Abstract Thoracotomy pain, if untreated, is excruciating and risks acute and chronic complications. Muscle dissection, rib retraction and intercostal nerve damage activate nociceptors. Management is challenging particularly with pre-existing respiratory and co-morbid disease. The gold standard of thoracic epidural analgesia is potentially eclipsed by paravertebral blockade. Post-thoracotomy pain syndrome, previously understated, is a significant problem.