Ultrasound-Guided Serratus Plane Block for Treatment of Postmastectomy Pain Syndromes in Breast Cancer Patients: A Case Series

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.

Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome

INTRODUCTION

Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option.

RESULTS

This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome.

CONCLUSION

This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

A Review on the Management of Peripheral Neuropathic Pain Following Breast Cancer

Postmastectomy pain syndrome (PMPS) is a common and debilitating form of postsurgical pain with neuropathic characteristics, presenting as burning, stabbing, or pulling sensations after mastectomy, lumpectomy, or other breast procedures. With a prevalence of 31%, the risk factors for PMPS include younger age, psychosocial factors, radiotherapy, axillary lymph node dissection, and a history of chronic pain. This review evaluates the pharmacological and surgical options for managing PMPS. Pharmacological treatment options include antidepressants, gabapentinoids, levetiracetam, capsaicin, and topical lidocaine. Procedural and surgical options include fat grafting, nerve blocks, radiofrequency ablation, peripheral nerve surgery, serratus plane block, and botulinum toxin injections. Despite the variety of therapeutic options available for patients, further randomized trials are required to conclude whether these treatments reduce the intensity of neuropathic pain in patients with PMPS. In particular, comparative studies and the inclusion of patients across a range of pain intensities will be essential to developing a treatment algorithm for PMPS. In conclusion, current management for these patients should be tailored to their individual requirements.

Interventional Treatment Options for Post-mastectomy Pain

PURPOSE OF REVIEW

Breast cancer is currently the most prevalent cancer diagnosed globally, and there is a significant gap in the availability of effective first-line treatment options. In addition to a cancer diagnosis, breast cancer patients face additional pain and morbidity after treatment. Radiation fibrosis, muscle spasms, muscle pain, neuropathy, and limited shoulder function are all potential side effects of breast cancer treatment and breast reconstruction. Post-mastectomy pain syndrome affects 25-60% of people after breast surgery. The current review moves forward to explain interventional pain management options that can be used to supplement conservative measures (physical therapy, medication, topical ointments) to help these patients.

RECENT FINDINGS

There are many new interventional procedures to treat chest wall pain, neuropathic pain, and spasticity after breast surgery. Currently, the most commonly performed procedures are botulinum toxin injections, serratus anterior plane blocks, intercostobrachial nerve blocks, thoracic paravertebral nerve blocks, pectoralis nerve blocks, and erector spinae nerve blocks. Utilizing one of these interventional procedures, along with physical therapy and pharmacologic interventions, can help manage post-mastectomy pain syndrome in the millions of breast cancer patients diagnosed and treated every year.

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.

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain

PURPOSE OF REVIEW

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies.

RECENT FINDINGS

In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

Incidence, risk factors, prevention and treatment of postmastectomy pain syndrome in breast cancer: A multicenter study

BACKGROUND

Postmastectomy pain syndrome (PMPS) is a common postoperative condition after breast cancer surgery.

PURPOSE

The aim of this study was to investigate the incidence rate and risk factors of PMPS, and to propose prevention and treatment methods.

METHODS

The study included 1790 postoperative breast cancer patients from three hospitals from 2017 to 2021, of which 302 (13.0%) patients with PMPS were included in the study.

RESULTS

Age, breast surgery type, axillary surgery type and radiotherapy are the risk factors of PMPS. Age, radiotherapy and chemotherapy affect the pain degree of PMPS during movement.

CONCLUSIONS

For breast cancer patients with high risk factors, pain should be actively prevented during perioperative period. Oral pharmacological agents, multidisciplinary combination therapy, local anesthetics and regional anesthesia are the most common treatment of PMPS.

AMAZONE: prevention of persistent pain after breast cancer treatment by online cognitive behavioral therapy-study protocol of a randomized controlled multicenter trial

Background

Surviving breast cancer does not necessarily mean complete recovery to a premorbid state of health. Among the multiple psychological and somatic symptoms that reduce the quality of life of breast cancer survivors, persistent pain after breast cancer treatment (PPBCT) with a prevalence of 15–65% is probably the most invalidating. Once chronic, PPBCT is difficult to treat and requires an individualized multidisciplinary approach. In the past decades, several somatic and psychological risk factors for PPBCT have been identified. Studies aiming to prevent PPBCT by reducing perioperative pain intensity have not yet shown a significant reduction of PPBCT prevalence. Only few studies have been performed to modify psychological distress around breast cancer surgery. The AMAZONE study aims to investigate the effect of online cognitive behavioral therapy (e-CBT) on the prevalence of PPBCT.

Methods

The AMAZONE study is a multicenter randomized controlled trial, with an additional control arm. Patients (n=138) scheduled for unilateral breast cancer surgery scoring high for surgical or cancer-related fears, general anxiety or pain catastrophizing are randomized to receive either five sessions of e-CBT or online education consisting of information about surgery and a healthy lifestyle (EDU). The first session is scheduled before surgery. In addition to the online sessions, patients have three online appointments with a psychotherapist. Patients with low anxiety or catastrophizing scores (n=322) receive treatment as usual (TAU, additional control arm).

