Case report
Erector spinae plane block for radical mastectomy: A new indication?
Bloqueo en el plano del músculo erector de la columna para mastectomía radical: ¿una nueva indicación?
Servicio de Anestesiología, Hospital Central do Funchal, Funchal, Portugal
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "112" "paginaFinal" => "115" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Veiga, D. Costa, I. Brazão" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Veiga" "email" => array:1 [ 0 => "nocas_veiga@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Costa" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Brazão" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Hospital Central do Funchal, Funchal, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo en el plano del músculo erector de la columna para mastectomía radical: ¿una nueva indicación?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1213 "Ancho" => 1583 "Tamanyo" => 192471 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In plane approach at the level of T5. Upper thoracic ultrasound. TM: trapezius muscle; RMM: rhomboid major muscle; ESM: erector spinae muscle; T5 TP: T5 transverse process; arrow: needle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Radical mastectomy is a surgical procedure that is often associated with moderate to severe post-operative pain for which opioids are usually prescribed. Effective pain management preserves the immune system by suppressing the stress response to surgery and reducing the need for opioids in the post-operative period.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Acute pain management after mastectomy reduces the incidence of chronic pain. Regional pain management techniques improve acute pain management and prevent the appearance of chronic pain.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The erector spinae plane block (ESB) was firstly described in September 2016, by Forero et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> in the context of chronic thoracic neuropathic pain and pain management during thoracoscopic surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe a case involving left radical mastectomy under combined anesthesia (ESB and general anesthesia), discussing the follow up measures and the advantages of the technique.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 40-year-old woman, weight 81<span class="elsevierStyleHsp" style=""></span>kg, height 168<span class="elsevierStyleHsp" style=""></span>cm, non-smoker, who was scheduled for left radical mastectomy due to breast cancer after a course of chemotherapy. The preoperative evaluation revealed no other pathology. The patient had no regular medication, no allergies, and no history of alcohol consumption.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In view of the potential immunosuppressive effect of opioids and their negative impact on cancer surgery outcomes described by Sacerdote et al., <a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> albeit unconfirmed in humans according to Cronin-Fenton et al.,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> we decided to perform ESB before the induction of general anesthesia. This combined technique has several advantages: it reduces intra-operative opioid consumption, avoids post-operative opioid consumption, allows mobilization of the left arm (ipsilateral to the resected axillary ganglion), and reduces the risk of post-operative chronic pain.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Monitoring was started and the ESB was performed in the block room under ultrasound guidance (S-Nerve, SonoSite, USA). The patient was placed in the sitting position and the spinous process of the fifth thoracic vertebra (T5) was identified with the probe in longitudinal position (HFL50x, SonoSite, USA). We proceeded with left lateral scanning, searching for the T5 transverse process (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Once identified, a 5<span class="elsevierStyleHsp" style=""></span>cm needle (Echoplex, Vygon, France) was inserted in plane in a cephalad to caudal direction until the tip lay in the interfascial plane between rhomboid major and erector spinae muscles, at the level of T5 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Once in place, 20<span class="elsevierStyleHsp" style=""></span>ml of levobupivacaine 0.5% were injected under the erector spinae muscle (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The local anesthetic spread in a longitudinal pattern. After performing the block, the patient was positioned in the supine position. Thirty minutes later, the level of blockade was evaluated. The area of diminished sensation to pinprick extended from T2 to T8 in the posterior and anterior chest wall. The inferior axillary region was also anaesthetized, with diminished sensation to pinprick (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>, adapted from <span class="elsevierStyleItalic">Netter's Clinical Anatomy</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>). After confirmation of the blockade, induction of general anesthesia was performed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Intravenous induction was performed with 60<span class="elsevierStyleHsp" style=""></span>mg of lidocaine, 100<span class="elsevierStyleHsp" style=""></span>mcg of fentanyl and 150<span class="elsevierStyleHsp" style=""></span>mg of propofol. A supraglottic device was inserted and anesthesia was maintained with sevoflurane. No further doses of fentanyl were required, and the patient remained stable throughout the procedure. Thirty minutes before the end of surgery, 30<span class="elsevierStyleHsp" style=""></span>mg of ketorolac, 1<span class="elsevierStyleHsp" style=""></span>g of paracetamol and 4<span class="elsevierStyleHsp" style=""></span>mg of ondansetron were administered.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After emergence, the patient was transferred to the post anesthesia care unit (PACU), where she remained hemodynamically stable. She reported upper axillary pain of 4 on a 10-point numerical rating scale (NRS), and 2<span class="elsevierStyleHsp" style=""></span>g of metamizole were administered. At discharge, 1<span class="elsevierStyleHsp" style=""></span>h after transfer to the PACU, pain was NRS 1. For post-operative analgesia, 30<span class="elsevierStyleHsp" style=""></span>mg of ketorolac every 8<span class="elsevierStyleHsp" style=""></span>h for 24<span class="elsevierStyleHsp" style=""></span>h and 1<span class="elsevierStyleHsp" style=""></span>g Paracetamol every 8<span class="elsevierStyleHsp" style=""></span>h for 48<span class="elsevierStyleHsp" style=""></span>h were prescribed. If pain reached NRS<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>5, 2<span class="elsevierStyleHsp" style=""></span>g of metamizole could be administered.