Ultrasound‐Guided Serratus Plane Block for Treatment of Postmastectomy Pain Syndromes in Breast Cancer Patients: A Case Series

Abstract

Postmastectomy pain syndrome is common after surgical treatment for breast cancer and may be challenging to manage. Currently, there are a wide variety of approaches to treat this type of pain, including medications, physical therapy, and interventional procedures. However, because of the complexity of innervation of the breast, the serratus plane block may better target the web of nerves innervating the anterior chest wall including the breast. We present a case series of 8 patients who were successfully treated with serratus plane block for pain after treatment for breast cancer. We feel that this particular application for the serratus plane block deserves further investigation, as it is relatively easy to perform and has good clinical utility for this type of pain.

Too Deep or Not Too Deep?

“…First, no trials have previously compared these 2 block techniques. While proponents of the "original" superficial serratus block have described successful analgesia without the potentially hazardous need for advancing the needle deeper toward the pleura, 3,5,8,[10][11][12][13] thoughtful consideration of anatomy arguably favors the deep serratus block as injection in the fascial plane below the serratus muscle theoretically facilitates blockade of higher-order lateral cutaneous intercostal nerves, which are known for their extensive ramification and collateral branching. 32 Our current findings encourage the transition to the deep serratus block in centers seeking alternatives for the superficial serratus block.…”

“…9 Indeed, effective analgesia, along with theoretical technical advantages, has been reported with each of these 2 block techniques for a variety of chest wall and thoracic surgeries. [1][2][3][4][5]8,[10][11][12][13][14][15] Our use of the superficial serratus plane block has posed several practical concerns to the breast oncologic surgeons, including (i) spread into the axilla, thus disrupting the surgical tissue planes; (ii) block of the long thoracic and thoracodorsal nerves, 8 thus interfering with surgeons' effort to identify these nerves (tweaking by forceps) 16 to preserve them; and (iii) needling through potentially metastatic lymph nodes, theoretically increasing the risk of tumor seeding. [17][18][19] By contrast, the deep serratus plane block performed more posteriorly, along the posterior axillary line, seems to mitigate these concerns.…”

“A Tale of Two Planes”

“…We have previously reported improved pain control with the SSPB, but we also illustrate the possibility that in certain situations a deep block may be preferred. 6 In either case, targeting the serratus plane seems to be a safe and, perhaps, simpler procedure than multiple intercostal or paravertebral blocks for anterior chest wall or PMPS.…”

A review of Recent Advances in the Management of Breast Cancer Related Pain

“…Further support for the use of the serratus anterior block as a treatment for chronic pain relating to treatment for breast cancer can be seen in a case report by Takimoto et al utilizing a series of serratus plane blocks for a woman with chronic pain after surgery for breast cancer. Repeating these blocks allowed the woman to participate more readily in other modalities such as physical therapy and over time she improved to the point of no longer requiring interventional treatment [42].…”