Primary endpoint is PPBCT prevalence 6 months after surgery.

Secondary endpoints are PPBCT intensity, the intensity of acute postoperative pain during the first week after surgery, cessation of postoperative opioid use, PPBCT prevalence at 12 months, pain interference, the sensitivity of the nociceptive and non-nociceptive somatosensory system as measured by quantitative sensory testing (QST), the efficiency of endogenous pain modulation assessed by conditioned pain modulation (CPM) and quality of life, anxiety, depression, catastrophizing, and fear of recurrence until 12 months post-surgery.

Discussion

With perioperative e-CBT targeting preoperative anxiety and pain catastrophizing, we expect to reduce the prevalence and intensity of PPBCT. By means of QST and CPM, we aim to unravel underlying pathophysiological mechanisms. The online application facilitates accessibility and feasibility in a for breast cancer patients emotionally and physically burdened time period.

Trial registration

NTR NL9132, registered December 16 2020.

Effects of Nalbuphine Combined with Anterior Serratus Plane Block in Elderly Patients Undergoing Thoracoscopic Surgery

Postoperative pain in elderly patients with lung cancer after thoracoscopic surgery is still an important factor affecting the prognosis of patients. In this study, 200 elderly patients with lung cancer who were positive and planned to undergo video-assisted thoracoscopic surgery were randomly divided into four groups: control group, SAPB (serratus anterior plane block) group, Nalbuphine group and Nalbuphine + SAPB group. The effects of drugs and nerve block on the perioperative indexes of elderly patients were observed. The results showed that ① The VAS and SAS scores of postoperative analgesia in the Nalbuphine + SAPB group were lower than those in the single group and the control group. ② The postoperative spontaneous respiratory recovery time, extubation time, resuscitation room stay time, extubation cough, restlessness and respiratory depression in the Nalbuphine + SAPB group were lower than those in the single group and the control group. ③ The heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and blood oxygen saturation (SpO2) of patients in Nalbuphine + SAPB group before induction, T2 after intubation, T3 before skin incision, T4 after skin incision, T5 after chest closure and T6 after extubation were lower than those in single group and control group. Therefore, this study concluded that Nabufine combined with SAPB can make the vital signs of intraoperative patients more stable, which is worthy of clinical promotion.

The Role of Serratus Anterior Plane Block During in Video-Assisted Thoracoscopic Surgery

Although thoracoscopy has characteristics such as a small surgical incision and low stress response, post-surgical pain after a thoracoscopic operation is no less than that after a thoracotomy. Moreover, poor post-surgical pain management is likely to cause an increased incidence of postoperative pulmonary complications (PPCs) and chronic post-surgical pain. The serratus anterior plane block (SAPB) is a regional anesthesia method whereby local anesthetics (LAs) are injected into the serratus anterior space to block the lateral cutaneous branch of the intercostal nerve, long thoracic nerve, and dorsal thoracic nerve. The block range of the SAPB covers the incisions of video-assisted thoracoscopic surgery (VATS) and the site of the chest tube, which are often located in the antero-lateral chest wall. Therefore, the SAPB can achieve effective analgesia in VATS. For example, 0.125% to 0.25% levobupivacaine (20-25 ml) is widely used for thoracic surgery, which can achieve effective analgesia and avoid adverse reactions. Moreover, it has advantages compared with thoracic segmental epidural block (TEA) and thoracic paravertebral block (TPVB), such as simple operation, increased safety, fewer complications, and hemodynamic stability. In addition, adequate analgesia is helpful for pulmonary function recovery and reduces the incidence of PPCs. This article introduces the anatomical mechanism of the SAPB, diverse operation approaches, how to choose drugs and adjuvants, and the resulting impacted area range. It summarizes the advantages and disadvantages of the SAPB compared with other analgesic methods and posits that the SAPB is beneficial to the recovery of postoperative lung function, which provides more options for postoperative analgesia after VATS.

Ultrasound-guided superficial serratus plane block for persistent post-mastectomy pain: four case reports

BACKGROUND

Persistent post-mastectomy pain (PPMP) is common after surgery. Although multiple modalities have been used to treat this type of pain, including medications, physical therapy, exercise interventions, cognitive-behavioral psychology, psychosocial interventions, and interventional approaches, managing PPMP may be still a challenge for breast cancer survivors. Currently, serratus plane block (SPB) as a novel regional anesthetic technique shows promising results for controlling chronic pain.

METHODS

We report four cases of patients with PPMP that were treated using superficial serratus plane block (SSPB) at our clinic. A retrospective review of effect of pain relief was collected through postprocedure interviews.

RESULTS

We found that two of our patients were successfully treated with SSPB for pain after treatment for breast cancer. The third patient had an intercostobrachial nerve block that produced incomplete pain relief but had adequate pain relief with a SSPB. However, the fourth patient reported no pain relief after SSPB.

CONCLUSION

These cases illustrate that the patients with PPMP could benefit from SSPB. Particularly, we find patients with a subjective sense of "tightness" relating to reconstructive surgeries may be a good candidate for SSPB. Further studies are warranted to evaluate this block for PPMP, as it is low risk and relatively simple to perform.

