Long Thoracic Nerve Block in Video-Assisted Thoracoscopic Wedge Resection for Pneumothorax

Abstract

We hypothesised that relaxation of the serratus anterior muscle by long thoracic nerve (LTN) block could help pain relief after video-assisted thoracoscopic surgery. Patients undergoing thoracoscopic wedge resection for pneumothorax were randomly assigned to control or LTN block. LTN block was performed before induction of general anaesthesia. Pain was evaluated using a visual analogue scale before anaesthesia induction (T0), on arrival to the post-anaesthetic care unit (PACU) (T1), every ten minutes after arrival in the PACU for 30 minutes (T2, T3 and T4) and one hour and 24 hours after discharge from the PACU (T5 and T6). Visual analogue scale scores from T1 to T5 in the block group were lower than the control group (T1: 36±11 vs 48±14 [P=0.001], T2: 36±11 vs 51±15 [P <0.001], T3: 35±10 vs 52±15 [P <0.001], T4: 30±7 vs 45±17 [P <0.001] and T5: 26±5 vs 32±5 [P <0.001]). Total intravenous patient-controlled analgesia bolus dose (alfentanil 75 µg/ml) during PACU stay (1.6±1.2 vs 3.9±2.0 ml, P <0.001) and one hour after discharge from the PACU (0.5±0.8 vs 1.7±1.2 ml, P <0.001) in the LTN group was significantly lower than the control group. Total intravenous patient-controlled analgesia bolus dose from 1-24 hours after discharge from the PACU was similar between groups (P=0.197). These findings indicate that LTN block reduced pain after video-assisted thoracoscopic surgery from end-ofsurgery to one hour after discharge from the PACU.

<p>Effects of serratus anterior plane block for postoperative analgesia after thoracoscopic surgery compared with local anesthetic infiltration: a randomized clinical trial</p>

“…However, most patients complain about the pain of the chest tube after operation. The chest tube directly stimulates the contraction and spasm of the serratus anterior muscle, which aggravates the pain 15. Kwon et al, reported that improving anterior serratus muscle relaxation by blocking the long thoracic nerve (LTN) could reduce pain after thoracoscopic surgery 15.…”

“…The chest tube directly stimulates the contraction and spasm of the serratus anterior muscle, which aggravates the pain 15. Kwon et al, reported that improving anterior serratus muscle relaxation by blocking the long thoracic nerve (LTN) could reduce pain after thoracoscopic surgery 15. Traditionally, SAP block can block the cutaneous branch of intercostal nerve to relieve postoperative pain 16.…”

Analysis of the positional relationship of the long thoracic nerve considering clinical treatment

“…Chakraborty et al (2016) included the TDN and LTN as well as the ICN as target nerves for SAPB, and Mayes et al (2016) mentioned the possibility of motor nerves affecting the pain management. Ramamurthy et al (1990) and Kwon et al (2012) reported that the LTN could affect the sensory function, and Chen et al (2019) reported that blocking the LTN can manage pain by reducing the strain of the SA. LTN block is commonly known for using a nerve stimulator for injection to distinguish the LTN in the axillary region, but it would be more convenient if the plane block is used.…”

“…The fifth rib at the MAL, the pathway of the LTN, would be the injection point at this time (Blanco, Parras, McDonnell, & Prats‐Galino, 2013), and it is recommended to avoid blocking the LTN, as it is a motor nerve that has no relationship with sensory function (Biswas et al, 2018; Pérez, Duany, & de la Torre, 2015). However, some authors reported cases in which LTN block helped relieve pain from thoracoscopic surgery, as the strain caused by the inserted tube can magnify the pain (Chen, Li, Zhang, & Fang, 2019; Kwon et al, 2012; Ramamurthy, Hickey, Maytorena, Hoffman, & Kalantri, 1990; Steinthorsdottir, Wildgaard, Hansen, Petersen, & Wildgaard, 2014). Although the SAPB to a superficial plane is known for blocking the LTN, dye spread studies argue the efficacy of this method for blocking the LTN sufficiently (Chen et al, 2019; Kunigo, Murouchi, Yamamoto, & Yamakage, 2018).…”

Rhomboid Intercostal and Subserratus Plane Block

“…1,2 Chest wall blocks represent an umbrella term wherein a number of successful approaches have been described. The serratus anterior plane block 3,4 has been used for analgesia after breast surgery, [5][6][7][8] postmastectomy pain, 9,10 thoracoscopic surgery, 11,12 pain associated with rib fractures, shoulder surgery, [13][14][15][16] open thoracotomy, 17 and postthoracotomy pain. [18][19][20] The erector spinae plane block 21 has been used for acute postsurgical pain, posttraumatic pain 21,22 and chronic neuropathic pain conditions.…”