Efficacy of single-shot ultrasound-guided erector spinae plane block for postoperative analgesia after mastectomy: A randomized controlled study

Comparison Between Erector Spinae Plane Block versus Serratus Anterior Plane Block Regarding Analgesia and Stress Response After Modified Radical Mastectomy: Randomized Controlled Trial

Background

Modified radical mastectomy (MRM) is the primary surgical treatment for breast cancer, yet it leads to significant postoperative pain.

Objectives

This randomized controlled trial evaluates the effects of an erector spinae plane block (ESPB) versus a serratus anterior plane block (SAPB) on post-MRM pain management and stress response reduction.

Methods

Sixty individuals scheduled for unilateral MRM under general anesthesia from October 2021 to October 2022 were divided into three groups. Group A comprised 20 patients who received ultrasound-guided ESPB (20 mL of 0.25% bupivacaine). Group B included 20 patients who received ultrasound-guided SAPB (20 mL of 0.25% bupivacaine). Group C was treated with intravenous morphine based on pain scores. Anesthesia was induced using 2 μg/kg of fentanyl and 2 - 3 mg/kg of propofol. The study compared the three groups regarding pain scores using a numerical rating scale, serum cortisol levels, total fentanyl, and morphine consumption, changes in mean arterial blood pressure (MAP) and heart rate (HR) during surgery, and the occurrence of postoperative complications.

Results

Statistically significant reductions in pain scores were observed in group A compared to groups B and C. Moreover, group A exhibited a significant decrease in postoperative morphine consumption, serum cortisol levels 1 hour post-surgery (P = 0.021), MAP, and postoperative vomiting and nausea compared to group B. Furthermore, groups A and B showed statistically significant improvements in all parameters compared to group C.

Conclusions

The study demonstrates that ESPB provides superior analgesic effects compared to SAPB in patients undergoing MRM, with reduced morphine use and lower postoperative cortisol levels. Both blocks offer more effective pain control than intravenous morphine alone.

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

Efficacy and safety of erector spinae plane block for postoperative analgesia in breast cancer surgery-A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

We aim to evaluate the analgesic efficacy and safety of erector spinae plane block (ESPB) for postoperative analgesia in breast cancer surgeries.

METHODS

PubMed, Web of Science, CBM, Embase, Cochrane, Wanfang, VIPP, and CNKI were searched to identify published eligible randomized controlled trials. The primary results were the postoperative 24 h morphine consumption and pain scores, while the secondary outcomes included pain scores at other times, press times of patient-controlled intravenous analgesia (PCIA), times to request for first rescue analgesia, the incidence of request for rescue analgesia, opioid-related complications, nerve blocks related complications and patient satisfaction.

RESULTS

We included 20 studies meeting the inclusion criteria, which involved 1293 participants. The morphine consumption and the pain scores during 24 h postoperatively were significantly decreased in the ESPB group versus the control group (p < 0.00001). Furthermore, ESPB also reduced pain scores at other time points, press times of PCIA, and times to first rescue analgesia requirement. Meanwhile, there was a lower incidence of postoperative nausea and vomiting, and skin pruritus in the ESPB group than in the control group.

CONCLUSIONS

Compared to general anesthesia alone, ESPB combined with general anesthesia can effectively reduce the postoperative pain intensity within 48 h and opioid consumption within 24 h after breast cancer surgery, and reduce the incidence of opioid and nerve blocks related complications.

Comparison of the Efficacy of UltrasoundGuided Serratus Anterior Plane Block Versus Erector Spinae Plane Block for Postoperative Analgesia After Modified Radical Mastectomy: A Randomised Controlled Trial

OBJECTIVE

Several interfascial interfacial plane blocks have been described in patients undergoing modified radical mastectomy. We conducted this study to evaluate the analgesic efficacy of ultrasound-guided serratus anterior plane block and erector spinae plane block in patients undergoing modified radical mastectomy.

METHODS

Totally, 80 female patients (18-70 years) undergoing modified radical mastectomy were randomised into 2 groups of 40 each and were given ultrasound-guided serratus anterior plane block or erector spinae plane block with 0.4 mL kg-1 of 0.375% ropivacaine in this prospective double-blind control trial. The groups were compared for the time to request of first dose of rescue analgesic, requirement of rescue analgesics, and patient satisfaction score.

