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  Table of Contents 
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 129-135

Analgesic efficacy of ultrasound-guided erector spinae block and pectoral nerve block in patients undergoing modified radical mastectomy: A randomized control trial

1 Department of Anaesthesiology and Critical Care, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
2 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Department of Health, Government Hospital, Nagaur, Rajasthan, India
4 Department of Anaesthesia, Dungarpur Medical College, Dungarpur, Rajasthan, India
5 Department of Health, Kanwatia Hospital, Jaipur, Rajasthan, India

Date of Submission25-Apr-2021
Date of Acceptance19-Jul-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Dr. Geeta Singariya
123, Vaishali Avenue, Jhanwar Road, Jodhpur - 342 008, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_74_21

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Background and Aims: Modified radical mastectomy (MRM) is the commonest surgical procedure performed for carcinoma breasts. MRM is associated with considerable postoperative pain. This study was aimed to compare the analgesic efficacy of erector spinae plane (ESP) block and pectoral nerve (PECS) block.
Materials and Methods: A total 70 female patients, American Society of Anesthesiologist Physical Status I-II, aged between 18 and 65 years, undergoing MRM surgery. Patients were randomly divided into two equal groups of 35 each, by computer-generated random number table. Group E patients, received ESP block with 20 mL of 0.25% levobupivacaine, and Group P patients, received PECS block with 30 mL of 0.25% of levobupivacaine. The surgical procedure was conducted under general anesthesia in both groups. The primary objective was total morphine consumption in the first 24 h and secondary objectives were intraoperative fentanyl needed, duration of analgesia, numeric rating scale (NRS) score, postoperative complications, and patient's satisfaction. The Statistical Package for the Social Science (SPSS) software version 22.0 used for statistical analysis.
Results: Demographic data, hemodynamic parameters, and intraoperative fentanyl consumption were comparable between the two groups (P > 0.05). Postoperative morphine consumed in the first 24 h was less in the Group P compared to Group E (P = 0.018). The duration of analgesia was significantly prolonged in the Group P than Group E (P < 0.0001). The NRS score, postoperative complications, and patient's satisfaction were comparable.
Conclusion: The PECS block is more effective analgesic modality compared to ESP blocks in patients undergoing MRM surgeries.

Keywords: Erector spinae plane block, levobupivacaine, modified radical mastectomy, pectoral nerve block

How to cite this article:
Singariya G, Pahuja H, Kamal M, Choudhary K, Meena S, Saini P. Analgesic efficacy of ultrasound-guided erector spinae block and pectoral nerve block in patients undergoing modified radical mastectomy: A randomized control trial. Indian Anaesth Forum 2021;22:129-35

How to cite this URL:
Singariya G, Pahuja H, Kamal M, Choudhary K, Meena S, Saini P. Analgesic efficacy of ultrasound-guided erector spinae block and pectoral nerve block in patients undergoing modified radical mastectomy: A randomized control trial. Indian Anaesth Forum [serial online] 2021 [cited 2023 Jun 4];22:129-35. Available from: http://www.theiaforum.org/text.asp?2021/22/2/129/326984

  Introduction Top

The modified radical mastectomy (MRM) with axillary lymph nodes dissection is commonly performed surgical procedure for breast cancer in women.[1] Inadequate postoperative pain control may attribute to negative physiological and psychological consequences and causative factors for the development of chronic pain.[2]

The thoracic epidural and ultrasound-(US) guided paravertebral blocks (PVB) are the effective postoperative analgesic technique, but not devoid of complications.[3],[4] The pectoral nerve block (PECS) and erector spinae plane (ESP) block are easy to perform block, with good analgesic efficacy and devoid of major side effects.

Modified pectoral nerve block (PECS II) described by Blanco et al. to provide effective analgesia after MRM surgeries. In PECS block, local anesthetic (LA) is deposited in the plane between the pectoralis major muscle (PMm) and the pectoralis minor muscle (Pmm) and Pmm and the serratus anterior (SA) muscle at the level of the third rib.[5]

The ESP block is introduced by Forero et al.[6] as a safer alternative of PVB block. In ESP block, LA is injected between erector spinae muscle and the transverse process of the vertebra into the fascial plane extending from nuchal fascia cranially to the sacrum caudally. The drug is diffused to PVB space through the fenestrations of costotransverse ligaments and blocks the dorsal rami, ventral rami, sympathetic nerves, and intercostal nerves.

