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array:24 [ "pii" => "S2341192921000871" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.11.004" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1269" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:338-45" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935620303248" "issn" => "00349356" "doi" => "10.1016/j.redar.2020.11.012" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1269" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2021;68:338-45" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Papel del bloqueo ecoguiado del plano del músculo serrato en el dolor neuropático crónico tras una cirugía de mama en una paciente de cáncer" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "338" "paginaFinal" => "345" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 1207 "Tamanyo" => 131134 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Técnica SPB: la aguja se introduce hacia la 5ª costilla, para alcanzar el plano profundo del músculo serrato anterior.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">LA: anestésico local.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.J. dos Santos Rodrigues da Silva, M.L.N. 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Delgado-Sánchez, G.M. Gutiérrez, J.L. López Romero, M.M. Martínez Gómez, A. Domínguez Blanco" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "de la Matta" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Delgado-Sánchez" ] 2 => array:2 [ "nombre" => "G.M." "apellidos" => "Gutiérrez" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López Romero" ] 4 => array:2 [ "nombre" => "M.M." "apellidos" => "Martínez Gómez" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Domínguez Blanco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003493562030267X" "doi" => "10.1016/j.redar.2020.10.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493562030267X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000883?idApp=UINPBA00004N" "url" => "/23411929/0000006800000006/v1_202106271045/S2341192921000883/v1_202106271045/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S234119292100086X" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.01.001" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1278" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:309-37" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Consensus document for anaesthesiologist-assisted sedation in interventional cardiology procedures" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309" "paginaFinal" => "337" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso para la Sedación en procedimientos de intervencionismo en Cardiología" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1699 "Ancho" => 2953 "Tamanyo" => 485669 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Point-by-point radiofrequency ablation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Martinez-Dolz, A. Pajares, M. López-Cantero, J. Osca, J.L. Díez, P. Paniagua, P. Argente, E. Arana, C. Alonso, T. Rodriguez, R. Vicente, M. Anguita, J. Alvarez" "autores" => array:14 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Martinez-Dolz" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pajares" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "López-Cantero" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Osca" ] 4 => array:2 [ "nombre" => "J.L." "apellidos" => "Díez" ] 5 => array:2 [ "nombre" => "P." "apellidos" => "Paniagua" ] 6 => array:2 [ "nombre" => "P." "apellidos" => "Argente" ] 7 => array:2 [ "nombre" => "E." "apellidos" => "Arana" ] 8 => array:2 [ "nombre" => "C." "apellidos" => "Alonso" ] 9 => array:2 [ "nombre" => "T." "apellidos" => "Rodriguez" ] 10 => array:2 [ "nombre" => "R." "apellidos" => "Vicente" ] 11 => array:2 [ "nombre" => "M." "apellidos" => "Anguita" ] 12 => array:2 [ "nombre" => "J." "apellidos" => "Alvarez" ] 13 => array:1 [ "colaborador" => "Working Group on Tutored Sedation in Interventional Procedures in Cardiology of the Spanish Society of Anesthesia Resuscitation and Therapeutic of Pain SEDAR and of the Spanish Society of Cardiology SEC" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621000517" "doi" => "10.1016/j.redar.2021.01.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621000517?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119292100086X?idApp=UINPBA00004N" "url" => "/23411929/0000006800000006/v1_202106271045/S234119292100086X/v1_202106271045/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "338" "paginaFinal" => "345" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.J. dos Santos Rodrigues da Silva, M.L.N. Ferreira, M. Fernandez Gacio, M.L.C. Miranda, Ana Agrelo" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M.J." "apellidos" => "dos Santos Rodrigues da Silva" "email" => array:1 [ 0 => "mjsilva2020@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.L.N." "apellidos" => "Ferreira" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Fernandez Gacio" ] 3 => array:2 [ "nombre" => "M.L.C." "apellidos" => "Miranda" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Agrelo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Anestesiología y Cuidados Intensivos, Instituto Portugués de Oncología de Porto, Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel del bloqueo ecoguiado del plano del músculo serrato en el dolor neuropático crónico tras una cirugía de mama en una paciente de cáncer" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 1207 "Tamanyo" => 131134 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">SPB technique: the needle is inserted at the level of the 5th rib until it reaches the deep plane of the serratus anterior muscle.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LA: local anaesthetic.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Breast cancer is the most common type of cancer among women worldwide.