice can provide. The following case study details the osteopathic manipulative management of a 61-year-old post-thoracotomy patient.
Chief Complaint
The patient was a 61-year-old white male admitted to the hospital for right thoracotomy and resection of lung mass.
History of Present Illness:
A small mass was found in the right lower lobe of the lung on computed tomography (CT) of the chest. The patient had an 80 pack per year smoking history.
Pulmonary function testing revealed moderately severe airway obstruction with a diffusing capacity of less than 50 percent of predicted, representing severe loss of reserve capacity and possible difficulty in weaning from mechanical ventilation. The patient underwent a small standard posterolateral thoracotomy with incision between the fifth and sixth intercostal space for wedge resection. The patient tolerated the procedure well, was extubated and sent to the Intensive Care Unit (ICU) for monitoring. Following post-thoracotomy protocol, an Osteopathic Manipulative Medicine (OMM) consultation was ordered for manipulative management.
Postoperative pain management was provided by the anesthesia department via thoracic epidural ropivicaine and patient-controlled analgesia (PCA) meperidine.
Physical Exam:
OMM consultation revealed the following key physical findings. Vitals: Height 5 feet and 8 inches; weight 160 pounds; blood pressure 95/42 mm Hg; heart rate 64 beats per minute; respiratory rate of 16 breaths per minute; and transcutaneous pulse oximetry estimation of oxygen saturation 99 percent on 4 liters of oxygen per minute via nasal cannula. Breathing was labored with the use of the accessory muscles including the scalene and sternocleidomastoid muscles bilaterally. Diminished breath sounds were auscultated at the right lower lobe and normal breath sounds were present in the left lung fields. The abdomen was flat and hypoactive bowel sounds were present. Osteopathic examination demonstrated thoracic inlet rotated left, tight paraspinal musculature from T3-L3 on the right, and very poor rib motion right ribs 4-9. Diffuse myofascial restrictions were present throughout the abdominal mesentery, the sacrum demonstrated generalized poor motion, and the pelvic fascia demonstrated a preference for right rotation.
Assessment:
Plan:
Clinical Course:
Pain control was maintained and the infusion rate of ropivicaine via the thoracic epidural catheter was gradually reduced. The anesthesia department removed the epidural catheter and discharged the patient from their service on POD #2. The patient was transferred from ICU status to surgical floor status on POD #2. The patient was transitioned to oral pain medication on POD #3. The chest tube was removed, resulting in a high degree of symptomatic relief, on POD #4. The patient was discharged to home on POD #5.
OMM Course:
Follow-up OMM visits focused on treatment of specific somatic dysfunctions found on daily physical examinations, autonomic referral areas, and support of homeostatic mechanisms. The patient tolerated OMT well and an adequate response to treatment was obtained. Rib stiffness and pain improved over the course of hospitalization, with the patient subjectively attributing some symptomatic relief to the OMT that he received. Relief of postoperative ileus was obtained. On the day of discharge the patient described mild rib pain with coughing in the right ribcage near the incision site. Over the course of the hospitalization an overall improvement in ribcage and spinal movement, respiratory and gastrointestinal function, and baseline pain levels were observed.
Discussion
Thoracotomy
There are a number of surgical approaches to a simple thoracotomy. The length and location of the incision is based on the exposure required, balanced with the needs of the patient for the best chance of full postoperative recovery.2,3 The most commonly used incision in thoracotomy, especially for resection of pulmonary lesions, is the posterolateral thoracotomy.2,3 The posterolateral thoracotomy is performed with the patient in a lateral recumbent position. The skin incision ordinarily begins at the anterior axillary line just below the nipple level, extends posteriorly below the tip of the scapula, and is then lengthened superiorly halfway between the medial border of the scapula and the spinous processes of the thoracic vertebrae. Generally following division on the latissimus dorsi, the serratus anterior is retracted, and the intercostal muscles are divided, commonly at the fifth intercostal space. (Figure 3) A rib spreader is then placed into the thoracic cavity and further surgical exploration allows for the thoracic cage to be opened for appropriate exposure while attempting to minimize rib cage injury.2
Postoperative Care
The most critical components of postoperative care of thoracotomy patients are adequate pain control and respiratory care.2 Some accepted modalities for pain control include epidural analgesia and intravenous analgesia delivered by a patient-controlled analgesia (PCA) pump. Supplemental nonsteroidal anti-inflammatory agents are used for breakthrough pain.