Acute pain after serratus anterior plane or thoracic paravertebral blocks for video-assisted thoracoscopic surgery: A noninferiority randomised trial

BACKGROUND

Serratus anterior plane blocks (SAPBs) and thoracic paravertebral blocks (TPVBs) can both be used for video-assisted thoracic surgery. However, it remains unknown whether the analgesic efficacy of a SAPB is comparable to that of a TPVB.

OBJECTIVE

We tested the primary hypothesis that SAPBs provide noninferior analgesia compared with TPVBs for video-assisted thoracic surgery.

DESIGN

A noninferiority randomised trial.

SETTING

Shanghai Chest Hospital, between August 2018 and November 2018.

PATIENTS

Ninety patients scheduled for video-assisted thoracic lobectomy or segmentectomy were randomised. Patients were excluded if they were unable to perform the visual analogue pain scale, or surgery was converted to thoracotomy.

INTERVENTIONS

Blocks were performed after induction of general anaesthesia. The three groups were paravertebral blocks (n = 30); serratus anterior plane blocks (n = 29); and general anaesthesia alone (n = 30).

PRIMARY OUTCOME MEASURES

Visual analogue pain scores (0 to 10 cm) at rest and while coughing, and Prince-Henry pain scores (0 to 4 points) were used to assess postoperative analgesia at 2, 24 and 48 h after surgery. We assessed the noninferiority of SAPBs with TPVBs on all three primary pain outcomes using a delta of 1 cm or one point as appropriate.

RESULTS

The mean difference (95% confidence intervals) in visual analogue scores between the SAPBs and TPVBs was -0.04 (-0.10 to 0.03) cm at rest, -0.22 (-0.43 to -0.01) cm during coughing and -0.10 (-0.25 to 0.05) for Prince-Henry pain scores. As the upper limit of the confidence intervals were less than 1 (all P < 0.001), noninferiority was claimed for all three primary outcomes. Compared with general anaesthesia alone, the VAS scores at rest and while coughing, and the Prince-Henry pain scores for the two blocks were significantly lower during the initial 2 h after surgery.

CONCLUSIONS

Serratus anterior plane blocks are quicker and easier to perform than paravertebral blocks and provide comparable analgesia in patients having video-assisted thoracic surgery. Both blocks provided analgesia that was superior to general anaesthesia alone during the initial 2 h after surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifier: ChiCTR1800017671.

The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient

BACKGROUND

Breast cancer is the most commonly occurring cancer among women. Among its treatment sequelae is chronic neuropathic pain after breast surgery (CNPBS). Pain management is difficult and classicaly consists in a pharmacological approach, however recent studies have advocated the use of locoregional techniques as adjuvants. Serratus plane block (SPB) has recently emerged as a potential tool for the control of CNPBS. This study aims to evaluate the efficacy and potencial role of the ultrasound-guided SPB on CNPBS.

METHODS

A retrospective analysis was performed on 30 patients with CNPBS refractory to drug therapy, who underwent SPB between 2017-2019. The following parameters were analyzed: basal pain, pain at 24 h, 1 week and at 1 month. The Mann-Whitney test was applied. Statistical significance was considered at the level of p < 0.05. All statistical analysis was performed with SPSS 20.

RESULTS

3 patients were excluded. At 24 h, we report pain improvement (at least 30% reduction on basal pain score) on 20 patients and after 1 week on 12. At 1 month after, 22 patients had improved, from these: 11 improved with no therapeutic adjustment; 11 patients improved with therapeutic adjustment (8 in gabapentinoid monotherapy, 3 with introduction of polytherapy). 5 patients didn't improve.

CONCLUSION

Our study demonstrated SPB as a valid alternative for CNPBS management when pharmacologic therapy has been proven insufficient, with no side effects reported. Randomized studies are needed to assess the magnitude of SPB on CNPBS and to identify the patients who benefit the most from SPB.

An Interventional Pain Algorithm for the Treatment of Postmastectomy Pain Syndrome: A Single-Center Retrospective Review

OBJECTIVE

Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS.

DESIGN

A retrospective study.

SETTING

An academic cancer hospital.

SUBJECTS

Adult females with PMPS diagnosis.

METHODS

We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks.

RESULTS

Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47).

CONCLUSIONS

Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.

Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment

Background:

Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete.

Objectives:

This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research.

Methods:

A PubMed search with the relevant keywords was done for articles published in the last 10 years.

Results:

The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy.

Conclusions:

PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient

BACKGROUND

Breast cancer is the most commonly occurring cancer among women. Among its treatment sequelae is chronic neuropathic pain after breast surgery (CNPBS). Pain management is difficult and classicaly consists in a pharmacological approach, however recent studies have advocated the use of locoregional techniques as adjuvants. Serratus plane block (SPB) has recently emerged as a potential tool for the control of CNPBS. This study aims to evaluate the efficacy and potencial role of the ultrasound-guided SPB on CNPBS.