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Due to early diagnosis coupled with new effective treatments it is now among the cancers with the best prognosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Because of this, the number of breast cancer survivors has increased, and this in turn has led to an increase in the prevalence of surgery-related complications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Mastectomy is now one of the most widely performed surgical procedures. It is estimated that between 30% and 47% of patients who undergo this procedure develop chronic post-surgical pain (CPSP)<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> in the surgical field or in a referred pain area. Pain persists for more than 3 months after surgery, and must be distinguished from other types of pain, namely, recurrent or persistent cancer.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> CPSP can have nociceptive or neuropathic components, the latter being the most frequent and difficult to treat. The pain is probably neuropathic when it has a neuroanatomically plausible distribution and a somatosensory lesion is identified on neurological examination.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The neurological examination should focus on evaluating the presence of alterations in the territory innervated by potentially injured structures. In the specific case of chronic neuropathic pain after breast surgery (CNPBS), the territory of interest in the ipsilateral breast, upper abdominal wall, axilla and medial aspect of the arm. Structures that could be injured are the branches of the 2nd to 6th intercostal nerves and the nerves of the superficial cervical plexus, in other words, the supraclavicular nerves.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Various strategies are used to prevent CNPBS, including changing the anaesthetic technique, using locoregional techniques, or modifying the surgical approach to preserve the nerve structures, namely, the intercostobrachial nerve.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> A previous study conducted in our hospital found an incidence of CNPBS of 21.1% in the first year, and 23% in the third year.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In terms of anatomical organization, CNPBS can potentially be treated using the serratus plane block (SPB). Initially described by Blanco et al.,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> SPB consists of blocking the intercostal nerve in one of 2 planes, one superficial and the other deep to the serratus anterior muscle. The latissimus dorsi muscle lies superficial to the serratus anterior muscle and bounds the serratus plane externally. The ribs and the parietal pleura bound the deep plane. The administration of local anaesthetic in either space blocks the lateral cutaneous branches and the sensory innervation of the breast and anterolateral chest wall. According to the first articles describing SPB, some merely descriptive and others addressing its clinical application,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13–15</span></a> both planes can be used to provide sensory block to the breast.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this study, we describe our experience with a group of 30 patients with CNPBS who underwent SPB after pharmacotherapy proved ineffective. Our objective is to evaluate the efficacy and side effects of ultrasound-guided SPB in CNPBS patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We conducted a retrospective study of 30 patients diagnosed with CNPBS according to the criteria of the International Association for the Study of Pain (IASP) and the DN4 questionnaire. All patients underwent SPB between 2017 and 2019, and gave their informed consent to participate in the study. Patients were offered SPB if they met one of the following inclusion criteria upon arrival at the Pain Unit: severe pain (8–9 on a numerical pain scale [NRS]), side effects of chronic pharmacotherapy, breakthrough pain, or having reached the maximum dose of gabapentin (adjusted for renal function). Exclusion criteria were: bleeding disorders, documented allergies to local anaesthetics, or absence of an informed consent form. The following parameters were analysed: baseline pain, pain after 24 h, pain after one week (reported during a telephone interview) and pain after one month (reported during a telephone interview).</p><p id="par0030" class="elsevierStylePara elsevierViewall">An M-Turbo® ultrasound device (SonoSite, Bothell, WA, USA) with a 10–13 Mhz linear transducer was used in all procedures. The nerve blocks were performed using a 50 mm, 17–21 gauge echoplex echogenic needle (Vygon-France). Patients were placed in the lateral decubitus position with the operative side non-dependent. Using aseptic technique, and after subcutaneous infiltration of 1% lidocaine, the plane of the serratus muscle was identified on ultrasound. SPB was performed by inserting the needle in plane from the 4th to the 5th rib (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and depositing 15 ml of 0.2% ropivacaine and 80 mg of methylprednisolone in the deep plane. Patients who reported significant parasternal pain also received ultrasound-guided parasternal nerve block with 10 ml of 0.2% ropivacaine and 40 mg of methylprednisolone.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Continuous variables were described as median and 25th and 75th percentiles (P25-P75). Categorical variables were described as numbers (n) and percentages (%). The Mann-Whitney test was used to compare means. Statistical significance was set at p < 0.05. All statistical analyses were performed using SPSS 20.