Very few studies were available that compared the ESP block and PECS block.[7],[8],[9] This study aimed to compare the analgesic efficacy and safety of US-guided ESP block and PECS block in patients undergoing MRM with axillary lymph dissection.

  Materials and Methods Top

This prospective, randomized, comparative study was performed in accordance with the principles outlined in the Declaration of Helsinki. The study was conducted between December 2018 and November 2019, after obtaining approval from Institutional Ethical Committee and registered with the Clinical Trial Registry - India. The written informed consent was obtained from all the participants of the study.

A total 70 female patients of the American Society of Anesthesiologist (ASA) physical status I-II and aged 18 and 70 years, who were scheduled for an elective unilateral radical mastectomy with axillary lymph node resection surgery under general anesthesia were included in the study. The patients with known allergy to LA agent, infection at the block site, opioid abuse, coagulopathy, body mass index (BMI) >35 kg/m2, major cardiac disorders, decreased pulmonary reserve, renal dysfunction, preexisting neurological deficits, or psychiatric illness were excluded.

Patients were randomized into two equal groups (35 each) by computer-generated random number table (Group P - PECS block, Group E - ESP block) by a researcher who was not involved in the study. An anesthesiologist took the corresponding sealed envelope indicating the treatment assigned to the patient which was opened just before the block performed. All blocks were performed by an experienced anesthesiologist.

The detailed preoperative anesthesia evaluation and education of numeric rating score (NRS) were done 1 day before the surgical procedure. All patients were kept fasting as per institutional protocol and were premedicated with lorazepam 2 mg and ranitidine 150 mg orally night before and 2 h before surgery.

In the procedure room, standard ASA monitors like electrocardiography (ECG), noninvasive blood pressure (NIBP), and peripheral oxygen saturation (SpO2) were applied in all the patients, and baseline data were recorded. An 18 G intravenous (i.v.) cannula was secured in the forearm opposite to the surgical side. The blocks in both groups were performed on the operative side, with 22 G block needle by using high-frequency linear array probe (6–13 MHz) under US guidance (Sonosite, M Turbo Inc., Bothell, Washington, USA) with all aseptic precautions on the side of surgery.

In Group E, ESP block was performed in lateral decubitus position. The ultrasonographic (USG) probe was placed vertically at the T4 spinous process, then probe move laterally 2–3 cm, until the tip of the transverses process was identified. Three muscles, trapezius, rhomboid major, and erector spinae muscle were identified superficial to the transverses process shadow. The skin was anesthetized with 2% lignocaine. The block needle, 22 G needle was introduced deep to erector spinae muscle and superficial to transverse process [Figure 1]. The location of the needle was confirmed by hydrodissection, then 20 ml of 0.25% levobupivacaine was injected after negative aspiration and simultaneous cranial-caudal spread of LA can be visualized.
Figure 1: Ultrasonographic picture of ESP block. T: Trapezius muscle, RM: Romboids major muscle, ESP: Erector spinae plane, TP: Transverse muscle

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In Group P, PECS block was performed in supine position with 90° ipsilateral upper arm abduction. The USG linear probe was placed inferolaterally to the clavicle at mid-point and identify the axillary artery and axillary vein, then probe was moved laterally until PMm, Pmm, and SA muscle were identified above the third and fourth ribs. The skin was infiltrated with lidocaine 2%, and then block needle was advanced in-plane approach from medial to lateral until the tip reached the plane between Pmm muscle and SA muscle, and 0.25% levobupivacaine 20 ml deposited (PECS II block). Now, needle was withdrawn till tip of the needle is between PMm and Pmm, and levobupivacaine 0.25% 10 ml was deposited. (PEC I) [Figure 2].
Figure 2: Ultrasonographic picture of pectoral nerve block. SA: Serratus anterior, PM: Pectoralis major, Pm: Pectoralis minor, R3: Third rib, R4: Fourth rib

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In all patients, the level of sensory block was assessed by the pin prick method in the anterior axillary line at every 5 min for the first 30 min after block performance, from T1 to T8 dermatome, by an anesthesiologist who was unaware about study group. The sensation to pinprick was compared to the opposite side. If pinprick sensation does not decrease even after 30 min in any segment, it was label as block failure and these patients were excluded from the analysis for analgesic consumption. After 30 min of the block, the patients were shifted to the operating room (OR). The observer, who collected perioperative data were blinded to the technique of analgesia used.