METHODS

A retrospective analysis was performed on 30 patients with CNPBS refractory to drug therapy, who underwent SPB between 2017-2019. The following parameters were analyzed: basal pain, pain at 24 hours, 1 week and at 1 month. The Mann-Whitney test was applied. Statistical significance was considered at the level of p < 0.05. All statistical analysis was performed with SPSS 20.

RESULTS

3 patients were excluded. At 24 hours, we report pain improvement (at least 30% reduction on basal pain score) on 20 patients and after 1 week on 12. At 1 month after, 22 patients had improved, from these: 11 improved with no therapeutic adjustment; 11 patients improved with therapeutic adjustment (8 in gabapentinoid monotherapy, 3 with introduction of polytherapy). 5 patients didn't improve. CONCLUSIóN: Our study demonstrated SPB as a valid alternative for CNPBS management when pharmacologic therapy has been proven insufficient, with no side effects reported. Randomized studies are needed to assess the magnitude of SPB on CNPBS and to identify the patients who benefit the most from SPB.

Erector Spinae Plane Block for the Treatment of Post Mastectomy Pain Syndrome

Postmastectomy pain syndrome (PMPS) is a common complication after breast cancer surgery and is often challenging to manage. Treatment options include medication management, physical therapy, and interventional procedures. The erector spinae plane block (ESPB) is a regional technique proven to help both acute postoperative analgesia and chronic neuropathic pain conditions. This block is becoming more popular in the chronic pain setting for neuropathic thoracic pain conditions. We describe the utilization of the ESP block for significant neuropathic breast pain after total mastectomy. Our case demonstrates the utility of this block for women suffering from severe PMPS.

Ultrasound-guided serratus plane block as an effective adjunct to systemic analgesia in four dogs undergoing thoracotomy

Background

Ultrasound-guided serratus plane block (UGSPB) is a loco-regional anesthesia technique designed to desensitize the thoracic wall. It is a compartmental block, where local anesthetic is delivered to the fascial, inter-muscular plane. Since its original description in humans, two cadaveric veterinary studies, redefining the technique, have been performed. Taking into account the successful use of the UGSPB in human medicine, we employed the veterinary description to perform this block in four dogs undergoing thoracotomy. The case series described below aims to share our experience of the clinical application of this new loco-regional anesthesia technique in dogs.

Case Description

Four dogs, with different underlying medical conditions underwent cranial lateral thoracotomy. The analgesia protocol consisted of intravenous methadone and UGSPB performed half an hour before the beginning of the procedure. The cardiovascular system was closely monitored for any signs of nociception. Fentanyl, although available as rescue analgesia, was not required in any of these cases as no signs of nociception were present.

Conclusion

To the authors' knowledge, this is the first veterinary clinical report using the UGSPB as a part of a multimodal analgesia protocol in dogs undergoing thoracotomy. Based on this observation, UGSPB has the potential to prevent nociception and reduce the intraoperative opioid requirements in dogs undergoing thoracotomy. A prospective randomized clinical trial is required to confirm these promising results.

Ultrasound-Guided Serratus Anterior Plane Block for Rib Fracture-Associated Pain Management in Emergency Department

CONTEXT

Traumatic Rib fractures are common and painful conditions to present in the emergency department. Ultrasound-guided serratus anterior plane block (SAPB) is a newer technique which is being used for managing postthoracotomy, thoracoscopic surgery, or post mastectomy pain by the anesthetists. However, we have recently started utilizing this novel technique in our emergency department for rib fracture patients with severe pain.

SETTINGS AND METHODS

We present a case series of 10 patients of multiple rib fractures (MFRs) with persistent Defense and Veterans Pain Rating Scale 7 or more even after intravenous analgesics where this block was applied by trained emergency physicians (EP).

RESULTS

Following SAPB median (± IQR) pain score reduction was 5 (±4) at 30 min and 7.5 (±2) after 60 min of administering the block. There were no incidences of block failure or block-related complications in our series.

CONCLUSIONS

Ultrasound-guided SAPB can be used safely by trained EP in the emergency department to relieve acute severe analgesic-resistant pain in MFR patients.

Chronic Pain Following Cosmetic Breast Surgery: A Comprehensive Review

INTRODUCTION

Cosmetic breast surgery is commonly performed in the United States; 520,000 procedures of the total 1.8 million cosmetic surgical procedures performed in 2018 were breast related. Postoperative chronic pain, defined as lasting 3 or more months, has been reported in a wide variety of breast surgical procedures including breast augmentation, reduction mammaplasty, mastectomy, and mastectomy with reconstruction. Patient characteristics associated with the development of postoperative chronic pain following cosmetic breast surgery include a younger age, larger BMI, smaller height, postoperative hyperesthesia, and elevated baseline depression, anxiety, and catastrophizing scores. The anatomical distribution of chronic pain following breast augmentation procedures is dependent upon incision site placement; pectoral and intercostal nerves have been implicated. The purpose of this review is to provide an update on the current literature addressing the pathophysiology, clinical presentation, and treatment of patients presenting with chronic postoperative pain following cosmetic breast surgery.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "cosmetic surgery", "breast surgery", "postoperative pain", and "chronic pain".

