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Clinical Investigations: SURGERY |

Spinal Prostaglandin Formation and Pain Perception Following Thoracotomy*: A Role for Cyclooxygenase-2

Connail McCrory; Desmond Fitzgerald
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*From the Department of Clinical Pharmacology, Royal College of Surgeons in Ireland, Dublin, Ireland.

Correspondence to: Desmond Fitzgerald, MD, Department of Clinical Pharmacology, Royal College of Surgeons in Ireland, Dublin, Ireland; e-mail: dfitzgerald@rcsi.ie



Chest. 2004;125(4):1321-1327. doi:10.1378/chest.125.4.1321
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Study objective: Prostaglandins (PGs) generated in the spinal cord may play a major role in pain perception. Consequently, the suppression of spinal cyclooxygenase (COX) and PG formation may contribute to the analgesic effect of nonsteroidal anti-inflammatory drugs (NSAIDs) in pain following surgery. Which isoform of COX is responsible for postsurgical pain and, consequently, should be targeted, is unclear.

Design: Prospective randomized blinded study.

Setting: University teaching hospital.

Patients: Thirty patients undergoing thoracotomy for lobectomy were recruited.

Interventions: Patients were randomized to receive the COX-2 selective inhibitor nimesulide, 100 mg orally twice daily, or ibuprofen (nonselective), 400 mg orally three times daily, in an open-label study. In addition, there was a randomized control group that received no NSAIDs. Cerebrospinal fluid (CSF) was analyzed for 6-keto-PGF1α, the principle metabolite of prostacyclin. COX-1 and COX-2 activity was determined by measuring serum thromboxane (TX) B2 and endotoxin-induced PGE2 generation in whole blood.

Measurements: Pain perception was measured by visual analog scores, and blinded assessment of opioid analgesic requirements and expiratory peak flow measurements were performed.

Results: At the doses used, nimesulide was selective for COX-2, while ibuprofen was nonselective based on serum TXB2 levels. The mean (± SEM) levels of 6-keto-PGF1α in CSF increased following surgery from 32 ± 4.9 to 127 ± 29 pg/mL (p < 0.001), and this was suppressed by nimesulide (49 ± 9.3 pg/mL; p = 0.0025) but not by ibuprofen (122 ± 35 pg/mL). Pain scores (p < 0.001), morphine requirement (p = 0.0175), and the fall in peak expiratory flow rate (p < 0.001) were significantly lower in the nimesulide group.

Conclusions: Increases in spinal PG synthesis after thoracotomy are repressed by a selective COX-2 inhibitor. This suggests that the inducible COX-2 mediates central PG synthesis, which may be important in the generation of pain, as the use of nimesulide also resulted in significant decreases in postoperative pain perception.

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