In OR, general anesthesia was induced with fentanyl (2 μg/kg), propofol (2 mg/kg), and endotracheal tube intubation was facilitated by vecuronium bromide (0.1 mg/kg). Anesthesia was maintained with 50% oxygen/air mixture, and isoflurane with minimum alveolar concentration of 0.9–1.0. The fentanyl (1 μg/kg) i.v. bolus was administered when heart rate (HR) or mean blood pressure (MBP) exceeded 20% of the preoperative values. Continuous monitoring of HR, NIBP, peripheral SpO2, and end-tidal carbon dioxide was done throughout intraoperative period and recorded every 15 min till the completion of surgery. The total dose of fentanyl required in intraoperative period was recorded. The patients received a continuous infusion of ringer lactate at the rate of 5–8 ml/kg/h during surgery. Fifteen minutes before completion of surgery, all patients received ondansetron 0.1 mg/kg i.v. The neuromuscular blockade was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg i.v. and extubated. All patients were shifted to postanesthesia care unit for monitoring and further to the surgical ward. The duration of surgical procedure was noted.

The hemodynamics data such as HR, NIBP, respiratory rate (RR), SpO2, and NRS scores at rest and movement were recorded at 2, 4, 6, 8, 10, 12, 18, and 24 h postoperatively. The NRS is a segmented numeric scale in which a horizontal bar or line which contains 11-point numeric scale ranging from 0 representing no pain to 10 worst pain imaginable.

The duration of analgesia was defined as the time interval from completion of LA administration to the first rescue analgesic requested. The morphine 3 mg slow i.v. was used as rescue analgesic, whenever NRS ≥4 on rest or patient's demand. Total morphine consumed in the first 24 h postoperatively was also recorded.

The block-related complications, like as vascular puncture, LA toxicity, Horner's syndrome or pneumothorax and any side effects, such as bradycardia (HR <40 bpm), hypotension (reduction of MBP ≥ 30% of baseline), respiratory depression (RR ≤8 breaths/min or SpO2 <90%), nausea, or vomiting, pruritus and chest pain were recorded and treated. Bradycardia was treated with atropine 0.6 mg i.v. Hypotension was treated with bolus of normal saline and if required mephentermine 6 mg i.v. was administrated. Nausea lasting > 10 min or vomiting was treated with ondansetron 0.1 mg/kg i.v. Respiratory depression was treated with oxygen supplementation by ventimask. Patient's satisfaction score was graded as 4 = excellent, 3 = good, 2 = fair, 1 = poor.

The primary objective was total morphine consumption in the first 24 h postoperative period and secondary objectives were intraoperative fentanyl needed, duration of analgesia, NRS score, postoperative complications, and patient's satisfaction.

Sample size was calculated based on pilot study with ten patients in each group. The mean difference of morphine consumption between the two groups was 0.73 ± 0.61 mg in the first 24 h after surgery (Group E; 8.49 ± 1.35 mg and Group P; 7.76 ± 0.74 mg). We estimated the minimum sample size with 90% confidence interval, 80% power, total sample size comes out 28 in each group, we took round off 35 patients in each group. The statistical analysis was done using the Statistical Package for the Social Science (SPSS) software version 22.0 (SPSS, IBM Corp, Armonk, NY). The normally distributed data were compared using Student's unpaired t-test, whereas nonparametric data were compared by χ2-test for intergroup differences. Intraoperative hemodynamics data were compared with baseline by repeated measured by Student's paired t-test.

