Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Thoracic paravertebral block is the preferred regional anesthetic technique for breast cancer surgery, but concerns over its invasiveness and risks have prompted search for alternatives. Pectoralis-II block is a promising analgesic technique and potential alternative to paravertebral block, but evidence of its absolute and relative effectiveness versus systemic analgesia (Control) and paravertebral block, respectively, is conflicting. This meta-analysis evaluates the analgesic effectiveness of Pectoralis-II versus Control and paravertebral block for breast cancer surgery. Methods Databases were searched for breast cancer surgery trials comparing Pectoralis-II with Control or paravertebral block. Postoperative oral morphine consumption and difference in area under curve for pooled rest pain scores more than 24 h were designated as coprimary outcomes. Opioid-related side effects, effects on long-term outcomes, such as chronic pain and opioid dependence, were also examined. Results were pooled using random-effects modeling. Results Fourteen randomized trials (887 patients) were analyzed. Compared with Control, Pectoralis-II provided clinically important reductions in 24-h morphine consumption (at least 30.0 mg), by a weighted mean difference [95% CI] of −30.5 mg [−42.2, −18.8] (P < 0.00001), and in rest pain area under the curve more than 24 h, by −4.7cm · h [−5.1, −4.2] or −1.2cm [−1.3, −1.1] per measurement. Compared with paravertebral block, Pectoralis-II was not statistically worse (not different) for 24-h morphine consumption, and not clinically worse for rest pain area under curve more than 24 h. No differences were observed in opioid-related side effects or any other outcomes. Conclusions We found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively when compared with systemic analgesia alone; and it also offers analgesic benefits noninferior to those of paravertebral block after breast cancer surgery. Evidence supports incorporating Pectoralis-II into multimodal analgesia and also using it as a paravertebral block alternative in this population.

Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

“…Two systematic reviews (Hussain et al, 2019;Versyck et al, 2019) comparing the PEC block to standard care found similar results to ours with a reduction in pain scores and in 24 hr opioid consumption. These reviews also compared the PEC block to the parvertebral block and their results suggested that the PEC block was not inferior to the paravertebral block.…”

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

“…Two meta‐analyses comparing PECS to paravertebral blocks reported similar results on pain reIief and analgesia consumption . A third meta‐analysis also demonstrated the efficacy of PECS blocks to reduce pain and morphine consumption when compared with no block or placebo .…”

<p>Rasternal Intercostal Block Complementation Contributes to Postoperative Pain Relief in Modified Radical Mastectomy Employing Pectoral Nerve Block I and Serratus-Intercostal Block: A Randomized Trial</p>

“…36 Hussain N and colleagues undertook a systematic review and meta-analysis to provide evidence that pectoral nerve blocks could be a promising alternative to paravertebral block. 37 To the best of our knowledge, this study is the first to evaluate the efficacy and safety of co-administering PECS I, SIPB, and PSI block in patients undergoing MRM. In contrast to another prospective clinical trial, 30 our findings indicate that combining all three nerve blocks reduced NRS scores and morphine requirement compared to PECS I block and SIPB alone.…”

“…15 Thoracic paravertebral block is regarded as the priority option for regional anesthesia during breast cancer surgery; however, the invasive procedure requires excellent skill, experience, and deep puncturing. 16 PECS I involves local anesthetic injection between pectoralis major and minor muscle, and it is a controlled and reliable technique that intercepts the innervation of the medial and lateral pectoralis nerves originating from cervical and brachial plexuses. 17 SIPB, an inter-fascial approach between the serratus anterior muscle and external intercostal muscle or below serratus anterior muscle, was initially proposed as an alternative regional anesthetic technique that targets the lateral cutaneous branches of the thoracic intercostal nerves (TICN).…”