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  1. Is cold only a biting bystander in this story?

    I have several points about this interesting case report.

    1/ The first point that surprised me is this: apparently, this patient has had neither at the end of the procedure nor after an intercostal infiltration with long-acting local anaesthetic drug

    2/ Then this could have helped in both diagnosis and treatment. The disappearing or alleviation of pain would have clearly identified the intercostal nerve injury and even broken the vicious circle of chronic pain if it had been done early after the onset. It would have also allowed an earlier onset of physiotherapy and potentially avoided such a risky and aleatory end for this chronic pain

    3/ About the mechanistic hypothesis Intercoastal nerve injury in thoracoscopy procedures is dependent on technique, size of the device and skill of the surgeon. It is a rather frequent complication of those procedures and prevention is key. It is mainly based on a surgical approach just at the upper edge of the rib in order to avoid any damage to the vessels which lead to a haematoma compressing the nerve or directly to the nerve

    4/ chronic pain is a neurobiological issue (https://www.ncbi.nlm.nih.gov/pubmed/12931188) which is the result of a persistent lesion of a peripheral nerve. Complex neurologic and epigenetic mechanisms are at the root of chronic pain and personal traits are associated to the development of chronic pain (https://www.ncbi.nlm.nih.gov/pubmed/16355225)(https://academic.oup.com/brain/article/137/3/724/389996). In my experience, one of the worst treatment for chronic pain in a thoracic surgical incision is systemic opioids (https://journals.lww.com/painrpts/Fulltext/2017/03000/Postoperative_pain_from_mechanisms_to_treatment.1.aspx). In this setting it is probable that strong and fast movements during the short swim can have released some local fibrous tissue in the wound and that a severe stress can have interrupted the vicious circle of chronic pain which is dependent on a central thalamic role (https://www.jscimedcentral.com/Neuroscience/neuroscience-5-1075.pdf)

    5/ Is cold a biting bystander in this case? We know on the contrary that cold could lead to neuropathy in case of chronic cold but non-freezing exposure(https://academic.oup.com/brain/article/140/10/2557/4100656). When cold is used for neurolysis it is with a cryoprobe and temperatures at the tip of the probe which is in contact with the nerve (CT guided procedure) is minus 50 Celsius. It is clear that the swimming episode did not reach this range of temperature.

    This case report is clearly mysterious and in absence of imagery and testing of the nerves, it is at odd to conclude of any direct action of cold water immersion on neuropathy.

    Conflict of Interest:

    None declared

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