RESULTS

The time to request of the first rescue analgesia was comparable in both groups (P =.056). Postoperative pain scores at rest at 0 minute were significantly lower in serratus anterior plane group as compared to erector spinae plane group (P =.03). The intraoperative fentanyl requirement and postoperative diclofenac and tramadol requirements were comparable between the 2 groups. The number of patients requiring rescue doses of fentanyl intraoperatively and rescue analgesics postoperatively was similar in both groups. The mean patient satisfaction score was also comparable in both groups.

CONCLUSION

Ultrasound-guided serratus anterior plane block and erector spinae plane block have comparable postoperative analgesic efficacy after modified radical mastectomy.

Effect of continuous intra-incisional bupivacaine on postoperative pain in non-traumatic spinal fixation surgeries: a randomized controlled trial

Background

Continuous injection of local anesthetics by using surgical wound catheters for postoperative pain relief has gained acceptance in recent years. However, whether this method can be alternatively used instead of systemic opioids in different surgical procedures has not yet been elucidated.

Objectives

The aim was to investigate the effect of continuous injection of bupivacaine through a catheter inside the surgical wound on reducing the postoperative pain of lumbar spine fusion surgeries.

Methods

In this clinical trial, 31 patients undergoing non-traumatic lumbar spine stabilization surgery were randomly assigned to receive (n = 15) or do not receive (n = 16) bupivacaine through a catheter inside the surgical wound, postoperatively. Pain intensity (NRS), dose of required morphine, and drug-related complications within 24 hours of intervention were assessed and compared by the Mann-Whitney and independent t-test.

Results

Mean pain intensity was significantly lower in the case group over the first postoperative hour in the recovery room (p < 0.001), which continued for the first 2 hours after entering the ward. The mean morphine intake was lower in the bupivacaine group during the first postoperative 24 hours (16 ± 0.88 vs. 7.33 ± 0.93 mg, p < 0.001). The two groups were not significantly different regarding drug-related complications.

Conclusion

Continuous intra-incisional infusion of bupivacaine helped better pain reduction during the early postoperative hours while sparing morphine consumption in the first postoperative day.

The quality of recovery after erector spinae plane block in patients undergoing breast surgery: a randomized controlled trial

BACKGROUND

The erector spinae plane (ESP) block has recently been shown to effectively alleviate postoperative pain and reduce opioid consumption in breast surgery patients. However, data are still limited concerning the quality of recovery in patients following this procedure.

METHODS

This study was a randomized controlled trial (RCT) performed in a university hospital. We randomly allocated patients to one of three groups: ESP, SHAM, and control (CON). Procedures in the ESP and SHAM blocks were performed ipsilaterally with 0.375% ropivacaine or 0.9% saline (0.4 mL/kg). Our primary outcome was the assessment of the patient's improvement with quality-of-recovery 40 (QoR-40) a day after surgery. Other outcome assessments included postoperative pain evaluation on the visual analog scale (VAS), 24-hour opioid consumption with patient-controlled analgesia (PCA), time to the first opioid demand, and global satisfaction with perioperative treatment.

RESULTS

Overall, patients in the ESP group had improved QoR-40 compared to the CON group, 186 [177-193] vs. 175 [165-183] (medians and interquartile ranges). Pain severity was significantly higher in the CON group compared to the ESP group at hours 2 (38 [23-53] vs. 20 [7-32]) and 4 (30 [18-51] vs. 19 [7-25]). Moreover, we observed lower oxycodone consumption after 24 hours with the PCA pump between the ESP (4 [2-8] mg) and the CON (9.5 [5-19]) groups. Patients in the CON group used PCA sooner than those in the ESP group. Participants in the ESP group were more satisfied with treatment than those in the CON group. We found no statistical difference between SHAM and the other groups.

CONCLUSIONS

Compared to the CON group, the ESP block improved the quality of recovery, alleviated pain intensity, and lowered opioid consumption in patients undergoing breast surgery. However, we did not observe this superiority in comparison with the SHAM group.

TRIAL REGISTRATION

NCT04726878 .

Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis

BACKGROUND

Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.

OBJECTIVES

To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.

DESIGN

Systematic review with network meta-analysis (PROSPERO:CRD42021250651).

DATA SOURCE

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).

