Serratus anterior plane block reduces the prevalence of chronic postsurgical pain after modified radical mastectomy: A randomized controlled trial

Ultrasound-guided fascial plane blocks in chronic pain: a narrative review

BACKGROUND

Recent studies have unveiled the intricate and distinctive nature of fascia, no longer regarding it solely as a muscle container. Recent research highlights its complex innervation and structure, signifying its significance in chronic pain pathways.

METHODS

We conducted a systematic literature search (updated on February 2024) to evaluate the role of fascial plane blocks in chronic pain treatment. All article types (randomized clinical trials, prospective and retrospective observational studies along with case reports and case series) were deemed eligible for inclusion if they referenced "fascial plane blocks" for the control of chronic pain conditions (persistent post-surgical, neuropathic, musculoskeletal-myofascial and cancer-related) and were published between 2010 and February 2024.

RESULTS

The search revealed an increasing evidence in the literature for the implementation of fascial blocks in chronic pain management, although still heavily limited to case reports or series.

CONCLUSION

With the integration of ultrasound technology and a deeper understanding of their mechanisms of action, the fascial plane blocks continue to broaden their application also in chronic pain management, as a part of a multimodal strategy or as an alternative to conventional drugs or opioids.

Perioperative Regional Anesthesia on Persistent Opioid Use and Chronic Pain after Noncardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Whether regional anesthesia impacts the development of chronic postsurgical pain is currently debateable, and few studies have evaluated an effect on prolonged opioid use. We sought to systematically review the effect of regional anesthesia for adults undergoing noncardiac elective surgery on these outcomes.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and CINHAL for randomized controlled trials (from inception to April 2022) of adult patients undergoing elective noncardiac surgeries that evaluated any regional technique and included one of our primary outcomes: (1) prolonged opioid use after surgery (continued opioid use ≥2 months postsurgery) and (2) chronic postsurgical pain (pain ≥3 months postsurgery). We conducted a random-effects meta-analysis on the specified outcomes and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to rate the quality of evidence.

RESULTS

Thirty-seven studies were included in the review. Pooled estimates indicated that regional anesthesia had a significant effect on reducing prolonged opioid use (relative risk [RR] 0.48, 95% CI, 0.24-0.96, P = .04, I 2 0%, 5 trials, n = 348 patients, GRADE low quality). Pooled estimates for chronic pain also indicated a significant effect favoring regional anesthesia at 3 (RR, 0.74, 95% CI, 0.59-0.93, P = .01, I 2 77%, 15 trials, n = 1489 patients, GRADE moderate quality) and 6 months (RR, 0.72, 95% CI, 0.61-0.85, P < .001, I 2 54%, 19 trials, n = 3457 patients, GRADE moderate quality) after surgery. No effect was found in the pooled analysis at 12 months postsurgery (RR, 0.44, 95% CI, 0.16-1.17, P = .10).

CONCLUSIONS

The results of this study suggest that regional anesthesia potentially reduces chronic postsurgical pain up to 6 months after surgery. Our findings also suggest a potential decrease in the development of persistent opioid use.

Prevention of Post-Mastectomy Pain Syndrome: A Review of Recent Literature on Perioperative Interventions

PURPOSE OF REVIEW

Up to 60% of breast cancer patients continue to experience pain three months or more after surgery, with 15 to 25% reporting moderate to severe pain. Post-mastectomy pain syndrome (PMPS) places a high burden on patients. We reviewed recent studies on perioperative interventions to prevent PMPS incidence and severity.

RECENT FINDINGS

Recent studies on pharmacologic and regional anesthetic interventions were reviewed. Only nine of the twenty-three studies included reported a significant improvement in PMPS incidence and/or severity, sometimes with mixed results for similar interventions. Evidence for prevention of PMPS is mixed. Further investigation of impact of variations in dosing is warranted. In addition, promising newer interventions for prevention of PMPS such as cryoneurolysis of intercostal nerves and stellate ganglion block need confirmatory studies.

The Impact of Preoperative Combined Pectoserratus and/or Interpectoral Plane (Pectoralis Type II) Blocks on Opioid Consumption, Pain, and Overall Benefit of Analgesia in Patients Undergoing Minimally Invasive Cardiac Surgery: A Prospective, Randomized, Controlled, and Triple-blinded Trial

OBJECTIVE

Acute postoperative pain remains a major obstacle in minimally invasive cardiac surgery (MICS). Evidence of the analgesic benefit of chest wall blocks is limited. This study was designed to assess the influence of combined pectoserratus plane block plus interpectoral plane block (PSPB + IPPB) on postoperative pain and the overall benefit of analgesia compared with placebo.

DESIGN

A prospective, randomized, triple-blinded study was conducted.

