Thoracic paravertebral blockade in breast surgery: Is pneumothorax an appreciable concern? A review of over 1000 cases

Abstract

There has been a substantial increase in ambulatory day-case breast surgery in recent decades. This has been largely due to improvements in anesthetic procedures and pre-emptive analgesia. Thoracic paravertebral blockade (TPVB) is increasing in popularity, though concerns over iatrogenic injury remain, especially pneumothorax. The purpose of this study was to conduct a review of the incidence of pneumothorax following TPVB prior to breast surgery. Data from of a consecutive series of patients having TPVB prior to breast surgery between 2009 and 2014 were reviewed. TPVB were used prior to unilateral and bilateral procedures. Medical records were retrospectively assessed for any complication including pleural punctures, pneumothorax, hypotension, bradycardia as well as signs and symptoms of local anesthetic toxicity.1152 patients underwent a total of 1322 TPVB injections (982 unilateral and 340 bilateral). Clinically significant hypotension and/or bradycardia occurred in 26 patients (2.2%). Two patients (0.17%) had a suspected toxicity from the local anesthetic. Incidence of pleural puncture was 0.6% (n=9) and pneumothorax 0.26% (n=3). All pneumothoraxes were managed conservatively. There was no statistical difference in complication rates in those that had unilateral vs bilateral TPVB or those that had ultrasound guidance (P=.09). Good pre-emptive analgesia is pertinent to prevent acute postoperative pain. TPVB have been shown to be successful in reducing rescue analgesia. This study shows TPVB is a well-tolerated procedure, with a low associated incidence of iatrogenic injury and complication. K E Y W O R D Sanesthetic care, breast surgery, complications, pain controlled, pneumothorax | INTRODUCTIONThere has been a substantial increase in the operative volume for breast cancer over recent decades.1 Advances in anesthetic procedures, have resulted in more patients being operated on an ambulatory basis. Therefore, the idea of pre-emptive analgesia is more pertinent to prevent acute postoperative pain and sensitization.2,3Thoracic paravertebral block (TPVB) is increasing in popularity, especially over the last two decades. 4 TPVB is the technique of injecting local anesthetic into the paravertebral space, resulting in ipisilateral somatic and sympathetic nerve blockade, which has an effective impact on postoperative pain levels. 5 Already there is good evidence that shows that early control of acute postoperative pain can have a positive impact in reducing the development of chronic pain states

Erector spinae plane versus paravertebral nerve blocks for postoperative analgesia after breast surgery: a randomized clinical trial

“…The risks of PVBs include pneumothorax, hypotension, bradycardia, epidural or intrathecal spread, vascular puncture, nerve damage, and Horner’s syndrome. Although most published reports suggest a relatively low incidence of pleural puncture and pneumothorax,9 10 26 27 PVBs have been shown to decrease early postoperative pain, nausea, vomiting, and to facilitate earlier return to normal activities after non-mastectomy breast surgery 7 28. In this current study, no pleural punctures or pneumothoraces were seen in either treatment group.…”

“…One such analgesic method for surgical procedures of the breast is the thoracic paravertebral nerve block (PVB), which decreases pain and opioid consumption in both the immediate and remote postoperative periods 8. However, given the proximity of the paravertebral space to the pleura, there remains a non-insignificant risk of iatrogenic pneumothorax during placement of PVBs,9 even with ultrasound guidance 10. Similarly, due to its depth and proximity to the neuraxis, this approach may be considered a more advanced regional anesthetic technique.…”

A randomised controlled trial of pectoral nerve‐2 (PECS 2) block vs. serratus plane block for chronic pain after mastectomy

“…The PECS 2 block reduced median (IQR [range]) morphine consumption in the first 24 h from 6 (3-9 [1-25]) mg after the serratus plane block to 4 (2-7 [0-37]) mg, p = 0.04. However, acute pain scores after serratus plane and PECS 2 blocks were similar, median (IQR [range]) 23 [0-70]) mm vs. 18 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27) [0-61]) mm, respectively, p = 0.44.…”

“…Thoracic epidural anaesthesia and thoracic paravertebral block have been associated with reduced chronic pain after mastectomy and thoracotomy [9][10][11][12][13][14]. In some rare cases, however, both techniques can cause complications, including hypotension, pneumothorax and haematoma [15][16][17]. Recently, ultrasound-guided thoracic interfascial plane blocks, which involve simple and easy-to-learn techniques, were developed as alternatives to thoracic epidural anaesthesia or paravertebral block [18,19].…”

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

“…Currently, no study has compared these techniques but the ultrasound-guided one is reasonably the most accurate and safe approach. The TPVB is easier and safer than TEA to perform, but it is not devoid of possible complications such as pneumothorax, hemodynamic compromise, or total spinal anesthesia (54)(55)(56)(57)(58). Thus, new approaches to the TPVB for breast surgery have been proposed: the retrolaminar block (RLB) and the midpoint transverse process to pleura block (MTP block) (59,60).…”