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Of the 30 patients initially recruited, 3 were excluded after pain had been attributed to other causes (2 patients with recurrent chest wall cancer and 1 with a rib fracture). Of the 27 patients included, 11 underwent axillary dissection during surgery. Sentinel node search was performed in the remaining patients. In this group of 16 patients, 11 underwent a partial mastectomy and 5 total mastectomy. In total, 22.2% (n = 6) of patients had previously been diagnosed with depression, and 59.3% (n = 16) had already undergone radiotherapy, a risk factor for chronic neuropathic pain. Mean age was 58 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The most common indication for SPB was the presence of side effects from the first-line medication prescribed for CNPBS (51.9%), followed by severe pain reported during a visit to the Pain Unit (22.2%). When offered SPB, 18 study patients were receiving gabapentin, 8 pregabalin, and 1 amitriptyline as first-line analgesia. Specific adverse effects that prevented adherence were: drowsiness (10 patients), dizziness (3 patients), visual disturbances (1 patient). The most frequent aetiology was pain in the intercostobrachial area (48.1%), followed by scar pain secondary to surgery-related injury to the anterior and lateral cutaneous branches of the intercostal nerves (29.6%).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Mean baseline pain intensity measured on the NRS was 7 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). We defined successful blockade using clinical criteria when pain intensity was reduced by at least 30% on the NRS scale at each follow-up evaluation. At 24 h, 74.1% of patients met the criteria for successful SPB; 44.4% of patients reported 30% less pain at 1 week, and 81.50% at 1 month. At 1 month, 71.4% reported a reduction in pain of at least 50% (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold"><span class="elsevierStyleUnderline">One month after SPB</span></span> we divided patients into 4 groups (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>):</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group I</span> - Patients reporting reduced pain at 1 month with no adjustment to their pharmacotherapy (progression):</p><p id="par0065" class="elsevierStylePara elsevierViewall">Eleven patients who continued with their pre-SPB gabapentinoid dosage had a reduction in pain severity of at least 30% at 1 month. Pre-SPB gabapentinoids were down-dosed in 2 patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In this group, all patients improved 24 h after the procedure, presenting a mean NRS pain score of 2 compared to the baseline score of 7. One week after the procedure, 8 patients reported a reduction in pain intensity of at least 30% on the NRS. The 3 remaining patients, despite reporting reduction baseline pain, continued to report localised parasternal pain. As this region is not completely covered by the SPB, these patients were offered parasternal nerve block, which was performed as described above. This additional procedure contributed to the mean NRS pain score of 3 reported during the 1-month follow-up evaluation.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the 3-month telephone or face-to-face follow-up evaluation, all patients in this group reported pain intensity levels similar to those reported during the 1-month follow-up evaluation.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In this group of patients, differences between the pain score at 24 h, 1 week, and 1 month after surgery and baseline pain score were statistically significant (p = 0.003).</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group II</span> - Patients reporting reduced pain at 1 month with adjustment to their pharmacotherapy (gabapentin monotherapy):</p><p id="par0090" class="elsevierStylePara elsevierViewall">Eight patients reported improvement in pain 1 month after SPB with progressive adjustment of their pharmacotherapy during this period. Mean baseline NRS pain score was 8, which was reduced to 3 points during the 1-month evaluation. In this group, 4 patients reported a reduction in pain intensity of at least 30% 24 h and 1 week after the procedure; this improvement was attributed directly to SPB. As pain levels remained moderate, gabapentinoids were gradually increased during the first month.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The remaining 4 patients reported improvement 24 h after surgery, but this effect subsided after 1 week. This explains the mean pain score of 5 one week after SPB (vs. 3.5 in the 24-h follow-up). As a result, gabapentinoid therapy was increased, thereby achieve satisfactory results 1 month after surgery. We assume that in this case improvement was due to therapeutic progression.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In this group of patients, differences between pain score at 24 h, 1 week, and 1 month after surgery and baseline pain score were statistically significant (p = 0.011).</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group III</span> - Patients reporting reduced pain 1 month after SPB with pharmacotherapy adjustment (polytherapy):</p><p id="par0110" class="elsevierStylePara elsevierViewall">Three patients reported no reduction in pain intensity of at least 30% 24 h or 1 week after SPB. Mean NRS pain score remained the same at baseline and 1 week after SPB (8). After evaluation, these patients received a combination of different analgesic therapies: topical capsaicin in 2 patients, and topical lidocaine and tramadol in the third patient. One month after the procedure, the patients reported a reduction in pain intensity of at least 30% (mean NRS score = 4), although this difference was not statistically significant.</p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group IV -</span> Patients with no reduction in pain intensity:</p><p id="par0120" class="elsevierStylePara elsevierViewall">Five patients did not report reduction in pain intensity at 1 month, despite starting different pharmacotherapies during this period. In this group of patients, differences between the pain score at 24 h, 1 week, and 1 month after surgery and baseline pain score were not statistically significant.