ELIGIBILITY CRITERIA

All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.

RESULTS

Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).

CONCLUSION

All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.

TRIAL REGISTRATION

PROSPERO (CRD4202125065).

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery.

METHODS

In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting.

RESULTS

Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting.

CONCLUSION

Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice.

STUDY REGISTRATION

PROSPERO (CRD42020198244); registered 19 October 2020.

The Effect of Single-Shot Erector Spinae Plane Block (ESPB) on Opioid Consumption for Various Surgeries: A Meta-Analysis of Randomized Controlled Trials

Study Objective

Design

Setting

Patients

Intervention

Measurements

Results

Conclusion

Opioid-sparing effects of ultrasound-guided erector spinae plane block for adult patients undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Erector spinae plane block (ESPB) is a new method of administering analgesics to patients perioperatively. The aim of this meta-analysis was to evaluate the opioid-sparing effects of erector spinae plane block in patients during the perioperative period compared to conventional analgesia and identify its role in the development of opioid-free anesthesia.

METHODS

Relevant study articles were retrieved from PubMed, the Web of Science, Medline via Ovid, Embase via Ovid, and the Cochrane Central Register of Controlled Trials (CENTRAL) on June 11, 2020. We included randomized controlled trials (RCTs) comparing the use of ESPB with control (no/sham block). The primary outcome was opioid consumption at 24 h after surgery and intraoperative opioid consumption. A random-effects model was used to calculate the standardized mean difference (SMD) and odds ratio (OR) with 95% confidence interval (CI) if there was significant heterogeneity in the data; otherwise, the fixed-effect model was used.

RESULTS

A total of 25 randomized controlled trials involving 1461 patients were included. The use of ultrasound-guided ESPB was associated with reduced opioid consumption at 24 h after surgery [SMD: -2.14, 95% CI: -2.61 to -1.67, p < 0.001] and during the intraoperative period [SMD: -2.30, 95% CI: -3.21 to -1.40, p < 0.001]. In addition, it took a longer time to administer the first rescue analgesia in the ESPB group [SMD: 3.60, 95% CI: 2.23-4.97, p < 0.001] and the group was associated with lower incidences of postoperative nausea or vomiting (PONV) [OR: 0.50, 95% CI: 0.34-0.72, p < 0.001].

CONCLUSIONS

Ultrasound-guided ESPB could provide an opioid-sparing effect and effective analgesia in adults undergoing surgeries with general anesthesia, and then promote opioid-free anesthesia development.

Analgesic effects of erector spinae plane block for patients after breast surgery: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis investigated the analgesic effects of erector spinae plane block (ESPB) in patients undergoing breast surgery.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched from database establishment to January 31, 2020. Two reviewers independently extracted the data. The primary outcomes were pain scores and opioid consumption during the first 24 hours after surgery. The risk of bias of the included studies was assessed according to the Cochrane Handbook.

RESULTS

Six randomized controlled trials of 415 patients were included. Compared with the control value, the pain score was significantly lower in the ESPB group at different time points postoperatively. Patients who underwent ESPB required lower opioid consumption (standardized mean difference = -2.02, 95% confidence interval [CI] = -2.85 to -1.20, I²= 91%. The rates of postoperative nausea (risk ratio [RR] = 0.79, 95% CI = 0.48-1.30, I² = 47%) and postoperative vomiting (RR = 0.76, 95% CI = 0.30-1.96, I² = 33%) did not differ between the groups. The quality of evidence was low or very low.

CONCLUSIONS

ESPB significantly alleviated pain and reduced opioid consumption after breast surgery. Further research is needed to expand its clinical application.PROSPERO registration number CRD42020167900.

The opioid sparing effect of erector spinae plane block for various surgeries: a meta-analysis of randomized-controlled trials

INTRODUCTION

The erector spinae plane block (ESPB) is a newer fascial plane block which has been broadly applied for postoperative analgesia after various surgeries, but the effectiveness in these populations is not well established.

EVIDENCE ACQUISITION

A systematic database search was conducted in PubMed, PMC, Embase, and Scopus for randomized controlled trials (RCTs) comparing ESPB with control, placebo, or other blocks. The primary outcome was intravenous opioid consumption in milligram morphine equivalents 24 h after surgery. Standardized mean differences (SMDs) with 95% confidence intervals (CI) were calculated using a randomeffects model.