Other interventional pain management options include intercostal nerve cryoablation, continuous delivery of local anesthetic, and intercostal nerve blocks.3,4 A logical continuation of pain management is the necessity of respiratory care for the post-thoracotomy patient. Proper pain control without excessive sedation allows the patient to produce an effective cough in order to clear secretions.2 Adjunctive respiratory care modalities, including incentive spirometry, and a dedicated team approach to patient care are utilized to further enhance respiratory function.
Although some data challenge the beneficial effects of incentive spirometry, this modality does encourage deep breathing and some authors suggest that it still has a beneficial role in patient rehabilitation.3,5
As in any major surgical procedure, general postoperative complications can occur, including atelectasis, pneumonia, and ileus.5
nother possible complication, chronic post-thoracotomy pain, can be a frustrating long-term morbidity for the post-thoracotomy patient and the physician, and its incidence has been found to be up to 67 percent in some studies.6 The cause of chronic post-thoracotomy pain can be varied, including: recurrence of malignancy, and neuropathic or myofascial pain secondary to surgical trauma.7
Osteopathic Considerations
As previously described in the literature, osteopathic manipulative medicine has a role in the care of thoracic surgery patients.8 Osteopathic manipulative treatment (OMT) has been found to be effective in minimizing postoperative complications including atelectasis and ileus.5 OMT can be used to increase ribcage motion, maximize respiratory effort, augment lymphatic flow, support homeostasis, and minimize somatic pain. Treatment of viscerosomatic reflexes and any somatic dysfunction that might contribute to a somatovisceral reflex has the potential to assist in pain management and facilitation of the healing process.5
Specifically regarding post-thoracotomy patients, one unpublished manuscript of a retrospective analysis of 120 thoracotomy patients showed fewer pneumonias, less atelectasis, less ileus, and a decrease in length of hospital stay by 1.82 days in patients receiving osteopathic manipulative management versus a group of controls that received no osteopathic manipulative management (K.J. Blanke, DO, FACOS, unpublished data, 2003).
When dealing with post-thoracotomy pain syndrome, select cases may benefit from OMT. Anecdotal reports have suggested that manipulative management can be helpful, especially in the subset of post-thoracotomy pain syndrome patients with a strong musculoskeletal component.9 Osteopathic manipulative management of postoperative thoracotomy patients appears to have a great deal of potential in augmenting pain control, respiratory care, and minimizing common postoperative complications. Further randomized, prospective studies on the role of OMT in post-thoracotomy patients would be useful for further characterization of its use and contraindications in this patient care setting.
Conclusion
In conjunction with a multi-disciplinary, cooperative team approach, osteopathic manipulative treatment can play a positive role in minimizing post-operative morbidity following thoracotomy.
| Figure 1. |
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| Indirect myofascial release technique performed on a thoracic inlet with left rotation preference. The tissues are contacted and directed towards the indirect physiologic barrier. The tissues are maintained at the indirect physiologic barrier until a release is appreciated. Finally, the myofascial structures should be rechecked. |
| Figure 2. |
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| Paraspinal muscle inhibition. Anterior pressure is maintained on the paraspinal musculature. Inhibitory pressure is generally maintained until softening and warmth of the tissues is appreciated, generally requiring 30 seconds to 2 minutes. When using this empiric technique with the intention of ileus resolution, one should focus attention to the thoracolumbar paraspinal musculature bilaterally. |
| Figure 3. |
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| Posterolateral thoracotomy incision. (From: Brunicardi et al. Scwhartz’s Principles of ]Surgery. 8th Ed. New York: The McGraw-Hill Companies, Inc.; 2005. Reproduced with permission of The McGraw-Hill Companies.) |
Austin Jones is an osteopathic medical student at the A.T. Still University-Kirksville College of Ostepathic Medicine, Kirskville, Missouri. He has completed a pre-doctoral teaching fellowship in osteopathic theory and methods and graduates in May 2008. Michael Lockwood, DO, FCA serves as professor and chair of the Department of Osteopathic Manipulative Medicine at the A.T. Still University-Kirksville College of Osteopathic Medicine.
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