This topic concerns the use of regional anesthesia in patients undergoing breast reconstruction. There are various regional anesthetic techniques for breast reconstruction, but this topic will focus on using 5 selective nerve blocks for postoperative breast reconstruction. This activity describes and explains the inter-professional team's role in the management of peri-operative & postoperative pain.
Describe the nerves involved with the distribution of the breast in relation to breast surgery.
Identify the benefits of specific nerve blocks in the setting of breast surgery.
Summarize the contraindications to peripheral nerve blocks in breast surgery.
Review some interprofessional strategies that can enhance patient outcomes when using regional anesthesia in breast surgery.
Breast cancer is the most common cancer in women around the world. It is presented as the second cause of cancer deaths after lung cancer. The incidence of this aggressive disease with around 17,000,000 new cases each year becomes worrying and alarming. The risk of dying from breast cancer increases by 5% for every one-year reduction in age at diagnosis, indicating the presence of more aggressive phenotypes than breast cancers occurring later in life.
According to US breast cancer statistics, 42,170 women in the US are expected to die of breast cancer in 2020. Cancer mortality is not related to the primary tumor but often to recurrence or general metastasis. Surgery remains the main modality for the management of resectable breast cancer because it plays an important role in controlling locally advanced or metastatic disease.
After a mastectomy, reconstruction should be offered to all breast cancer patients. These are the recommendations of the National Institute for Health and Clinical Excellence (NICE), but the type of reconstruction to be used is currently at the discretion of the surgeon and patient. About 10% to 20% of patients experience acute postoperative pain, which may progress to chronicity known as postmastectomy pain syndrome.
The improvement of anesthesia factors has positive significance for promoting the rehabilitation of patients. Effective pain management is a crucial component in enhanced recovery after surgery; thus, proper follow-up with a pain physician could prove beneficial to those presenting with postmastectomy pain syndrome.
Several recent studies have shown a decrease in postoperative pain when regional anesthesia techniques are combined with general anesthesia during breast reconstruction surgery. These studies suggest that locoregional anesthesia is involved in controlling acute postoperative pain, reducing opioid consumption, leading to early revalidation, and reduced patient length of stay.
In this article, we will describe the main techniques of locoregional anesthesia involved in breast reconstruction surgery. These are paravertebral block, intercostal nerve block, erector spinae plane block (EPSB), pectoralis nerve block (Pecs), and serratus anterior plane blocks.
Anatomy and Physiology
Anatomy and landmarks will depend on the different types of blocks that can be made:
First discovered by Hugo Sellheim from Leipzig in 1905 and described by Lawen (1911) and Kappis (1919), but did not have much success until the late 1970s, thanks to the efforts of Eason and Wyatt who reevaluated thoracic paravertebral block (TPVB) and showed its beneficial effect on reducing postoperative pain.
The paravertebral space is delimited anterolaterally by the parietal pleura, posteriorly by the costotransverse ligament, medially by the vertebrae and intervertebral foramina, inferior and superior by the ribs. In this space, we perceive the division of the vertebral root, which emerges from the intervertebral foramen to give dorsal and ventral branches. The sympathetic chain lies in the same plane, in front of the intercostal nerve, and communicates with it via the rami communicates. Fig 1
Injection of local anesthetic along the thoracic vertebra near where the spinal nerves emerge from the intervertebral foramen will cause unilateral, segmental, somatic, and sympathetic anesthesia, including the posterior ramus in multiple thoracic dermatomes. This extension of the somatic and sympathetic blockade was evaluated by Cheema et al. (1995) using a thermographic imaging technique. A contralateral distribution of the paravertebral block was reported by Karmakar et al. (2000) with a contrast agent.
Intercostal Nerve Block
First described in the Die Lokalanastesie manual by Braun in 1907, today, it is used in thoracic and abdominal surgery to manage acute and chronic pain.
The thoracic nerves T1 to T12, after they emerge from the respective intervertebral foramina, give rise to the following rami: Fig 2
The anterior communicates rami, which pass anteriorly to the sympathetic ganglion and chain.
The posterior cutaneous rami, responsible for the innervation of the skin and muscles of the paravertebral region
The ventral ramus: gives rise to intercostal nerves.
Each intercostal nerve exists in a neurovascular bundle with an intercostal artery and vein; the nerve remains inferior to the two blood vessels—their paths in the thorax pass between the parietal pleura and the internal and external intercostal muscles. Near the midaxillary line, the nerves divide into a dorsal and ventral branch.
T1 and T2 support the innervation of the upper limbs and upper thorax, T3 to T6 cover the thorax, T7 to T11 supply the lower thorax and abdomen, and T12 the anterior gluteal region.
The injection of local anesthetic into the subcostal groove spreads both distally and proximally to block the ipsilateral sensory and motor fibers of the intercostal nerves.