EVIDENCE SYNTHESIS

A total of 29 RCTs were included. An analysis was conducted by subgroups differentiated by surgery type, 'no block' vs. ESPB, and other blocks vs. ESPB. ESPB was effective in reducing opioid consumption against no block for breast surgery (SMD -1.13; CI 95%), thoracic surgery (SMD -3.00; CI 95%), and vertebral surgery (SMD -1.78; CI 95%). ESPB was effective against alternative blocks for breast surgery (vs. paravertebral, SMD -1.07; CI 95%) and abdominal surgery (SMD -1.77; CI 95%). ESPB showed moderate effect in thoracic surgery against paravertebral (SMD 0.58; CI 95%) and against no block in abdominal surgery (SMD 0.80; CI 95%). In only one case did ESPB perform worse than another block: vs. PECS block for breast surgery (SMD 1.66; CI 95%).

CONCLUSIONS

ESPB may be a useful addition to the multimodal analgesic regimen for a variety of surgeries especially when the alternative is no block. Unanswered questions include determining of the mechanism of action, refining of the EPSB technique, and establishing recommended local anesthetic dose and volume.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis

STUDY OBJECTIVE

Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery.

DESIGN

Systematic review and network meta-analysis.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients scheduled for breast surgery under general anesthesia.

INTERVENTIONS

Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced.

MEASUREMENTS

Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status.

MAIN RESULTS

In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques.

CONCLUSIONS

In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.

Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.

Analgesic efficacy and safety of erector spinae plane block in breast cancer surgery: a systematic review and meta-analysis

Background

Surgical resection is considered to be the primary and most effective therapy for breast cancer, postoperative pain is an issue gaining significant attention. In recent years, erector spinae plane block (ESPB) has attracted much attention in postoperative analgesia, but its effectiveness is still controversial. This meta-analysis was implemented to verify the clinical analgesic efficacy and safety of erector spinae plane block in patients undergoing breast cancer surgery.

Methods

We searched PubMed, EMBASE, Web of Science, the Cochrane Library and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing ESPB with general anesthesia (GA) in breast cancer surgery that were published before December 25, 2020. The primary outcome was opioid consumption at the first 24 h after surgery, while secondary outcomes included pain scores at 1, 6,12 and 24 h after surgery, opioid consumption at 1, 6 and 12 h after surgery, intraoperative opioid consumption, number of patients who need for rescue analgesia, and the incidence of postoperative nausea and vomiting (PONV).

Results

Eleven randomized controlled trials involving 679 patients met the study inclusion criteria and were included in this study. In comparison to GA group, the ESPB group showed a significant reduction in morphine consumption at the first 24 h after surgery by a mean difference (MD) of − 7.67 mg [95% confidence interval (CI) − 10.35 to − 5.00] (P <  0.01). In addition, the ESPB group showed lower pain scores than the GA group in the four time periods (1, 6, 12 and 24 h after surgery). ESPB group significantly reduce the intraoperative consumption of fentanyl, the need for postoperative rescue analgesia, and the incidence of PONV.

Conclusions

Ultrasound-guided ESPB is an effective approach for reducing morphine consumption and pain intensity within the first 24 h after breast cancer surgery, compared with GA alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01277-x.

Perioperative Analgesic Modalities for Breast Cancer Surgeries: A Prospective Randomized Controlled Trial

Purpose

Various analgesic modalities are adopted for perioperative analgesia in breast cancer surgeries. This study aimed to compare the efficacy of intravenous morphine versus serratus anterior plane block (SAPB) and erector spinae plane block (ESPB) in breast cancer surgeries.

Patients and Methods

Seventy-five breast cancer patients undergoing modified radical mastectomy from January 2020 to June 2020 were randomly allocated into 3 groups; the morphine group received morphine 0.1 mg/kg, the SAPB group received ultrasound-guided SAPB with 25 mL bupivacaine 0.25% and the ESPB group received ultrasound-guided ESPB with 25 mL bupivacaine 0.25%. A visual analogue scale (VAS) 0–10 was used to evaluate pain postoperatively, where 0 denotes no pain and 10 worst pain. If any patient in the 3 studied groups reported breakthrough pain with VAS ≥ 4 then a bolus of 3 mg morphine was given.