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was evaluated at 24 and 48<span class="elsevierStyleHsp" style=""></span>h to assess pain management and sleep quality. The patient reported a pain of NRS 0 on movement and at rest, with full range of movement in the left arm. Pain was evaluated every 4<span class="elsevierStyleHsp" style=""></span>h, and no rescue analgesia (metamizole) was required during her stay. The patient reported no insomnia at any time, and no hypnotics were required.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">ESB is a simple regional anesthesia technique with a good safety profile. After it was first described by Forero et el., studies evaluating this blockade in various surgical procedures have been published. In 2017, Hamilton et al. described a case of ESB for pain management of several rib fracture.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In the same year, Chin et al. described the analgesic effect of ESB for ventral hernia repair, in this case performed at the seventh thoracic vertebrae (T7).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> In May 2017, the first experience with ESB for breast surgery was described in the case of a patient undergoing breast implant replacement.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In 2015, Roué et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> described an intercostal/paraspinal block technique for thoracic surgery that resembles ESB. However, ESB uses a more medial approach to a point upstream of the division of the ventral and dorsal rami of the thoracic nerves, where there are no structures at risk of needle injury in the immediate vicinity.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Anesthesia and surgery affect the immune response. Opioid-induced changes in the immune system have been reported in HIV positive patients and intravenous drug users. The effect of these drugs in patients receiving chemotherapy treatment and in the postoperative period is not fully understood, but is likely to be detrimental.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">To the best of our knowledge, based on the results of a search for similar studies in the literature, this is the first description of the use of ESB in radical mastectomy. Further studies are needed to confirm the efficacy of this technique.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0070" class="elsevierStylePara elsevierViewall">ESB is a novel, easy to use technique with a good safety profile that has attracted much attention in recent months, and appears to be a good regional technique for radical mastectomy.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The duration of analgesia, the extent of the blockade (including the axillar region), and the possibility of opioid avoidance in the postoperative period appear to favor the use of this technique in oncologic breast surgery.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres982035" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec949617" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres982034" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec949618" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-07-05" "fechaAceptado" => "2017-08-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec949617" "palabras" => array:4 [ 0 => "Regional anesthesia" 1 => "Pain management" 2 => "Mastectomy" 3 => "Erector spinae" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec949618" "palabras" => array:4 [ 0 => "Anestesia regional" 1 => "Terapéutica del dolor" 2 => "Mastectomía" 3 => "Erector spinae" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The erector spinae plane block is a technique recently described by Forero et al. in September 2016. It has applications in the control of chronic pain with neuropathic component of the chest wall, and for pain control in thoracoscopic surgery. In this article, we describe the use of this technique as part of a multimodal analgesic approach in a 40-year-old woman, who underwent radical mastectomy due to breast cancer. By performing this block before anesthetic induction, we have achieved an opioid sparing effect, avoiding a possible immunomodulatory effect, although not yet proven in humans. During hospitalization, the patient reported no pain (0/10 in numeric scale), without resorting to rescue analgesia. The easy, fast and safe execution of erector spinae plane block makes it a promising technique in the context of surgical pain during radical mastectomy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El bloqueo de la fascia del músculo erector de la columna es una técnica recientemente descrita por Forero et al. en septiembre de 2016. Tiene aplicaciones en el control del dolor crónico con componente neuropático de la pared torácica, y para el control del dolor en cirugía toracoscópica. En este artículo, describimos el uso de esta técnica como parte de un enfoque analgésico multimodal en una mujer de 40 años, que fue sometida a una mastectomía radical a causa de un cáncer de mama. Al realizar este bloqueo antes de la inducción anestésica, conseguimos un efecto ahorrador de opioides, evitando el posible efecto inmunomodulador, que todavía no está comprobado en humanos. Durante la hospitalización, la paciente no reportó dolor (0/10 en escala numérica), sin recurrir a analgesia de rescate. La ejecución fácil, rápida y segura del bloqueo de la fascia del músculo erector de la columna hace que esta sea una técnica prometedora en el contexto del dolor quirúrgico durante la mastectomía radical.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Veiga M, Costa D, Brazão I. Bloqueo en el plano del músculo erector de la columna para mastectomía radical: ¿una nueva indicación? Rev Esp Anestesiol Reanim. 2018;65:112–115.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1180 "Ancho" => 1583 "Tamanyo" => 260683 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Upper thoracic ultrasound. TM: trapezius muscle; RMM: rhomboid major muscle; ESM: erector spinae muscle; T5 TP: T5 transverse process.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1213 "Ancho" => 1583 "Tamanyo" => 192471 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In plane approach at the level of T5. Upper thoracic ultrasound. TM: trapezius muscle; RMM: rhomboid major muscle; ESM: erector spinae muscle; T5 TP: T5 transverse process; arrow: needle.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1214 "Ancho" => 1583 "Tamanyo" => 153065 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">View of the needle in plane, showing spread of local anesthetic. TM: trapezius muscle; RMM: rhomboid major muscle; ESM: erector spinae muscle; T5 TP: T5 transverse process; arrow: needle; LA: local anesthetic.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1717 "Ancho" => 1583 "Tamanyo" => 470482 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Extent of the area of diminished sensation to pinprick (outlined in purple on a volunteer).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of ketamine added to local anesthetic in modified pectoral block for management of postoperative pain in patients undergoing modified radical mastectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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