CASE REPORTS
Sternal Wire-Induced Persistent Chest Pain: A Possible Hypersensitivity Reaction Perry G. Fine, MD, and Shreekanth V. Karwande, MD Department of Anesthesiology, Pain Management Center, and Division of Cardiothoracic Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah
Persistent chest pain has been reported to be a relatively common complaint after operations through a median sternotomy approach. We report a case that we believe represents a sternal pain syndrome resulting from sensitivity to nickel in the stainless steel sternal wires. In view of the high incidence of nickel sensitivity in the general
population, we question whether such sensitivity may be involved in similar poststernotomy pain syndromes when any other clear-cut pathophysiological process is not apparent.
P
scar. There was no evidence of trigger-point tenderness or clinical signs of infection. There was tenderness to palpation of the periincisional area throughout that reproduced her pain symptoms. A trial of topical capsaicin cream (Zostrix; GenDerm Corp, Northbrook, IL) was discontinued when the patient reported a severe rash after the first dose. Due to the severity of this rash, we sought a more detailed history, which revealed multiple allergic reactions in the past, including skin sensitivity to jewelry. The stainless steel sutures used to close the patient’s sternum in both operations contained 8% nickel (Ethicon). Because skin patch-testing showed that the patient was 4+ reactive to nickel, she consented to surgical removal of the wires. Examination of the sternum at the time of operation revealed that all wires were intact and the sternum was well healed. All wire sutures were removed. The patient was discharged from the hospital later that day with a complaint of mild incisional pain. This resolved in a few days, and she returned to full-time employment without pain and required no analgesic medication. She continued to be asymptomatic at 3-month follow-up.
ersistent sternal pain after median sternotomy for open heart operations is reported as a relatively common complaint. Many poststernotomy pain syndromes have been defined with a specific cause-effect relationship directly related to an underlying pathological process (eg, infection, nonunion, protruding wire, ischemia) [l].Most cases appear to be poorly defined, however, and have been attributed to nonspecific anxietyrelated or muscular pain disorders. We report a case of disabling chest pain after an open heart operation through a median sternotomy incision in which stainless steel sutures were used for sternal closure. Removal of the sternal wires led to complete relief of pain. A 47-year-old woman underwent ablative therapy through a midline sternotomy incision for treatment of Wolff-Parkinson-White syndrome. This procedure was successful, but the patient had persistent periincisional pain that increased with motion and was unable to return to work 2 months postoperatively. Computed tomography of the chest revealed a partial nonunion of the lower aspect of the anterior table of the sternum, although there was no clinically apparent instability. Because of the patient’s continuing pain, we decided to split and rewire the sternum surgically, with the hope of alleviating her pain. About five days postoperatively, the patient again began to experience disabling pain beneath the skin incision such that she was unable to return to work or perform most household duties; she continued to require analgesic medication. She was referred to our pain clinic 2 months after this repair with radiographic evidence of a solid sternal fusion and no broken or protruding wires. Her pain had been unresponsive to nonsteroidal antiinflammatory drugs, nortriptyline, and clonazepam. Physical examination showed a well-healed midsternal Accepted for publication June 9, 1989 Address reprint requests to Dr Fine, Department of Anesthesiology, University of Utah Health Sciences Center, 50 N Medical Dr, Salt Lake City, UT 84132.