RESULTS

Cosmetic breast surgery can have a similar presentation as post-mastectomy pain syndrome and thus have overlapping diagnostic criteria. Seven domains are identified for a diagnosis of PBSPS: Pain after breast surgery, neuropathic in nature, at least a moderate intensity of pain, as defined as within the middle one-third of the selected pain scale, pain for at least 6 months, symptoms occurring for 12 or more hours a day for a minimum of 4 days each week, pain in at least one of the following sites: breast, chest wall, axilla, or arm on the affected side, pain exacerbated by movement. Patient risk factors and surgical risk factors may influence the development of chronic post-cosmetic surgery breast pain. Improved perioperative analgesia including preoperative regional nerve anesthesia and postoperative catheter infusion have been shown to improve chronic postoperative pain outcomes.

CONCLUSIONS

The present review provides a discussion of clinical presentation, pathophysiology, and treatment and preventative strategies for chronic breast pain following cosmetic surgery. This review provides evidence from multiple randomized controlled trials (RCTs) and systematic reviews of efficacy and effectiveness. While chronic postoperative breast pain remains challenging to treat, various preventative strategies have been described to improve postoperative pain outcomes.

Treating Persistent Pain After Breast Cancer Surgery

Breast cancer is one of the most commonly diagnosed cancers among women, and since the prognosis of breast cancer has substantially improved in past decades, complications of management are becoming increasingly apparent. Persistent pain lasting greater than 3 months after breast cancer surgery is unfortunately a common complication affecting approximately 30% of patients after tumour resection. Persistent breast cancer pain has neuropathic features and is typically mild-to-moderate in intensity, with approximately 10% suffering from severe pain. There is an increasing need to prevent persistent pain through the use of transitional pain programmes and perioperative interventions, and to identify novel treatment modalities to reduce suffering in those who unfortunately develop persistent pain. This review serves to provide an overview on persistent pain after breast cancer surgery, its pathophysiology, and current management strategies.

A Novel Technique: Ultrasound-Guided Serratus Anterior Plane Block for the Treatment of Posttraumatic Intercostal Neuralgia

Serratus anterior plane block has been used for pain management during the acute period of conditions affecting the thorax, such as postthoracotomy recovery, rib fracture, and breast surgery recovery. Here, we report the use of serratus anterior plane block in posttraumatic chronic pain treatment. We describe a case of posttraumatic chronic intercostal neuralgia, in which successful pain relief was achieved via repeated injections of local anesthetic and steroid combinations in the serratus anterior plane under ultrasonographic guidance. This novel technique is easy to administer, reliable, and warrants further investigation with regard to its use for rehabilitation of patients who are experiencing posttraumatic chronic neuropathies of the chest wall.

Ultrasound-guided superficial serratus plane block in dog cadavers: an anatomical evaluation and volume dispersion study

OBJECTIVE

To evaluate the anatomy of the serratus plane in dogs to establish the optimal landmarks for a superficial serratus plane (SSP) block and evaluate ropivacaine-methylene blue solution dispersion with three volumes of injection.

STUDY DESIGN

Prospective experimental cadaveric study.

ANIMALS

A formaldehyde solution-preserved dog cadaver and 15 frozen/thawed adult dog cadavers.

METHODS

The thoracic wall of the formaldehyde-preserved cadaver was dissected. An SSP injection was performed on each hemithorax of the cadavers, with the ultrasound transducer placed over the fourth and fifth ribs, at the level of the shoulder joint. A needle was inserted in-plane in a caudocranial direction until it could be visualized between the serratus ventralis thoracis and latissimus dorsi muscles. Dog cadavers were injected with a ropivacaine-methylene blue solution at 0.3, 0.6 and 1.0 mL kg^-1 and were dissected to determine the spread of the dye.

RESULTS

The thoracic wall muscles identified in the formalinized cadaver were the cutaneous trunci, latissimus dorsi, external abdominal oblique, serratus ventralis thoracis, scalenus, serratus dorsalis cranialis and external intercostal. The nerves identified in the SSP included the lateral cutaneous branches of intercostal nerves, intercostobrachial nerves and long thoracic nerve. The solution was successfully injected at the SSP in 26 of 29 (89.7%) attempts. Dermatomal dye spread, median (range), was 4 (3-6), 4 (2-5) and 5 (4-8) for 0.3, 0.6 and 1.0 mL kg^-1, respectively, with no significant difference among them.

CONCLUSIONS AND CLINICAL RELEVANCE

Injections for an SSP block were easily performed under ultrasound guidance, using the fourth and fifth ribs at the level of the shoulder joint as reference landmarks. An injected volume of 0.3 mL kg^-1 may be sufficient for hemithorax analgesia in dogs. Further studies in dogs are required to determine the utility of this technique.

Efficacy of Ultrasound-Guided Serratus Plane Block on Postoperative Quality of Recovery and Analgesia After Video-Assisted Thoracic Surgery: A Randomized, Triple-Blind, Placebo-Controlled Study

BACKGROUND

The optimal regional technique for analgesia and improved quality of recovery after video-assisted thoracic surgery (a procedure associated with considerable postoperative pain) has not been established. The main objective in this study was to compare quality of recovery in patients undergoing serratus plane block (SPB) with either ropivacaine or normal saline on the first postoperative day. Secondary outcomes were analgesic outcomes, including postoperative pain intensity and opioid consumption.