</p><p id="par0125" class="elsevierStylePara elsevierViewall">There was a clinically relevant reduction in pain in 22 patients; in 19 cases, this was statistically significant. Eleven (40.7%) of these 19 patients reported improvement without the need for pharmacotherapy adjustment, and the remaining 8 (29.6%) required adjustment of gabapentinoids, which was given in monotherapy. In 4 of these 8 patients, SPB-induced pain reduction 24 h and 1 week after the procedure required only minor adjustment of gabapentinoids. This, in turn, reduced the risk of side effects and improved therapeutic adherence, since gabapentinoids are relatively slow-acting analgesics.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Six patients underwent parasternal nerve block: 3 from group I, 2 from group II, and 1 from group IV. In the patients from groups I and II, the block was performed 2 weeks after SPB because at that time persistent pain was located mainly at the parasternal level. In the patient who did not report improvement (group IV), parasternal nerve block was performed earlier, as soon as she reported persistent pain.</p><p id="par0135" class="elsevierStylePara elsevierViewall">No complications were reported in any patients during this study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">In our study, a significant percentage of patients experienced improvement in pain: 40.7% (n = 11) without the need for pharmacotherapy adjustment, and 29.6% (n = 8) with gradual up-dosing of gabapentinoids in monotherapy. In the first group, our data show that the statistically significant reduction in pain intensity over the study period was clearly due to SPB, because no new pharmacotherapy was started in these patients. In the second group, the slow therapeutic progression of gabapentinoids was taken to be responsible for the statistically significant improvement in pain at 1 month. However, in this group, SPB was responsible for the reduction in pain intensity 24 h and 1 week after the procedure. This is because the analgesic effect of gabapentinoids would not have been felt for 1 week, and during this time SPB reduced the intensity of pain while gabapentinoids were gradually up-dosed. This also reduced the incidence and intensity of gabapentinoid side effects and improved therapeutic compliance, and ruled out the need to progress to combination therapy.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The first line of treatment for neuropathic pain consists of gabapentinoids or antidepressants in monotherapy, which can be combined with other drugs, such as topical lidocaine and capsaicin patches and opioids if unsuccessful.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Various studies have reported the use of nerve blocks in these patients as an additional option. Specifically, various blocks have been described for CNPBS, including the intercostal nerve block, the stellate ganglion block, and the paravertebral nerve block, with varying degrees of success.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> Nerve blocks are an alternative to pharmacotherapy. They control pain while analgesic drugs are gradually up-dosed until good management is achieved in monotherapy. They also avoid progression to polypharmacy and unnecessary side effects. In this study, SPB allowed us to control CNPBS while maintaining 70.1% (n = 19) of patients on gabapentinoid monotherapy.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The mechanisms by which nerve blocks help control neuropathic pain are not yet fully understood. The analgesic effect is known to last longer than the expected effect of drugs in monotherapy, and can be extended beyond the area covered by the dermatome of the blocked nerve. Some authors have suggested that nerve blocks eliminate or reverse central sensitization, thereby enhancing the effect of the technique.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Corticosteroids are known to exert an anti-inflammatory effect on injured nerves, and their membrane-stabilising effect suppresses ectopic neural discharge.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">There are no controlled studies on the analgesic effect of nerve blocks in neuropathic pain. Vlassakov et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> conducted a systematic analysis to evaluate the effect of peripheral nerve blocks with local anaesthetics to treat neuralgia. The authors searched MEDLINE and Embase between 1969 and 2010 and found 12 articles. Although these were either case reports or case series, but no controlled studies, they provided important data that can be used to evaluate the quality of the evidence: the large magnitude of the effect (more than half of the patients experienced >50% pain relief), and the consistency of the results reported (all articles reported pain relief). Nine articles evaluated the outcome of a specific nerve block in a total of 69 patients, 30 (43%) of whom experienced complete pain relief, often with a longer-than-expected duration of effect, given the drugs used. The remaining studies evaluated various nerve blocks simultaneously, and showed positive results in all 270 study patients.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The introduction of ultrasound-guided chest wall blocks has provided a new approach to treating the type of nerve injury that is responsible for postoperative chronic neuropathic pain in breast cancer, while avoiding the problems commonly associated with central techniques, such as epidural and paravertebral block.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–24</span></a> Two such alternative nerve blocks that are relatively easy to administer are SPB and erector spinae block, both of which, unlike the intercostal block, are single-injection techniques. PECS I and II blocks have given greater insight into the innervation of the breast and the administration of anaesthesia in this region,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> but SPB specifically targets the nerves innervating the breast and the anterolateral chest wall.