0 1990 by The
Society of Thoracic Surgeons
(Ann Thorac Surg 1990;49:1356)
Comment We found only 1 other case in the literature in which removal of intact, nonprotruding wire sutures resolved disabling sternal pain [2]. That patient’s reaction to the sutures was not explained, however. We hypothesize that sensitivity to the nickel component in the stainless steel sutures can account for our patient’s symptoms. This hypothesis is based on the indirect evidence of this woman’s 4+ patch test reactivity and her history of previous skin hypersensitivity reactions. We recognize, with hindsight, that a tissue biopsy at the time of suture removal could have yielded conclusive evidence. A tissue reaction compatible with allergy would have supported this hypothesis. Without this evidence, but in the face of completely intact, well-placed sutures, with no soft tissue protrusion and a solidly fused sternum, the complete resolution of 0003-4975/90/$3.50
136
CASE REPORT FINE AND KARWANDE PERSISTENT STERNOTOMY PAIN
this patient’s pain several days after removal of the sutures is highly suggestive that a nonmechanical type of reaction was operative. Allergic reactions to skin clips have been reported, with the determination that these reactions are caused by the nickel content in surgical grade stainless steel clips [3].It has been suggested that a history of metal sensitivity should be sought in patients undergoing surgical procedures in which skin clips might be used for wound closure. A recent large multicenter epidemiological study demonstrated an overall incidence of nickel hypersensitivity of 7.3%. Nickel hypersensitivity is more common in females (10.5%) than in males (2.1%) [4].Because of this 5:l ratio of females to males demonstrating nickel hypersensitivity, it would be interesting to know the prevalence of females who have poststernal wiring pain as compared with males. We are unaware of any studies reporting such data. Although some prospective studies have addressed the long-term tissue reactivity to some synthetic sutures, stainless steel (which incorporates nickel) has not been included [5].The importance of considering potentially
Ann Thorac Surg 1990;49:1356
treatable causes of postoperative sternal pain before attributing such symptoms to anxiety or incisional pain has been stressed [l]. We question whether the common occurrence of nickel sensitivity in the general population might contribute to persistent poststernotomy pain when stainless steel sutures are used for closure. If so, this pain syndrome is both curable and preventable by the selection of other suture material.
References 1. Weber LD, Peters RW. Delayed chest wall complications of median sternotomy. South Med J 1986;79:723-7. 2. Weber LD, Nashel DJ, Peters RW. Persistent chest pain due to sternal wire sutures: a complication of coronary artery bypass surgery. South Med J 1985;781018-9. 3. Oakley AMM, Ive FA, Carr MM. Skin clips are contraindicated when there is nickel allergy. J R SOCMed 1987;80:290-1. 4. Schubert H, Berova N, Czernielewski A, et al. Epidemiology of nickel allergy. Cont Dermatol 1987;16:122-8. 5. Postlethwait RW. Five year study of tissue reaction to synthetic sutures. Ann Surg 1979;190:54-9.
Sternal Wire-Induced Persistent Chest Pain: A Possible Hypersensitivity Reaction Perry G. Fine, MD, and Shreekanth V. Karwande, MD Department of Anesthesiology, Pain Management Center, and Division of Cardiothoracic Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah
Persistent chest pain has been reported to be a relatively common complaint after operations through a median sternotomy approach. We report a case that we believe represents a sternal pain syndrome resulting from sensitivity to nickel in the stainless steel sternal wires. In view of the high incidence of nickel sensitivity in the general
population, we question whether such sensitivity may be involved in similar poststernotomy pain syndromes when any other clear-cut pathophysiological process is not apparent.
P
scar. There was no evidence of trigger-point tenderness or clinical signs of infection. There was tenderness to palpation of the periincisional area throughout that reproduced her pain symptoms. A trial of topical capsaicin cream (Zostrix; GenDerm Corp, Northbrook, IL) was discontinued when the patient reported a severe rash after the first dose. Due to the severity of this rash, we sought a more detailed history, which revealed multiple allergic reactions in the past, including skin sensitivity to jewelry. The stainless steel sutures used to close the patient’s sternum in both operations contained 8% nickel (Ethicon). Because skin patch-testing showed that the patient was 4+ reactive to nickel, she consented to surgical removal of the wires. Examination of the sternum at the time of operation revealed that all wires were intact and the sternum was well healed. All wire sutures were removed. The patient was discharged from the hospital later that day with a complaint of mild incisional pain. This resolved in a few days, and she returned to full-time employment without pain and required no analgesic medication. She continued to be asymptomatic at 3-month follow-up.