METHODS

Ninety patients undergoing video-assisted thoracic surgery were randomized to receive ultrasound-guided SPB with 0.4 mL/kg of either 0.375% ropivacaine (SPB group) or normal saline (control group) after anesthetic induction. The primary outcome was the 40-item Quality of Recovery (QoR-40) score at 24 hours after surgery. The QoR-40 questionnaire was completed by patients the day before surgery and on postoperative days 1 and 2. Pain scores, opioid consumption, and adverse events were assessed for 2 days postoperatively.

RESULTS

Eighty-five patients completed the study: 42 in the SPB group and 43 in the control group. The global QoR-40 scores on both postoperative days 1 and 2 were significantly higher in the SPB group than in the control group (estimated mean difference 8.5, 97.5% confidence interval [CI], 2.1-15.0, and P = .003; 8.5, 97.5% CI, 2.0-15.1, and P = .004, respectively). The overall mean difference between the SPB and control groups was 8.5 (95% CI, 3.3-13.8; P = .002). Pain scores at rest and opioid consumption were significantly lower up to 6 hours after surgery in the SPB group than in the control group. Cumulative opioid consumption was significantly lower up to 24 hours postoperatively in the SPB group.

CONCLUSIONS

Single-injection SPB with ropivacaine enhanced the quality of recovery for 2 days postoperatively and improved postoperative analgesia during the early postoperative period in patients undergoing video-assisted thoracic surgery.

The effects of ultrasound-guided serratus plane block, in combination with general anesthesia, on intraoperative opioid consumption, emergence time, and hemodynamic stability during video-assisted thoracoscopic lobectomy: A randomized prospective study

BACKGROUND

Thoracotomy is one of the most painful surgeries; therefore, video-assisted thoracoscopic surgery (VATS) was developed to reduce the surgical stress of thoracotomy. Although VATS results in reduced postoperative pain compared with thoracotomy, it is still painful. Serratus plane block (SPB) is a novel technique that provides lateral chest wall analgesia by blocking the lateral branch of the intercostal nerve.

METHODS

We conducted a prospective study in 50 patients, aged 20 to 75 years, undergoing three-port VATS lobectomy. Group G (n = 25) received conventional general anesthesia and Group S (n = 25) received SPB before induction of general anesthesia. In Group S, 20 ml of 0.375% ropivacaine was injected between the serratus anterior and latissimus dorsi muscles. During surgery, anesthesia was maintained by adjusting the propofol dose to maintain a bispectral index of 40 to 60 and the remifentanil dose to maintain blood pressure and heart rate within 70 to 130% of baseline.

RESULTS

Intraoperative remifentanil consumption was significantly lower in Group S compared to that in Group G (519.9 μg vs 1047.7 μg, P < .001). Moreover, emergence time was significantly shorter in Group S compared to Group G (10.8 minutes vs 14.9 minutes, P = .01). However, there were no significant differences in systolic blood pressure and heart rate (HR) between the groups at each time point. The doses of rescue drugs for the control of blood pressure and HR were not significantly different between the 2 groups.

CONCLUSIONS

Ultrasound-guided SPB could be a safe and effective regional anesthesia technique for VATS.

Use of the Ultrasound-Guided Erector Spinae Plane Block in Segmental Mastectomy

Erector spinae plane (ESP) block is a recently described regional anaesthesia/analgesia technique. Although there is stil no consensus on its mechanism, the published case series seem to promise a new block for both chronic and acute pain. In this case report, the use of ESP block in 47-year-old female patient scheduled for bilateral segmental mastectomy surgery is presented. ESP was formerly reported for rib fracture, bariatric surgery, open abdominal surgery and breast implant surgery. To the best of our knowledge, no article has been published for ESP block in breast cancer surgery including axillary dissection.

Too Deep or Not Too Deep?: A Propensity-Matched Comparison of the Analgesic Effects of a Superficial Versus Deep Serratus Fascial Plane Block for Ambulatory Breast Cancer Surgery

BACKGROUND AND OBJECTIVES

Serratus fascial plane block can reduce pain following breast surgery, but the question of whether to inject the local anesthetic superficial or deep to the serratus muscle has not been answered. This cohort study compares the analgesic benefits of superficial versus deep serratus plane blocks in ambulatory breast cancer surgery patients at Women's College Hospital between February 2014 and December 2016. We tested the joint hypothesis that deep serratus block is noninferior to superficial serratus block for postoperative in-hospital (pre-discharge) opioid consumption and pain severity.

METHODS

One hundred sixty-six patients were propensity matched among 2 groups (83/group): superficial and deep serratus blocks. The cohort was used to evaluate the effect of blocks on postoperative oral morphine equivalent consumption and area under the curve for rest pain scores. We considered deep serratus block to be noninferior to superficial serratus block if it were noninferior for both outcomes, within 15 mg morphine and 4 cm·h units margins. Other outcomes included intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and incidence of postoperative nausea and vomiting.