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The breast has a complex, segmental sensory innervation consisting of the anterior and lateral cutaneous branches of the 2nd to 6th intercostal nerves. Arising from the thoracic spinal nerves, each intercostal nerve courses through the plane separating the internal and deep intercostal muscle. The lateral cutaneous branches arise near the angle of the rib, pierce the intercostales externi and serratus anterior, and divide into anterior and posterior branches. After the emergence of the lateral cutaneous branches, the remaining intercostal nerve courses anteriorly to become an anterior cutaneous branch. These branches pierce the transverse thoracic muscle, emerging in the parasternal line where they divide into the lateral and medial branches. They innervate the anterior chest wall medial to the midclavicular line, together with the anterior division of the lateral cutaneous branch of the intercostal nerve. The latter courses anteriorly over the edge of the pectoralis major muscle before entering the parenchyma of the breast. Cranially, the nerve structures of the superficial cervical plexus, particularly the supraclavicular nerves, also provide innervation to the upper part of the breast. Arising from the brachial plexus, the medial and lateral pectoral nerves, though supplying the motor innervation to the pectoral muscles, also play a role in this complex sensory system. Injury to any of these nerve structures can potentially contribute to the development of post- mastectomy neuropathic pain. Ultrasound-guided SPB is easy to perform, highly reproducible, and has minimal side effects.</p><p id="par0165" class="elsevierStylePara elsevierViewall">SPB, however, does not cover the anterior cutaneous branches of the intercostal nerves, which are responsible for innervating the internal mammary region. Therefore, chronic pain may persist in this region after SPB, and must be treated using additional analgesic techniques. Piraccini et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> reported the case of a patient diagnosed with post-thoracotomy pain syndrome who reported persistent pain in the internal mammary region after PBS. In this patient, the parasternal block (associated in this case with blockade of the transverse thoracic muscle plane) gave excellent pain control that extended to the internal mammary region. In our study, we performed parasternal block as an adjunct to SPB in 6 patients who presented pain localized in the internal mammary region after SPB; the technique gave good pain control in 5 of these patients.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Several articles have recently described the use of SPB in different anaesthetic techniques targeting the chest wall, and others have discussed the role of this block to treat chronic post-mastectomy syndrome. Takimoto et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> first described the use of SPB with 10 ml of 1% lidocaine repeated 10 times over 6 months at 2- to 4-week intervals in a patient with CNPBS. They observed a sustained reduction in pain that continued for 11 months after the last block. Following this, Zocca et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> published a case series of 8 patients who were treated with SPB for CNPBS. Results ranged from 25% pain relief to almost complete pain relief, with no reported complications. These authors performed SPB with a local anaesthetic and corticosteroids. The analgesic effect lasted from between 2 to 3 days to 12 weeks, and was repeated in 50% of the patients. It should be noted that some women continued to report no pain at the end of the study, and were still under follow-up.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Ours is the first structured analysis of the response to SPB up to the end of the first month in a large sample of patients with CNPBS of diverse origin recruited from our unit. We also analyse the therapeutic strategies applied to each patient.</p><p id="par0180" class="elsevierStylePara elsevierViewall">We argue that the deep plane approach is preferable in our oncological context, given the risk of radiotherapy-induced fibrosis of the thoracic fascia inhibiting the spread of the local anaesthetic, a situation also reported by Zocca et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> In addition, the latissimus dorsi muscle was dissected from the thoracodorsal nerve during axillary dissection. This procedure can promote fibrosis in the plane between the latissimus dorsi and the serratus anterior muscle, thereby restricting anaesthetic spread to the axilla and, therefore, to the anterior lateral cutaneous branch of the 2nd intercostal nerve (intercostobrachial nerve), as recently described by Piracha et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> This is important in this context, since the intercostobrachial nerve is often a source of neuropathic pain in these patients.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> As SPB is a fascial block, restricted spread caused by radiation therapy and axillary dissection can significantly affect the success of the block. We believe that these factors had no significant effect on nerve block success in our patients because we injected the anaesthetic into the deeper plane.</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study has several limitations. First, being a retrospective analysis of patients who underwent SPB, some were eliminated from the study if their data were incomplete. Pain was assessed during a telephone interview 1 week after the intervention; therefore, it was impossible to perform a detailed physical examination that would have revealed any slight alteration in the area of pain distribution. Patients were followed up for 1 month after SPB. We were therefore unable to draw conclusions regarding the effect that the block on the long-term course of CNPBS, not only with respect to the intensity of pain, but also to other pharmacological requirement, or the need to repeat the SPB. Because of our small sample, we were unable to identify which patients most benefitted from SPB as a therapeutic option for CNPBS.