ersistent sternal pain after median sternotomy for open heart operations is reported as a relatively common complaint. Many poststernotomy pain syndromes have been defined with a specific cause-effect relationship directly related to an underlying pathological process (eg, infection, nonunion, protruding wire, ischemia) [l].Most cases appear to be poorly defined, however, and have been attributed to nonspecific anxietyrelated or muscular pain disorders. We report a case of disabling chest pain after an open heart operation through a median sternotomy incision in which stainless steel sutures were used for sternal closure. Removal of the sternal wires led to complete relief of pain. A 47-year-old woman underwent ablative therapy through a midline sternotomy incision for treatment of Wolff-Parkinson-White syndrome. This procedure was successful, but the patient had persistent periincisional pain that increased with motion and was unable to return to work 2 months postoperatively. Computed tomography of the chest revealed a partial nonunion of the lower aspect of the anterior table of the sternum, although there was no clinically apparent instability. Because of the patient’s continuing pain, we decided to split and rewire the sternum surgically, with the hope of alleviating her pain. About five days postoperatively, the patient again began to experience disabling pain beneath the skin incision such that she was unable to return to work or perform most household duties; she continued to require analgesic medication. She was referred to our pain clinic 2 months after this repair with radiographic evidence of a solid sternal fusion and no broken or protruding wires. Her pain had been unresponsive to nonsteroidal antiinflammatory drugs, nortriptyline, and clonazepam. Physical examination showed a well-healed midsternal Accepted for publication June 9, 1989 Address reprint requests to Dr Fine, Department of Anesthesiology, University of Utah Health Sciences Center, 50 N Medical Dr, Salt Lake City, UT 84132.
0 1990 by The
Society of Thoracic Surgeons
(Ann Thorac Surg 1990;49:1356)
Comment We found only 1 other case in the literature in which removal of intact, nonprotruding wire sutures resolved disabling sternal pain [2]. That patient’s reaction to the sutures was not explained, however. We hypothesize that sensitivity to the nickel component in the stainless steel sutures can account for our patient’s symptoms. This hypothesis is based on the indirect evidence of this woman’s 4+ patch test reactivity and her history of previous skin hypersensitivity reactions. We recognize, with hindsight, that a tissue biopsy at the time of suture removal could have yielded conclusive evidence. A tissue reaction compatible with allergy would have supported this hypothesis. Without this evidence, but in the face of completely intact, well-placed sutures, with no soft tissue protrusion and a solidly fused sternum, the complete resolution of 0003-4975/90/$3.50
136
CASE REPORT FINE AND KARWANDE PERSISTENT STERNOTOMY PAIN
this patient’s pain several days after removal of the sutures is highly suggestive that a nonmechanical type of reaction was operative. Allergic reactions to skin clips have been reported, with the determination that these reactions are caused by the nickel content in surgical grade stainless steel clips [3].It has been suggested that a history of metal sensitivity should be sought in patients undergoing surgical procedures in which skin clips might be used for wound closure. A recent large multicenter epidemiological study demonstrated an overall incidence of nickel hypersensitivity of 7.3%. Nickel hypersensitivity is more common in females (10.5%) than in males (2.1%) [4].Because of this 5:l ratio of females to males demonstrating nickel hypersensitivity, it would be interesting to know the prevalence of females who have poststernal wiring pain as compared with males. We are unaware of any studies reporting such data. Although some prospective studies have addressed the long-term tissue reactivity to some synthetic sutures, stainless steel (which incorporates nickel) has not been included [5].The importance of considering potentially
Ann Thorac Surg 1990;49:1356
treatable causes of postoperative sternal pain before attributing such symptoms to anxiety or incisional pain has been stressed [l]. We question whether the common occurrence of nickel sensitivity in the general population might contribute to persistent poststernotomy pain when stainless steel sutures are used for closure. If so, this pain syndrome is both curable and preventable by the selection of other suture material.
References 1. Weber LD, Peters RW. Delayed chest wall complications of median sternotomy. South Med J 1986;79:723-7. 2. Weber LD, Nashel DJ, Peters RW. Persistent chest pain due to sternal wire sutures: a complication of coronary artery bypass surgery. South Med J 1985;781018-9. 3. Oakley AMM, Ive FA, Carr MM. Skin clips are contraindicated when there is nickel allergy. J R SOCMed 1987;80:290-1. 4. Schubert H, Berova N, Czernielewski A, et al. Epidemiology of nickel allergy. Cont Dermatol 1987;16:122-8. 5. Postlethwait RW. Five year study of tissue reaction to synthetic sutures. Ann Surg 1979;190:54-9.