RESULTS

Deep serratus block was associated with postoperative morphine consumption and pain scores area under the curve that were noninferior to those of the superficial serratus block. Intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and postoperative nausea and vomiting were not different between blocks.

CONCLUSIONS

The postoperative in-hospital analgesia associated with deep serratus block is as effective (within an acceptable margin) as superficial serratus block following ambulatory breast cancer surgery. These new findings are important to inform both current clinical practices and future prospective studies.

Interfascial block at the serratus muscle plane versus conventional analgesia in breast surgery: a randomized controlled trial

Background and objectives

In the context of opioid-sparing perioperative management, there is still little evidence from randomized controlled trials regarding the effectiveness of interfascial thoracic blocks. This study hypothesizes that receiving a serratus plane block reduces opioid requirements, pain scores, and rescue medication needs.

Methods

This double-blind, randomized controlled study was conducted on 60 adult females undergoing oncologic breast surgery. After general anesthesia, patients were randomly allocated to either conventional analgesia (control group, n=30) or single-injection serratus block with L-bupivacaine 0.25% 30mL (study group, n=30). First 24-hour total morphine consumption (primary outcome), pain scores at 1, 3, 6, 12, and 24 hours, time-to-first opioid rescue analgesia, and adverse effects were recorded.

Results

Median 24 hours’ opioid dose was greater in the control group (median difference 9 mg (95% CI 4 to 14.5 mg); p<0.001). Proportional odds model showed that the study group has a lower probability of receiving opioid drugs (OR=0.26 (95% CI 0.10 to 0.68); p<0.001), while mastectomies have a higher probability of receiving them (OR=4.11 (95% CI 1.25 to 13.58); p=0.002). Pain scores in the study group were significantly lower throughout the follow-up period (p<0.001). Control group subjects needed earlier morphine rescue and had a higher risk of rescue dose requirement (p=0.002).

Conclusions

Interfascial serratus plane block reduces opioid requirements and is associated with better pain scores and lower and later rescue analgesia needs in the first 24 hours, compared with conventional intravenous analgesia, in breast surgery.

Trial registration number

NCT02905149.

An overview of interventional strategies for the management of oncologic pain

Pain is a ubiquitous part of the cancer experience. Often the presenting symptom of malignancy, pain becomes more prevalent in advanced or metastatic disease and often persists despite curative treatment. Although management of cancer pain improved following publication of the WHO's analgesic ladder, when used in isolation, conservative approaches often fail to control pain and are limited by intolerable side effects. Interventional strategies provide an option for managing cancer pain that remains refractory to pharmacologic therapy. The purpose of this review is to investigate these strategies and discuss the risks and benefits which must be weighed when considering their use. Therapies anticipated to have an increasingly important role in the future of cancer pain management are also discussed.

Impact of the Ultrasound-Guided Serratus Anterior Plane Block on Post-Mastectomy Pain: A Randomised Clinical Study

Objective

A variety of methods, including neuraxial and regional blocks, have been used to manage post-mastectomy pain. This study evaluates the effect of serratus anterior plane block on acute pain after mastectomy.

Methods

A total of 60 patients who were candidates for mastectomy under general anaesthesia were divided in this trial into two groups. After entering the recovery room, the first-experimental-group (SAB) underwent the ultrasound-guided serratus anterior block, but the second-control-group (CTL) received no block intervention. An intravenous patient-controlled analgesia (PCA) device was used to deliver fentanyl in both groups. Using the Visual Analog Scale (VAS), the patients' pain was assessed at intervals of 1, 6, 12 and 24 hours after entering the recovery room. Intravenous acetaminophen was administered as a rescue analgesic if the pain exceeded 3 on the VAS. A total amount of fentanyl consumed, the time to first PCA request, a total amount of acetaminophen consumption and possible adverse effects were evaluated.

Results

The pain scores assessed at the time intervals were not significantly different between the two groups (p>0.5). The total consumption of fentanyl was significantly lower in the SAB group than in the CTL group (p=0.0001). Duration of the time to first PCA request was remarkably longer in the SAB group than in the CTL group (p=0.0001). The total amount of acetaminophen consumed was notably higher in the CTL group than in the SAB group (p=0.001). None of the patients experienced side effects.

Conclusion

Undertaking serratus anterior block following mastectomy can reduce pain scores and lower opioid usage.

Ultrasound Guided Transversus Thoracic Plane block, Parasternal block and fascial planes hydrodissection for internal mammary post thoracotomy pain syndrome

INTRODUCTION

Pectoral Nerves Block (PECS) and Serratus Plane Block (SPB) have been used to treat persistent post-surgical pain after breast and thoracic surgery; however, they cannot block the internal mammary region, so a residual pain may occur in that region. Parasternal block (PSB) and Thoracic Transversus Plane Block (TTP) anaesthetize the anterior branches of T2-6 intercostal nerves thus they can provide analgesia to the internal mammary region.

METHODS

We describe a 60-year-old man suffering from right post-thoracotomy pain syndrome with residual pain located in the internal mammary region after a successful treatment with PECS and SPB. We performed a PSB and TTP and hydrodissection of fascial planes with triamcinolone and Ropivacaine.