  Results Top

A total of 80 patients were enrolled in the study. Ten patients were excluded from the study for various reasons (7 patients were not meeting in inclusion criteria, 3 patients declined to participate in the study). The remaining 70 patients were allocated into the two groups of study. Three patients in Group E and 2 patients in Group P were discontinued from intervention due to failed/partial block and excluded from the analysis [Figure 3].
Figure 3: Consort flow diagram

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Both groups were comparable regarding demographic data (age, weight, height, BMI, ASA physical status) and the duration of surgery [Table 1]. There was no statistically significant difference in hemodynamics parameters (HR, NIBP, SpO2, RR) during the perioperative period between the groups.
Table 1: Demographic data and duration of surgerya

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The intraoperative requirement of fentanyl was comparable between two groups, (20.31 ± 4.95 μg in Group E vs. 16.66 ± 3.93 μg in Group P; P = 0.549). The total dose of morphine consumption in first 24 h postoperative was significantly less in Group P compared to Group E (7.27 ± 2.25 mg, and 10.21 ± 1.49 mg, respectively; P < 0.0001) [Table 2]. The median total number of rescue analgesic dose was higher in Group E than Group P (3 vs. 2; P = 0.018) [Table 2]. The mean duration of analgesia was significantly longer in Group P compared to Group E (804.84 ± 109.72 min and 573.43 ± 91.95 min; P < 0.0001) [Table 2].
Table 2: Intraoperative and postoperative analgesic used and duration of analgesiaa

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The postoperative NRS scores at rest and on movement scores were higher in Group E in comparison to Group P [Table 3]. The postoperative NRS at rest was statistically significant at 6, 8 and 10 h (P = 0.0007, P < 0.0001, P = 0.002). The postoperative NRS-M score was statistically significant at 4, 6, 8 and 10 h (P = 0.0009, P < 0.0001, P < 0.0001, P < 0.0001).
Table 3: Comparison of postoperative numeric rating score at rest and numeric rating score at movementa

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In Group P, three patients complained of nausea and one patient vomiting, three patients developed drowsiness and one developed respiratory depression, whereas in Group E, one patient had hypotension and three patients developed nausea and two developed vomiting, one patient developed pruritis and three patients became drowsy and one had an episode of bradycardia, which was statistically not significant (P = 0.770). Block-related complications, such as pneumothorax, vascular puncture, or LA toxicity was not seen in any of the groups. The patient's satisfaction score was better in Group P then Group E, but the difference was not statistically significant (P = 0.48).

  Discussion Top

The result of our study showed that PECS block had significantly less postoperative morphine consumption in the first 24 h, and better pain control for prolonged duration of analgesia compared to ESP block in patients scheduled for MRM.

As per breast cancer statistics, one in eight females is affected during their lifetime.[10] The MRM is associated with moderate-to-severe acute postoperative pain. Failure to provide adequate acute pain control is associated with poor quality of recovery and chronic postsurgical pain.[2],[11] Acute postoperative pain after MRM can be managed with either parenteral analgesic or regional analgesics techniques. The regional techniques obviate the need of parenteral analgesia, hence associated side effects are also minimized. However, an ideal method has not yet been identified and all of these blocks also have some associated drawbacks too.

The fascial plane blocks are considered safer alternatives of central neuraxial blocks due to less invasiveness. These fascial plane blocks can be introduced accurately under US guidance. PECS I, PECS II, SAP block, and ESP block are fascial plane blocks used as postoperative analgesia for breast surgeries.

The skin over the breast is innervated mainly by T2–T6 spinal nerves. In addition to these, nerves of brachial plexus, i.e., the long thoracic nerve, thoracodorsal nerve, medial pectoral nerve, and lateral pectoral nerve, are also involved in conveying sensation from the breast and axillary region.[12] Therefore, to provide complete postoperative analgesia for breast cancer surgery, it is necessary to theoretically block the ten spinal nerve dermatomes from vertebral C5 to T6. The modified PECS block can provide regional anesthesia both for the chest wall and axillary areas.[13] Various studies proved the efficacy of PECS block compared to PVB for postoperative analgesia following MRM.[14],[15]