Erector Spinae Plane Block
First described by Forero m et al.It concerns the paraspinal interfascial plane in which the infiltration applies between the erector muscle of the spine and the thoracic transverse processes. Fig 3
The local anesthetic administered ensures the blocking of the dorsal and ventral rami of the thoracic and abdominal spinal nerves, Which leads us to a multi-dermatomal sensory block of the anterior, posterior and lateral thoracic and abdominal walls. due to the cranial and caudal spread of the injected product.
Recent studies based on imagery highlight this diffusion of the injected local anesthetic, which passes through the connective tissues and towards the spinal nerve roots, thus allowing coverage of 3 to 4 cephalic and caudal dermatomes.
Pectoralis Nerve Block
The nerves involved in pectoral nerve block (PECS) I and II are the pectoral nerve, intercostal nerve 3-6, intercostobrachial nerve, and long thoracic nerve.
The Pecs I block anesthetizes both the medial pectoral nerve and the lateral pectoral nerve. It focuses on the interfacial region between the pectoralis major muscle and the pectoral minor muscle at the level of the third rib.
The PECS II, the anatomical region concerned, is located between the pectoralis major and the pectoralis minor as for a Pecs I block, followed by infiltration between the pectoralis minor and the serratus anterior, which will block the anterior skin branches of intercostal nerves 3 to 6, intercostobrachial nerves, and the long thoracic nerve.
Serratus Anterior Plane Blocks
First described by Blanco et al. in 2013, the anatomical region concerned is located between the latissimus dorsi and the anterior serratus muscle, on the mid-axillary line at the level of the fifth rib, thus exerting its analgesic effects on the lateral thoracic region. This effect is achieved by blocking the nerves of the axillary fossa, which includes the intercostobrachial nerve, the cutaneous intercostal nerve (T3-T9), the long thoracic nerve and the thoracodorsal nerve located in the compartment between the serratus anterior muscle and latissimus dorsi muscle, and between the posterior and midaxillary lines.
According to current literature, two-thirds of women who have had breast cancer surgery develop chronic pain.
Several recent studies suggest that regional anesthesia combined with general anesthesia is involved in controlling acute postoperative pain avoiding a transition to chronicity, reducing opioid consumption, which prevents side effects like nausea and vomiting, respiratory depression, and hallucinations in elderly patients, leading to early revalidation, and reduced patient length of stay.
Regional anesthesia has been widely implemented nowadays by anesthesiologists in breast cancer clinics because of its beneficial effects on reducing the resurgence of cancers demonstrated by several retrospective studies. Neshith Govil et al. even demonstrated that instillation of lignocaine to block the pectoral nerves allows better postoperative analgesia compared to other patients without regional anesthesia and decreases the secretion of angiogenesis markers, which contributes to tumor generalization.
Therefore, regional anesthesia is best indicated in patients with a history of chronic neuropathy who present with high opioid consumption before surgery or in patients with significant comorbidity factors in whom reduction of general anesthetics may be beneficial for their cardiorespiratory function and cerebral function.
The contraindications for regional anesthesia include:
Infection at the site of injection
Allergy to local anesthetics
Systemic anticoagulation (INR >1.4 or inadequate time since cessation of anticoagulant per ASRA guidelines)
The various locoregional anesthesia techniques for breast reconstruction surgery are currently performed under ultrasound to minimize the risks of nerve damage and pneumothorax for certain nerve blocks and requires the following equipment:
Ultrasound guidance with the high-frequency probe or low-frequency curvilinear probe depending on the depth of the block and the patient's body
Sterile sleeve and gel
One 23 to 25 gauge needle for skin infiltration
20 mL of local anesthetic
Needle size: 80mm B-bevel nerve block needle
1 pack of gauze 4-inch x 4-inch
Chlorhexidine gluconate solution for skin asepsis
Locoregional anesthesia must be performed by qualified anesthesia and resuscitation personnel capable of managing the complications. For some nerve blocks, Sedation is recommended depending on the patient's stress level.
The presence and assistance of a nurse trained in regional anesthesia are mandatory and beneficial to help the anesthesiologist in the proper functioning of the procedure and managing patient sedation if necessary.
According to WHO recommendations and guidelines, a full assessment of the checklist should be performed before installing the patient. An assessment of the patient's morbidity and mortality should be performed before. This evaluation should include medical history, physical examination, airway assessment, and analysis of preoperative tests.
The patient should be informed of the risks and benefits of regional anesthesia and the possible complications before obtaining informed consent.
The procedure should be performed in a clinic specializing in regional anesthesia. Patient monitoring is mandatory and should monitor pulse oximetry, electrocardiography, and blood pressure, as described in the American Society of Anesthesiologists standards for basic anesthetic monitoring.
Thoracic Paravertebral Block
The conventional technique relies on the loss of resistance described by Eason and Wyatt (1979) to locate the paravertebral space after penetration and passage of the needle through the superior costotransverse ligament to end in the space. However, this technique is less used by locoregional anesthesia centers because the importance of failure rates and complications such as the invasion of the parietal pleura that can lead to pneumothorax have led the authors to modify their technique and to using an ultrasound-guided approach to ensure the correct location of the space.