Results

There was no difference in VAS scores between the 3 groups postoperatively. Morphine consumption was higher in the morphine group (9.19 ± 2.32 mg) than the SAPB group (4.00 ± 1.55 mg) and the ESPB group (4.20 ± 1.64 mg), respectively. First time to receive postoperative morphine was significantly longer for the ESPB and SAPB groups than the morphine group (20.40 ± 4.98 hours), (19.00 ± 5.9 hours), (5.00 ± 4.62 hours), respectively. Intraoperative hemodynamics and fentanyl consumption showed no difference between groups, whereas postoperative mean arterial blood pressure values at 2 and 4 hours were higher in the morphine group. Ramsay sedation score and postoperative nausea and vomiting values in the post anesthesia care unit were higher for the morphine group compared to the SAPB and ESPB groups. No complications related to the blocks were reported.

Conclusion

SAPB and ESPB can be used as an effective and safe alternative to opioids with fewer side effects in breast cancer patients undergoing modified radical mastectomy.

Trial Registration

This trial was prospectively registered at Clinical Trials.gov on 22 January 2020 with registration number NCT04248608 (https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009JS5&selectaction=Edit&uid=U0004LIG&ts=7&cx=−81xkwa).

Statistically significant but clinically unimportant: a systematic review and meta-analysis of the analgesic benefits of erector spinae plane block following breast cancer surgery

The novel erector spinae plane block (ESPB) has been reported to provide important postoperative analgesic benefits following a variety of truncal and abdominal surgical procedures. However, evidence of its analgesic efficacy following breast cancer surgery, compared with parenteral analgesia, is unclear. This meta-analysis evaluates the analgesic benefits of adding ESPB to parenteral analgesia following breast cancer surgery.Databases were searched for breast tumor resection trials comparing ESPB to parenteral analgesia. The two co-primary outcomes examined were 24-hour postoperative oral morphine equivalent consumption and area-under-curve of rest pain scores. We considered reductions equivalent to 3.3 cm.h and 30 mg oral morphine in the first 24 hours postoperatively for the two co-primary outcomes, respectively, to be clinically important. We also assessed opioid-related side effects and long-term outcomes, including health-related quality of life, persistent postsurgical pain and opioid dependence. Results were pooled using random effects modeling.Twelve trials (699 patients) were analyzed. Moderate quality evidence suggested that ESPB decreased 24-hour morphine consumption and area-under-curve of rest pain by a mean difference (95% CI) of -17.60 mg (-24.27 to -10.93) and -2.74 cm.h (-3.09 to -2.39), respectively; but these differences were not clinically important. High-quality evidence suggested that ESPB decreased opioid-related side effects compared with parenteral analgesia by an OR (95% CI) of 0.43 (0.28 to 0.66). None of the studies evaluated long-term block benefits.Adding ESPB to parenteral analgesia provides statistically significant but clinically unimportant short-term benefits following breast cancer surgery. Current evidence does not support routine use of ESPB. Given the very modest short-term benefits and risk of complications, the block should be considered on a case-by-case basis.

Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks

STUDY OBJECTIVE

This narrative review discusses the anatomy, mechanism of action, techniques, pharmacology, indications, complications and substitutes for erector spinae plane (ESP) blocks.

INTERVENTIONS

The Medline, Embase and Google Scholar databases (inception-last week of April 2020) were searched. For indications and alternative blocks, a systematic analysis of the available evidence was carried out. In order to highlight the best evidence available, only randomized trials with prospective registration, blinded assessment and sample size justification were retained for analysis.

MAIN RESULTS

The collective body of anatomical studies suggests that ESP block may work through a combination of different mechanisms (e.g., local anesthetic spread to the thoracic paravertebral space, epidural space, and dorsal ramus). Compared to control, the available evidence suggests that ESP block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal surgical interventions. Erector spinae plane blocks and thoracic paravertebral blocks seem to provide comparable benefits for thoracoscopic and breast cancer surgery when performed with a similar number of injections. Currently, ESP blocks should be favored over intercostal blocks since, at best, the latter provide similar analgesia to ESP blocks despite requiring multiple-level injections.