SETTING

The setting was the operating room and intensive care unit of a university hospital.

PARTICIPANTS

A total of 60 patients undergoing elective right-lateral MICS were enrolled.

INTERVENTIONS

Patients were randomly assigned to preoperative PSPB + IPPB with 30 mL of ropivacaine 0.5% or saline.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was total intravenous morphine milligram equivalents administered in the first 24 hours after extubation. Secondary endpoints included the Overall Benefit of Analgesia Score (OBAS) at 24 hours after extubation and repeated Visual Analogue Scale (VAS). Values for intravenous morphine milligram equivalents administered in the first 24 hours after extubation were significantly lower (median [interquartile range]: 4.2 mg [2.1 - 7.9] v 8.3 mg [4.2 - 15.7], p = 0.025; mean difference: 6.7 mg [0.94 - 12 mg], p = 0.024, Cohen's d: 0.64 [0.09 - 1.2]). Moreover, OBAS at 24 hours and VAS after extubation were significantly lower (4.0 [3.0 - 6.0] v 7.0 [3.0 - 9.0], p = 0.043; 0.0 cm [0.0 - 2.0] v 1.5 cm [0.3 - 3.0], p = 0.030). VAS did not differ between groups at later points.

CONCLUSIONS

Preoperative PSPB + IPPB reduced 24-hour postextubation opioid consumption, pain at extubation, and OBAS. Given its low risk and expedient placement, it could be a helpful addition to MICS protocols. Future studies should evaluate these findings in multicenter settings and further elucidate the optimal timing of block placement.

The effect of different nerve block strategies on the quality of post-operative recovery in breast cancer patients: A randomized controlled study

OBJECTIVE

To compare the effects of three types of ultrasound-guided nerve blocks on post-operative recovery quality in patients undergoing modified radical mastectomy for unilateral breast cancer.

METHODS

In this randomized double-blinded trial (chictr.org.cn, ChiCTR2200059428), 150 female patients were equally assigned to S group (serratus anterior plane block, SAPB) group, P group (paravertebral block, PVB) or ST group (serratus anterior combined with transverse thoracic muscle plane blocks, SA-TTMPB). The primary outcome was QoR-15 at five time points after surgery. Secondary outcomes were pain scores, time of first rescue analgesic and chronic pain incidence at 3 months.

RESULTS

The QoR-15 total score of S group at 24 h, 48 h, 72 h and 7 days post-surgery was significantly lower in groups P and ST, while there was no significant difference between groups P and ST (S vs. P vs. ST, 100.29 ± 6.20 vs. 108.51 ± 7.46 vs. 106.46 ± 6.95; 105.59 ± 6.18 vs. 113.06 ± 7.44 vs. 111.22 ± 6.56; 112.51 ± 6.32 vs. 119.88 ± 6.44 vs. 117.62 ± 6.09; 123.00 ± 5.78 vs. 128.86 ± 5.96 vs. 126.92 ± 5.72, p < 0.05). The dynamic and rest NRS scores at 6 and 12 h post-surgery were significantly higher in group S than in groups P and ST.

CONCLUSION

Serratus anterior plane block combined with transverse thoracic muscle plane block and paravertebral block both have better effects than serratus anterior plane block alone in improving patients' early post-operative recovery quality, and also have an advantage in improving early post-operative pain.

CLINICAL TRIAL REGISTRATION

chictr.org.cn (ChiCTR2200059428).

DATE OF REGISTRATION

29 April 2022.

SIGNIFICANCE

Serratus anterior combined with transverse thoracic muscle plane block may be a safer, easier, and equally effective nerve block strategy than paravertebral block in patients undergoing modified radical mastectomy for unilateral breast cancer.

Comparison of Performance Characteristics and Efficacy of Bilateral Thoracic Paravertebral Blocks in Obese and Non-Obese Patients Undergoing Reduction Mammaplasty Surgery: A Historical Cohort Study

BACKGROUND

Although ultrasound (US)-guided regional anesthesia techniques are advantageous in the management of obese patients; the procedures can still be associated with technical difficulties and greater failure rates. The aim of this study is to compare the performance properties and analgesic efficacy of US-guided bilateral thoracic paravertebral blocks (TPVBs) in obese and non-obese patients.

METHODS

Data of 82 patients, who underwent bilateral reduction mammaplasty under general anesthesia with adjunctive TPVB analgesia between December 2016 and February 2020, were reviewed. Patients were allocated into two groups with respect to their BMI scores (Group NO: BMI < 30 and Group O: BMI ≥ 30). Demographics, ideal US visualization time, total bilateral TPVB procedure time, needle tip visualization and performance difficulties, number of needle maneuvers, surgical, anesthetic and analgesic follow-up parameters, incidence of postoperative nausea and vomiting (PONV), sleep duration, length of postanesthesia care unit (PACU) and hospital stay, and patient/surgeon satisfaction scores were investigated.

