<p>Preoperative ultrasound-guided multilevel paravertebral blocks reduce the incidence of postmastectomy chronic pain: a double-blind, placebo-controlled randomized trial</p>

Abstract

PurposeChronic postsurgical pain is a challenging problem after breast cancer surgery. This prospective, randomized, double-blinded, parallel-group, placebo-controlled trial was conducted to evaluate the influence of preoperative ultrasound-guided multilevel paravertebral blocks (PVBs) on chronic pain following mastectomy.Patients and methodsOne hundred eighty-four women were randomized to receive ultrasound-guided multilevel (T1–T5) PVBs with 5 mL of ropivacaine 0.5% or normal saline per level. The primary end point was the incidence of chronic pain at 3 months following mastectomy assessed by the brief pain inventory (BPI), while the secondary end points were the acute postoperative pain, the number of patients requiring rescue analgesia, postoperative nausea and vomiting (PONV), side effects, and chronic pain at 6 months after surgery assessed by the BPI.ResultsA total of 172 patients completed the study. Ultrasound-guided multilevel PVBs significantly decreased immediate postoperative pain for the first 12 hours (P<0.001). Additionally, fewer patients in the PVB group required rescue analgesia in the first 48 hours post-operatively compared to the control group (5/86 vs 28/86, OR =0.128, 95% CI: 0.047–0.351, P<0.001). No statistically significant difference was tested between the two groups (9.3% vs 17.4%, OR =0.419, 95% CI: 0.162–1.087, P=0.068) in the incidence of PONV. At 3 months, the incidence of chronic pain (BPI average pain score ≥3) was 34.5% and 51.2% (OR =0.511, 95% CI: 0.277–0.944, P=0.031) in the PVB and control groups, respectively, and at 6 months, the incidence was 22.1% and 37.2% (OR =0.479, 95% CI: 0.245–0.936, P=0.03), respectively. No complications occurred during the study.ConclusionThis study indicated that perioperative ultrasound-guided multilevel PVBs with ropivacaine improved acute postoperative pain and decreased postmastectomy chronic pain at 3 and 6 months postoperatively.

Pilot Study in Temporary Peripheral Nerve Stimulation in Oncologic Pain

“…However, some studies suggest that early intervention, including improved perioperative analgesia can reduce incidence. One prospective, randomized, double-blinded, placebo-controlled trial showed that one-time preoperative paravertebral blocks with local anesthetic at levels T1-5 before breast cancer surgery reduced risk of persistent pain at three and six months postoperative by 32.6% and 40.5%, respectively (21). We feel PNS of the proximal spinal nerves introduces a novel modality to consider in treating this patient population, as we demonstrated with Patient 1 in our case series.…”

“…Breast cancer is the most commonly diagnosed cancer among women with five-year survival greater than 90% (19). The prevalence of persistent pain after breast cancer treatment is 25-60% (20,21). Three of the common causes of chronic pain in these patients include intercostobrachial neuralgia from transection of the intercostobrachial nerve during surgery, radiation-induced cutaneous changes, and radiation-induced inflammation (20).…”

The Effect of Preoperative Ultrasound-Guided Erector Spinae Plane Block on Chronic Postsurgical Pain After Breast Cancer Surgery: A Propensity Score-Matched Cohort Study

“…Theoretically, RA could alleviate acute postoperative pain by blocking peripheral nociceptive input into the spinal cord, which contributed to spinal sensitization. Previous studies have reported that PVB and PECS could reduce incidence of chronic pain after breast surgery [22][23][24]. In a recent meta-analysis, the use of single-shot PVB has been shown to be protective against CPSP at 6 months following BCS, but the studies included are weakened by methodological limitations [12].…”

“Post Mastectomy Pain Syndrome: A Systematic Review of Prevention Modalities”

“… Ilfeld et al., 2018 27 Uni- or bilateral mastectomy Ultrasound- guided continuous PVB catheter 12 Presence of pain, pain intensity and interference (BPI) PVB catheter significantly decreased incidence ( P = 0.011 ) and intensity of pain ( P = 0.007 ). Qian et al., 2019 22 Unilateral partial mastectomy Ultrasound-guided single-injection multilevel TPVB 6 Presence of pain, pain intensity and interference (BPI) PVB significantly reduced severity ( P < 0.001 ). and incidence (P = 0.03 ) of chronic pain.…”