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0190" class="elsevierStylePara elsevierViewall">Peripheral nerve blocks can be an important tool in controlling neuropathic pain. SPB is a novel, single-injection, ultrasound-guided block that targets the breast, and thus reduces possible collateral effects (such as pneumothorax). Ours is the first structured analysis of the response to SPB up to the end of the first month in a large sample of patients with CNPBS. Randomized studies are needed to better evaluate the effects of SPB, and to identify which patients would most benefit from this technique.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0195" class="elsevierStylePara elsevierViewall">This study did not receive any financial support.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1534430" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1391147" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1534429" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1391146" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-08-26" "fechaAceptado" => "2020-11-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1391147" "palabras" => array:5 [ 0 => "Cancer" 1 => "Postoperative pain" 2 => "Chest pain" 3 => "Neuropathic pain" 4 => "Serratus plane bloc" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1391146" "palabras" => array:5 [ 0 => "Cáncer" 1 => "Dolor postoperatorio" 2 => "Dolor torácico" 3 => "Dolor neuropático" 4 => "Bloqueo del plano del músculo serrato" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Breast cancer is the most commonly occurring cancer among women. Among its treatment sequelae is chronic neuropathic pain after breast surgery (CNPBS). Pain management is difficult and classicaly consists in a pharmacological approach, however recent studies have advocated the use of locoregional techniques as adjuvants. Serratus plane block (SPB) has recently emerged as a potential tool for the control of CNPBS. This study aims to evaluate the efficacy and potencial role of the ultrasound-guided SPB on CNPBS.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A retrospective analysis was performed on 30 patients with CNPBS refractory to drug therapy, who underwent SPB between 2017–2019. The following parameters were analyzed: basal pain, pain at 24 h, 1 week and at 1 month. The Mann-Whitney test was applied. Statistical significance was considered at the level of p < 0.05. All statistical analysis was performed with SPSS 20.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">3 patients were excluded. At 24 h, we report pain improvement (at least 30% reduction on basal pain score) on 20 patients and after 1 week on 12. At 1 month after, 22 patients had improved, from these: 11 improved with no therapeutic adjustment; 11 patients improved with therapeutic adjustment (8 in gabapentinoid monotherapy, 3 with introduction of polytherapy). 5 patients didn’t improve.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Our study demonstrated SPB as a valid alternative for CNPBS management when pharmacologic therapy has been proven insufficient, with no side effects reported. Randomized studies are needed to assess the magnitude of SPB on CNPBS and to identify the patients who benefit the most from SPB.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El cáncer de mama es el tipo de cáncer más frecuente entre las mujeres. Entre las secuelas de su tratamiento se encuentra el dolor neuropático crónico tras la cirugía de mama (CNPBS). El tratamiento del dolor es difícil y consiste normalmente en una terapia farmacológica aunque, sin embargo, los estudios recientes han defendido el uso de técnicas locorregionales como adyuvantes. El bloqueo del plano del músculo serrato (SPB) ha surgido recientemente como herramienta potencial para controlar el CNPBS. El objetivo de este estudio es evaluar la eficacia y papel potencial del SPB ecoguidado en el CNPBS.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se realizó un análisis retrospectivo en 30 pacientes con CNPBS refractario a terapia farmacológica, sometidas a SPB entre 2017 y 2019. Se analizaron los parámetros siguientes: dolor basal, dolor a las 24 horas, una semana y un mes. Se aplicó la prueba de Mann-Whitney. Se consideró significación estadística al nivel de p < 0,05. Todos los análisis estadísticos se realizaron utilizando SPSS 20.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Tres pacientes fueron excluidas. Transcurridas 24 horas, reportamos mejora del dolor (al menos una reducción del 30% sobre la puntuación del dolor basal) en 20 pacientes, y en 12 transcurrida una semana. Al cabo de un mes, 22 pacientes habían experimentado mejora, de los cuales: 11 mejoraron sin ajuste terapéutico, 11 pacientes mejoraron con ajuste terapéutico (ocho con monoterapia de gabapentinoides, tres con introducción de politerapia), y cinco pacientes no experimentaron mejora.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Nuestro estudio demostró que SPB es una alternativa válida para el tratamiento de CNPBS cuando la terapia farmacológica se ha mostrado insuficiente, no habiéndose reportado efectos secundarios. Son necesarios estudios aleatorios para evaluar la magnitud de SPB en CNPBS, e identificar a los pacientes que más se beneficiarían de SPB.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: dos Santos Rodrigues da Silva MJ, Lousame AA, Ferreira MLN, Fernandez Gacio M, Miranda MLC. Papel del bloqueo ecoguiado del plano del músculo serrato en el dolor neuropático crónico tras una cirugía de mama en una paciente de cáncer. Rev Esp Anestesiol Reanim. 