What's the verdict on regional analgesia in breast surgery?
Is there any need to use it at all?
The 2018 Cochrane review concluded that synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low‐quality evidence).
https://www-ncbi-nlm-nih-gov.elib.tcd.ie/pmc/articles/PMC6377212/
However, the recent 11-year RCT published in the Lancet 2019 with 2132 patients across 13 hospitals internationally showed there was no difference in incisional pain:
Incisional pain was reported by 442 (52%) of 856 patients assigned to regional anaesthesia-analgesia and 456 (52%) of 872 patients allocated to general anaesthesia at 6 months, and by 239 (28%) of 854 patients and 232 (27%) of 852 patients, respectively, at 12 months (overall interim-adjusted odds ratio 1·00, 95% CI 0·85-1·17; p=0·99). Neuropathic breast pain did not differ by anaesthetic technique and was reported by 87 (10%) of 859 patients assigned to regional anaesthesia-analgesia and 89 (10%) of 870 patients allocated to general anaesthesia at 6 months, and by 57 (7%) of 857 patients and 57 (7%) of 854 patients, respectively, at 12 months.
If it doesn't reduce chronic post surgical pain, is there any point in using it?
(Note: these studies involved paravertebral regional analgesia)
dear Cormac Francis Mullins ,
As an anesthesiologist and clinician in the field ı strictly suggest the use of regional analgesia techniques not for breast surgeries but all surgeries to control the early postoperative pain and for the prevention of chronic pain in the future. The use of regional analgesia as a part of multimodal analgesia decreases the need for opioid consumption as well. therefore ı strongly suggest the regional analgesia techniques.
Mehmet Canturk thanks a lot for your answer. I would question whether it prevents chronic pain in breast surgery on the basis of this very large multi centre RCT (below). Previously I would have recommended paravertebral/erector spinae block + Pecs 2 would infusion catheter but I am questioning the benefit of this. I admit it does improve immediate postoperative pain but i am unsure whether it reduces CPSP.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32313-X/fulltext
Conventional Surgery for breast cancer, modified radical mastectomy usually cut the sensory nerves. This will lead to loss of sensation of chest wall as well as axillary skin. In my humble opinion, regional analgesia will not add any benefit here. Benign surgery/ breast preservation surgery are not very painful. Oral medications are good enough.
What about this systematic review published 2020 which recommends PECS block or paravertebral as Grade A evidence? Article PROSPECT guideline for oncological breast surgery: a systema...
Some type of breast surgeries need regional anesthesia. Not all of them. For example, augmentation surgeries including subpectoral prothesis cause severe postoperative pain due to muscle retraction and surgical trauma. So regional anesthesia techniques such as pecs blocks, espb or rhomboid intercostal block may be performed for these patients. In addition, surger including axillary dissection causes postoperative pain, too. The other types, such as mastectomy, or segmental mastectomies or biopsies do not cause pain so the pain may be treated with only iv drugs.
Best regards
In high risk patients para vertebral block in T2 and T4 level with or without serratus anterior plane block MRM can be done.. should be done under light sedation...