CONCLUSIONS

In recent years, ESP blocks have become the topic of considerable clinical interest. Future trials are required to investigate their optimal technique, dose of local anesthetic and perineural adjuvants. Moreover, additional investigation should compare ESP blocks with robust multimodal analgesic regimens as well as truncal blocks such as thoracic epidural block, midpoint transverse process to pleura block, PECS block, quadratus lumborum block, and transversus abdominis plane block.

Erector spinae plane block versus retrolaminar block for postoperative analgesia after breast surgery: a randomized controlled trial

PURPOSE

The newly introduced erector spinae plane block (ESPB) has given anesthesiologists an alternative regional anesthetic technique for thoracic analgesia. Although ESPB and retrolaminar block (RLB) have similar puncture sites, no clinical study comparing ESPB and RLB has been reported. The aim of this study was to compare ESPB and RLB in terms of analgesic efficacy in the context of multimodal analgesia following breast surgery.

METHODS

Fifty female patients undergoing breast surgery under general anesthesia were randomly allocated to receive either ultrasound-guided ESPB or RLB with 20 mL of 0.375% levobupivacaine for postoperative analgesia. The primary outcome was analgesic efficacy in terms of time to first postoperative rescue analgesic after the block procedure. The secondary outcomes were consumption of remifentanil during anesthesia, pain intensity at rest for 24 h postoperatively, and occurrence of postoperative nausea and vomiting (PONV).

RESULTS

After excluding five patients, 45 patients (22 and 23 patients in the ESPB and RLB group, respectively) were analyzed. Median time until the first postoperative rescue analgesic after the block procedure in the ESPB group was not significantly longer than that in the RLB group (8.6 [range 2.7-24] vs. 4.8 [3.0-24] h; P = 0.83). There was no significant difference in the consumption of remifentanil during anesthesia, pain intensity at rest for 24 h postoperatively, and occurrence of PONV between the two groups.

CONCLUSION

ESPB is equivalent, and not superior, to RLB for postoperative analgesia after breast surgery when 20 mL of 0.375% levobupivacaine is injected at the fourth thoracic vertebra.

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis

The erector spinae plane block is a new regional anaesthesia technique that provides truncal anaesthesia for breast surgery. This systematic review and meta-analysis was undertaken to determine if the erector spinae plane block is effective at reducing pain scores and opioid consumption after breast surgery. This study also evaluated the outcomes of erector spinae plane blocks compared with other regional blocks. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomised controlled trials reporting the use of the erector spinae plane block in adult breast surgery. Risk of bias was assessed with the revised Cochrane risk-of-bias tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess trial quality. Thirteen randomised controlled trials (861 patients; 418 erector spinae plane block, 215 no blocks, 228 other blocks) were included. Erector spinae plane block reduced postoperative pain compared with no block: at 0-2 hours (mean difference (95% CI) -1.63 (-2.97 to -0.29), 6 studies, 329 patients, high-quality evidence, I²  = 98%, p = 0.02); at 6 hours (mean difference (95% CI) -0.90 (-1.49 to -0.30), 5 studies, 250 patients, high-quality evidence, I²  = 91%, p = 0.003); at 12 hours (mean difference (95% CI) -0.46 (-0.67 to -0.25), 5 studies, 250 patients, high-quality evidence, I²  = 58%, p < 0.0001); and at 24 hours (mean difference (95% CI) -0.50 (-0.70 to -0.30), 6 studies, 329 patients, high-quality evidence, I²  = 76%, p < 0.00001). Compared with no block, erector spinae plane block also showed significantly lower postoperative oral morphine equivalent requirements (mean difference (95% CI) -21.55mg (-32.57 to -10.52), 7 studies, 429 patients, high-quality evidence, I²  = 99%, p = 0.0001). Separate analysis of studies comparing erector spinae plane block with pectoralis nerve block and paravertebral block showed that its analgesic efficacy was inferior to pectoralis nerve block and similar to paravertebral block. The incidence of pneumothorax was 2.6% in the paravertebral block group; there were no reports of complications of the other blocks. This review has shown that the erector spinae plane block is more effective at reducing postoperative opioid consumption and pain scores up to 24 hours compared with general anaesthesia alone. However, it was inferior to the pectoralis nerve block and its efficacy was similar to paravertebral block. Further evidence, preferably from properly blinded trials, is required to confirm these findings.