RESULTS

Pain disappeared and the result was maintained 3 months later.

DISCUSSION

This report suggests that PSB and TTP with local anaesthetic and corticosteroid with hydrodissection of fascial planes might be useful to treat a post thoracotomy pain syndrome located in the internal mammary region.

SIGNIFICANCE

The use of Transversus Thoracic Plane and Parasternal Blocks and fascial planes hydrodissection as a novel therapeutic approach to treat a residual post thoracotomy pain syndrome even when already treated with Pectoral Nerves Block and Serratus Plane Block.

A review of recent advances in the management of breast cancer related pain

The incidence of breast cancer has stabilized over the past 10 years, while death rates have declined. Thus, many women are living with long-term effects of breast cancer, including pain syndromes relating to breast cancer. As our understanding of these types of pain syndromes improves, delivery of care to this population becomes paramount. In this review, we discuss advances in rehabilitation and interventional pain management to improve pain and symptom management. Appropriate use of physical therapy may significantly improve a patient's functional status, while fascial plane blocks can lead to pain relief which may last for months. Targeted therapies for pain relief may result in better quality of life for individuals suffering from breast cancer related pain.

Newer regional analgesia interventions (fascial plane blocks) for breast surgeries: Review of literature

Surgical resection of the primary tumour with axillary dissection is one of the main modalities of breast cancer treatment. Regional blocks have been considered as one of the modalities for effective perioperative pain control. With the advent of ultrasound, newer interventions such as fascial plane blocks have been reported for perioperative analgesia in breast surgeries. Our aim is to review the literature for fascial plane blocks for analgesia in breast surgeries. The research question for initiating the review was 'What are the reported newer regional anaesthesia techniques (fascial plane blocks) for female patients undergoing breast surgery and their analgesic efficacy?.' The participants, intervention, comparisons, outcomes and study design were followed. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. Of the 989 manuscripts, the present review included 28 manuscripts inclusive of all types of published manuscripts. 15 manuscripts directly related to the administration of fascial plane blocks for breast surgery across all type of study designs and cases were reviewed for the utility of fascial plane blocks in breast surgeries. Interfascial blocks score over regional anaesthetic techniques such as paravertebral block as they have no risk of sympathetic blockade, intrathecal or epidural spread which may lead to haemodynamic instability and prolonged hospital stay. This review observed that no block effectively covers the whole of breast and axilla, thus a combination of blocks should be used depending on the site of incision and extent of surgical resection.

Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series

Background and aims

Post thoracotomy pain syndrome (PTPS) remains a common complication of thoracic surgery with significant impact on patients’ quality of life. Management usually involves a mul¬tidisciplinary approach that includes oral and topical analgesics, performing appropriate interventional techniques, and coordinating additional care such as physiotherapy, psychotherapy and rehabilitation. A variety of interventional procedures have been described to treat PTPS that is inadequately managed with systemic or topical analgesics. Most of these procedures are technically complex and are associated with risks and complications due to the proximity of the targets to neuraxial structures and pleura. The ultrasound-guided erector spinae plane (ESP) block is a novel technique for thoracic analgesia that promises to be a relatively simple and safe alternative to more complex and invasive techniques of neural blockade. We have explored the application of the ESP block in the management of PTPS and report our preliminary experience to illustrate its therapeutic potential.

Methods

The ESP block was performed in a pain clinic setting in a cohort of 7 patients with PTPS following thoracic surgery with lobectomy or pneumonectomy for lung cancer. The blocks were performed with ultrasound guidance by injecting 20–30mL of ropivacaine, with or without steroid, into a fascial plane between the deep surface of erector spinae muscle and the transverse processes of the thoracic vertebrae. This paraspinal tissue plane is distant from the pleura and the neuraxis, thus minimizing the risk of complications associated with injury to these structures. The patients were followed up by telephone one week after each block and reviewed in the clinic 4–6 weeks later to evaluate the analgesic response as well as the need for further injections and modification to the overall analgesic plan.

Results

All the patients had excellent immediate pain relief following each ESP block, and 4 out of the 7 patients experienced prolonged analgesic benefit lasting 2 weeks or more. The ESP blocks were combined with optimization of multimodal analgesia, resulting in significant improvement in the pain experience in all patients. No complications related to the blocks were seen.

Conclusion

The results observed in this case series indicate that the ESP block may be a valuable therapeutic option in the management of PTPS. Its immediate analgesic efficacy provides patients with temporary symptomatic relief while other aspects of chronic pain management are optimized, and it may also often confer prolonged analgesia.

Implications

The relative simplicity and safety of the ESP block offer advantages over other interventional procedures for thoracic pain; there are few contraindications, the risk of serious complications (apart from local anesthetic systemic toxicity) is minimal, and it can be performed in an outpatient clinicsetting. This, combined with the immediate and profound analgesia that follows the block, makes it an attractive option in the management of intractable chronic thoracic pain. The ESP block may also be applied to management of acute pain management following thoracotomy or thoracic trauma (e.g. rib fractures), with similar analgesic benefits expected. Further studies to validate our observations are warranted.