Management of Post-Sternotomy Pain

Initial Clinical Assessment

Post-sternotomy pain is common, affecting more than half of patients after cardiac surgery, and requires systematic evaluation to distinguish benign musculoskeletal pain from serious complications like sternal wound infection, dehiscence, or cardiac issues, according to the American Heart Association 1
Assessing for sternal stability by palpating for a sternal gap >3 mm is crucial, as it correlates with significantly higher chest pain intensity and indicates sternal nonunion or dehiscence, as recommended by the American College of Radiology 2
Evaluating pain characteristics is essential, as post-sternotomy pain syndrome presents as discomfort persisting for at least 2 months without apparent cause, with an incidence ranging from 7% to 66%, according to the American Heart Association 1

The American College of Radiology recommends ordering a CT chest with contrast if there is clinical suspicion of sternal wound infection, concern for sternal dehiscence or nonunion, or a need to assess the degree of osseous healing and residual chest wall deformities 2
FDG-PET/CT is useful for determining the depth of infection and involvement of costal cartilages when deep sternal wound infection is suspected, with a sensitivity of 91% and specificity of 97% for sternal wound infections, as reported by the American College of Radiology 2
A bone scan maintains a high negative predictive value for osteomyelitis in patients with equivocal CT findings, according to the American College of Radiology 2

The American College of Cardiology recommends initiating multimodal analgesia for uncomplicated post-sternotomy pain, with acetaminophen as the first-line treatment, and adding ibuprofen for anti-inflammatory effect if not contraindicated, as suggested by the American College of Cardiology 4
Reserving opioids for severe pain not controlled by non-opioid analgesics is recommended by the American College of Cardiology 4

The American Heart Association advises against dismissing persistent pain as "normal", as pain persisting beyond 2 months warrants thorough evaluation 1
The American College of Radiology warns against premature CT in the early postoperative period due to a high false-positive rate in the first 17 days post-surgery 2
The American College of Cardiology recommends recognizing that multiple pain mechanisms can coexist, including musculoskeletal pain, nerve entrapment, and infection, and that these may occur simultaneously 4