2021;68:338–345.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 1207 "Tamanyo" => 131134 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">SPB technique: the needle is inserted at the level of the 5th rib until it reaches the deep plane of the serratus anterior muscle.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LA: local anaesthetic.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Median (P25-P75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (44−64) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Depression</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (22.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Radiotherapy</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (59.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Reason for blockade</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pharmacological side effects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (51.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intense pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (22.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Breakthrough pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (14.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maximum drug dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Type of pain</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intercostobrachial neuralgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (48.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Scar tissue pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (29.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neuroma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (18.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Phantom breast pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (3.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640538.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pain \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Median (P25-P75) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pain reduction ≥30% N (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (6−9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At 24 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (2−6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (74.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At 1 week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (4−7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (44.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At 1 month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3−4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (81.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain reduction 1 month after SPB</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At least 50%</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640537.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Evaluation of neuropathic pain after SPB.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:4 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reduction in pain intensity ≥30% at 1 month</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640533.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Need for pharmacotherapy adjustment</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640534.png" ] ] 2 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Drug adjusted \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gabapentinoid 8</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Others 3</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group: \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">II \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">III \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IV \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Reason for blockade</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pharmacological side effects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intense pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Breakthrough pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maximum drug dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Origin of pain</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intercostobrachial neuralgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Scar tissue pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neuroma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Phantom breast pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640536.png" ] ] 3 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pain (NRS)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Median (P25-P75)</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Median</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Start \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (6−9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (7−8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At 24 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0−4)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.5 (3−4)<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At 1 week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (0−5)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (4.3−5.8)<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At 1 month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (1−3)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3−4)<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640535.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">p = 0.003.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">p = 0.011.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Reduction of pain intensity according to NRS in each group.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence and mortality and epidemiology of breast cancer in the world" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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