RESULTS

Seventy-nine patients' data were complete. Ideal US visualization and total TPVB performance times were shorter, number of needle maneuvers were fewer and length of PACU stay was shorter in Group NO (p < 0.05). Postoperative pain scores were generally similar within first 24 h (p > 0.05). Time to postoperative pain, total analgesic requirements, incidence of PONV, sleep duration, length of hospital stay were comparable (p > 0.05). Satisfaction was slightly higher in Group NO (p < 0.05).

CONCLUSIONS

US-guided TPVB performances in obese patients might be more challenging and take longer time. However, it is still successful providing good acute pain control in patients undergoing reduction mammaplasty surgeries.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

TRIAL REGISTRATION

NCT04596787.

Research Progress on Serratus Anterior Plane Block in Breast Surgery: A Narrative Review

Breast surgery, especially radical mastectomy, is often accompanied by moderate to severe acute pain, which significantly reduces postoperative quality of life. Effective pain management can accelerate patient recovery. Serratus anterior plane block (SAPB) is a new type of fascial plane block technique, which can better target the nerve network innervating the chest wall and breast and provide good analgesia in the anterolateral chest wall. Current clinical research evidence indicates that SAPB has significant benefits in breast surgery. Further research avenues for this technology include optimal local anesthetic dosing strategy, the type of SAPB which is more suitable for breast surgery, comparison of SAPB and pectoral nerve block II (PECS II) in breast surgery, and high-quality randomized controlled study with outcomes of chronic pain or cancer prognosis.

One year follow-up on a randomized study investigating serratus anterior muscle and pectoral nerves type I block to reduced neuropathic pain descriptors after mastectomy

Breast cancer is the second most common diagnosed type of cancer in women. Chronic neuropathic pain after mastectomy occurs frequently and is a serious health problem. In our previous single-center, prospective, randomized controlled clinical study, we demonstrated that the combination of serratus anterior plane block (SAM) and pectoral nerve block type I (PECS I) with general anesthesia reduced acute postoperative pain. The present report describes a prospective follow-up study of this published study to investigate the development of chronic neuropathic pain 12 months after mastectomy by comparing the use of general anesthesia alone and general anesthesia with SAM + PECS I. Additionally, the use of analgesic medication, quality of life, depressive symptoms, and possible correlations between plasma levels of interleukin (IL)-1 beta, IL-6, and IL-10 collected before and 24 h after surgery as predictors of pain and depression were evaluated. The results showed that the use of SAM + PECS I with general anesthesia reduced numbness, hypoesthesia to touch, the incidence of patients with chronic pain in other body regions and depressive symptoms, however, did not significantly reduce the incidence of chronic neuropathic pain after mastectomy. Additionally, there was no difference in the consumption of analgesic medication and quality of life. Furthermore, no correlation was observed between IL-1 beta, IL-6, and IL-10 levels and pain and depression. The combination of general anesthesia with SAM + PECS I reduced the occurrence of specific neuropathic pain descriptors and depressive symptoms. These results could promote the use of SAM + PECS I blocks for the prevention of specific neuropathic pain symptoms after mastectomy.Registration of clinical trial: The Research Ethics Board of the Hospital Sirio-Libanes/Brazil approved the study (CAAE 48721715.0.0000.5461). This study is registered at Registro Brasileiro de Ensaios Clinicos (ReBEC), and ClinicalTrials.gov, Identifier: NCT02647385.

Association of peripheral nerve blocks with patient-reported quality of recovery in female patients receiving breast cancer surgery: a systematic review and meta-analysis of randomized controlled studies

PURPOSE

This systematic review and meta-analysis investigated the impact of peripheral nerve blocks (PNBs) on patient-reported quality of recovery (QoR) following breast cancer surgery.

SOURCE

Medline, EMBASE, Cochrane Library, and Google scholar databases were searched for randomized controlled trials (RCTs) comparing the QoR with or without PNBs in patients receiving breast cancer surgery from inception to September 2021. Using a random effects model, the primary outcome was total scores of postoperative QoR scales (i.e., QoR-15 and QoR-40).

