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

Abstract

BackgroundParavertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique.MethodsSubjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB.ResultsBoth pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI −3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI −1.2 to −0.1; p=0.0043). No block-related adverse events occurred in either group.ConclusionsPVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1–2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery.Trial registration numberNCT03549234.

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

“…Swisher et al. [32] reported that the median (IQR) duration of block was 17.7 (9.7–20.1) h for erector spinae plane block vs. 16.0 (11.9–19.9) h for paravertebral block (p = 0.833). Moustafa et al.…”

Bilateral continuous erector spinae block versus multimodal intravenous analgesia in coronary bypass surgery. A Randomized Trial

“…Although this concept has changed recently, the fear of hematoma formation with systemic heparinization remains a crucial issue [4,5]. Therefore, the absence of major neurovascular bundles in and around the area of interest renders ESPB safe especially with anticoagulation [14,15]. Despite that, studies investigating the analgesic effect of ESPB in cardiac surgeries with sternotomy are scarce.…”

<p>Erector Spinae Plane Block and Paravertebral Block for Breast Surgery: A Retrospective Propensity-Matched Noninferiority Trial</p>

“…The results are also similar to those of previous clinical studies showing significantly higher pain scores up to around 6 h after ESPB compared with after TPVB in patients undergoing breast surgery. 11,14 Swisher et al showed that TPVB as compared with ESPB provided superior analgesia and reduced opioid consumption during Post-anesthesia Care Unit (PACU) stay after breast surgery. The median PACU length of stay was 105 min and 124 min in the TPVB and ESPB groups, respectively.…”

“…We showed that ESPB was performed in a shorter period of time than TPVB, as previous studies have shown. 14,31 This can be explained by the following two reasons. First, TPVB requires more careful needle handling and advancement of a needle for a longer distance to the target.…”

“…[10][11][12] However, whether ESPB has similar analgesic effects to TPVB for breast surgery is still inconclusive. 11,13,14 Moreover, information on sensory blockade after ESPB is still mostly limited in case reports. [15][16][17] Injectate administered by ESPB is expected to make a wide spread in the craniocaudal direction, yet the results of cadaveric studies show inconsistent and unpredictable dye spread with little spread to the paravertebral space.…”