ESP block is a newer block wherein the drug is deposited more superficial and far from midline compared to TEA and PVB. ESP block is a safer truncal block, and provides better cephalocaudal spread of LA. The analgesia of ESP because of drug diffusion into PVB space, hence it is also known as indirect PVB. The literature described that drug deposited has better craniocaudal spread as it is tight compartment and ESP fascia extend cranially from cervical level to caudally at sacral level. Several other randomized controlled trial results have shown significantly decreased morphine consumption for the first 24 h postoperatively in the ESP block group compared to the control group.[16],[17]

The PECS block has additional advantage of blocking the branches of the brachial plexus, which innervates the chest wall and axilla.[16] Several studies reported that modified PECS block provided better analgesia and reduction in postoperative opioid consumption in comparison to thoracic PVB following MRM.[17],[18]

In our study, we found 30% reduction in total morphine consumption in Group P compared to Group E. Similarly, Sinha et al. found 32% decrease in 24 h postoperative mean morphine consumption in the PECS group compared to the ESP group.[9] Other studies, also found that PECS block is better in comparison to ESP block with lower analgesic consumption and lower pain scores in the postoperative period following MRM surgery.[7],[8]

The intraoperative fentanyl consumption was almost similar in both groups. This shows that both blocks provide equal analgesia during the surgical period. The results of our study were similar to other studies.[7],[8],[9] The duration of analgesia was significantly prolonged in patients receiving the Group P compared to Group E. A similar result was obtained in the study by Sinha et al.[9] The NRS pain scores were significantly lower in Group P compared to Group E, but this statistical difference does not have any clinical significance. The finding of our study was supported by other studies.[7],[8],[9] The side effects were comparable in both groups. Other studies also concluded that PECS block was more efficacious than ESP.[7],[8],[9]

Our study has a few limitations. First, our patients were not blinded to the block administered to them. Secondly, we did not follow up our patients to find the effect of PECS/ESP block on chronic postoperative pain.

  Conclusion Top

The PECS block is more effective in terms of reduced morphine consumption and lower pain scores in the first 24 h postoperative period compared to ESP block in patients undergoing modified radical mastectomy surgeries.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gu X, Zheng R, Xia C, Zeng H, Zhang S, Zou X, et al. Interactions between life expectancy and the incidence and mortality rates of cancer in China: A population-based cluster analysis. Cancer Commun (Lond) 2018;38:44.  Back to cited text no. 1
Andersen KG, Kehlet H. Persistent pain after breast cancer treatment: A critical review of risk factors and strategies for prevention. J Pain 2011;12:725-46.  Back to cited text no. 2
Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: A meta-analysis of randomized controlled trials. Br J Anaesth 2010;105:842-52.  Back to cited text no. 3
Cheng GS, Ilfeld BM. A review of postoperative analgesia for breast cancer surgery. Pain Manag 2016;6:603-18.  Back to cited text no. 4
Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012;59:470-5.  Back to cited text no. 5
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 6
Altiparmak B, Toker MK, Uysal Al, Turan M, GữmữsDemorobilek S. Comparison of the effects of modified pectoral nerve block and erector spinae block on postoperative opioid consumption and pain scores of patients after radical mastectomy surgery: A prospective, randomized, controlled trial. J Clin Anesth 2019;54:61-5.  Back to cited text no. 7
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Sinha C, Kumar A, Kumar A, Prasad C, Singh PK, Priya D. Pectoral nerve versus erector spinae block for breast surgeries: A randomised controlled trial. Indian J Anaesth 2019;63:617-22.  Back to cited text no. 9
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Kaya M, Oğuz G, Şenel G, Kadıoğulları N. Postoperative analgesia after modified radical mastectomy: The efficacy of interscalene brachial plexus block. J Anesth 2013;27:862-7.  Back to cited text no. 12
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Siddeshwara A, Singariya G, Kamal M, Kumari K, Seervi S, Kumar R. Comparison of efficacy of ultrasound-guided pectoral nerve block versus thoracic paravertebral block using levobupivacaine and dexamethasone for postoperative analgesia after modified radical mastectomy: A randomized controlled trial. Saudi J Anaesth 2019;13:325-31.  Back to cited text no. 15
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