PRINCIPAL FINDINGS

Eight RCTs (QoR-15, n = 4; QoR-40, n = 4) involving 653 patients published from 2018 to 2021 were included. For the QoR-40 scale, pooled results revealed a significantly higher total score (mean difference [MD], 12.8 [8.2%]; 95% confidence interval [CI], 10.6 to 14.9; I² = 59%; five RCTs; n = 251) and scores on all subscales, except psychological support, in the PNB group than in controls at 24 hr after surgery. For the QoR-15 scale, pooled results also showed favorable QoR (MD, 7.7 [5.2%]; 95% CI, 4.9 to 10.5; I² = 75%; four RCTs; n = 402) in the PNB group at 24 hr after surgery. Sensitivity analysis showed no effect on the QoR-40 score and the difference in total QoR-15 score was no longer significant when a single trial was omitted. The use of PNBs was associated with a significantly lower opioid consumption and risk of postoperative nausea and vomiting without significant differences in the pain score between the two groups.

CONCLUSION

Our results verified the efficacy of PNBs for enhancing postoperative QoR using two validated patient-reported tools in female patients receiving breast cancer surgery under general anesthesia.

STUDY REGISTRATION

PROSPERO (CRD42021272575); first submitted 9 August 2021.

Extending Perioperative Analgesia with Ultrasound-Guided, Percutaneous Cryoneurolysis, and Peripheral Nerve Stimulation (Neuromodulation)

The use of regional anesthesia is key to a successful approach to improving postoperative analgesia, which involves local anesthetic deposition either around peripheral nerves or within a fascial plane. Unfortunately, the realistic duration even with continuous peripheral nerve blocks usually does not match the duration of surgical pain, comprising a major limitation. Here, the use of 2 interventional modalities-ultrasound-guided percutaneous cryoneurolysis and peripheral nerve stimulation-is discussed, both of which may be used to treat acute and subacute pain and may therefore have a positive impact on the incidence and severity of chronic pain development.

Postoperative recovery: how and when is it assessed: a scoping review

BACKGROUND

There is no consensus about the type of instrument with which to assess postoperative recovery or the time points when assessments are most appropriate. It is also unclear whether instruments measure the four dimensions of postoperative recovery, that is physical, psychological, social, and habitual recovery. This scoping review had three objectives: (1) to identify and describe instruments used in clinical trials to assess postoperative recovery; (2) to determine how, when, and the number of times postoperative recovery was measured; and (3) to explore whether the four dimensions of postoperative recovery are represented in the identified instruments.

METHODS

A literature search was conducted in CINAHL, MEDLINE, and Web of Science. The search terms were related to three search strands: postoperative recovery, instrument, and clinical trials. The limits were English language and publication January 2010 to November 2021. In total, 5015 studies were identified.

RESULTS

A total of 198 studies were included in the results. We identified 20 instruments measuring postoperative recovery. Different versions of Quality of Recovery represented 81.8% of the included instruments. Postoperative recovery was often assessed at one time point (47.2%) and most often on postoperative day 1 (81.5%). Thirteen instruments had items covering all four dimensions of postoperative recovery.

CONCLUSIONS

Assessing recovery is important to evaluate and improve perioperative care. We emphasise the importance of choosing the right instrument for the concept studied and, if postoperative recovery is of interest, of assessing more than once. Ideally, instruments should include all four dimensions to cover the whole recovery process.

Enhanced Recovery after Surgery (ERAS) in DIEP-Flap Breast Reconstructions-A Comparison of Two Reconstructive Centers with and without ERAS-Protocol

Enhanced recovery after surgery (ERAS) is established for autologous breast reconstruction. ERAS leads to a shortened hospital stay and improved outcome after elective surgery. In this retrospective, two-center case−control study, we compared two different treatment regimens for patients undergoing a DIEP-flap breast reconstruction from two centers, one with an established ERAS protocol and one without. All patients with DIEP breast reconstructions over the period of 12 months were included. The primary outcome measure was the length of hospital stay (LOS) in days. A total of 79 patients with 95 DIEP-flaps were analyzed. In group A (ERAS) 42 patients were operated with DIEP flaps, in group B (non-ERAS) 37 patients. LOS was significantly reduced in the ERAS group (4.51 days) compared to the non-ERAS group (6.32; p < 0.001). Multivariate analysis showed that, in group A, LOS is significantly affected by surgery duration. BMI in the ERAS group had no effect on LOS. In group B a higher BMI resulted in a significantly higher LOS. In multivariate analysis, neither age nor type for surgery (primary/secondary/after neoadjuvant therapy, etc.) affected LOS. In both groups, no systemic or flap-related complications were observed. Comparing two reconstructive centers with and without implemented ERAS, ERAS led to a significantly decreased LOS for all patients. ERAS implementation does not result in an increased complication rate or flap loss. Postoperative pain can be well managed with basic analgesia using NSAID when intraoperative blocks are applied. The reduced use of opioids was well tolerated. With implementation of ERAS the recovery experience can be enhanced making autologous breast reconstructions more available and attractive for various patients.