In 2009, a study based on cadaveric imaging Luyet et al. described a catheter placement in the paravertebral space under ultrasound guidance. Surgical disinfection should include the cervicothoracic para-vertebral areas up to the lower edge of the scapula. Protection of the ultrasound probe and cable with a sterile ultrasound probe cover is mandatory. Therefore, an initial ultrasound examination of T2 to T6 of the paravertebral region on the surgical site is performed. Transportable ultrasound equipment and a 50mm 15-6 MHz linear probe are used.
After identifying the spinous process T4 or T5 by decrementing from the prominent vertebra of C7, the ultrasound probe is positioned on the spinous process of T4; a lateral movement is then made to visualize the transverse process. An oblique movement of the probe allows visualizing the typical double layer of the internal intercostal membrane, the transverse process, and the pleura.
After skin infiltration with 1% lidocaine (1 ml), the guidance of the needle out of the plane with the needle positioned 1 cm caudal from the ultrasound probe is performed. Once the needle tip is in position between the internal intercostal membrane and the pleura, a local anesthetic is then administered over a period of 30 seconds after negative aspiration.
Erector Spinae Plane Block
After identifying the spinous process of the 5th thoracic vertebra (T5), the transverse process is traced laterally about 2.5 to 3 cm from the midline in a longitudinal position; it is identified as a hyperechoic curvilinear structure with acoustic shading below (a sign of the trident) we can also see the vertebral lamina (sawtooth pattern) and the spinous processes medially with the costochondral junction laterally. One can identify the famous three muscles, the trapezius, rhomboid major, and erector spinae deeper, which insert on the transverse process of T5. The parietal pleura moves according to the patient's breathing and visible as a hyperechogenic line between the transverse processes.
After skin disinfection, an 8 cm 22-G needle is inserted in the craniocaudal direction and advanced through the trapezius, rhomboid major, and erector spinae to contact the transverse process. The action must be done delicately. Hydrodissection with an injection of 2 to 3 ml of normal saline is necessary to confirm the correct placement of the needle. An injection of 20 ml of the local anesthetic into interfascial plane deep to erector spinae and linear pattern lifting the muscle is visible after this injection.
Serratus Plane Block
After skin disinfection around the mid-axillary line area, moving the probe laterally and distally allows viewing of the 4th and 5th ribs. The probe can be rotated in the coronary plane and tilted posteriorly until the serratus anterior muscle and latissimus dorsi muscle are identified. A local anesthetic is injected on the fascia between the serratus anterior muscle and latissimus dorsi muscle after local infiltration.
Pectoralis Nerve Block
The patient is placed in the supine position with the arm in abduction. The ultrasound probe (high frequency) is placed infraclavicular to the lateral third of the clavicle. It is then moved laterally to locate the axillary artery and the vein directly above the first rib. This allows us to identify the pectoralis major and pectoralis minor muscles. The pectoral branch of the thoracoacromial artery becomes visible on color Doppler at the level of the 2nd rib or sometimes pulsatile for good examiners. The needle is inserted under ultrasound control from the superomedial to the inferolateral direction between the pectoral muscles. The local anesthetic solution can then be injected (Pectoralis nerve block I). Then, the probe is moved towards the axilla to identify the serratus anterior muscle above the 2nd, 3rd and 4th ribs, the lateral border of the pectoralis minor, and Gerdy's ligament. The needle is then reinserted into the fascial plane between the pectoral minor muscle and the serratus anterior muscle; the local anesthetic is injected after a negative aspiration test (Pectoralis nerve block II).
Intercostal Nerve Block
It blocks the intercostal nerves' ipsilateral sensory and motor fibers; local anesthetic solution injected into the subcostal groove spreads distally and proximally. In adults, the injection site is at the angle of the rib (6 to 8 cm from the spinous processes). In children, the block is performed at the level of the axillary line posterior to the angle of the rib.
Ultrasound guidance reduces the risk of intravascular injection and pneumothorax. The probe is placed in a sagittal plane 4 cm laterally to the spinous process; the practitioner then visualizes the costal shadow and the parietal pleura, which moves with the patient's breathing. The needle can then be inserted in or out of a transducer plane and advanced to the lower edge of the rib. An injection of local anesthetic is then performed.
The practice of locoregional anesthesia techniques requires a thorough knowledge of the potential complications associated with each procedure.
Complications include, as with any act of regional anesthesia: infections related to sterilization errors, bleeding with the appearance of hematomas at the puncture site, nerve damage, and local anesthetic toxicity. History of coagulopathy or anticoagulation should be reported before any regional anesthesia procedure. Thanks to the existence and progress of ultrasound devices, ultrasound-guided techniques seem to have less risk of nerve or vascular damage.
A paravertebral and intercostal block should preferably be practiced in the awake patient because of the risk of pneumothorax and intraneural injection for the intercostal block.
For certain nerve blocks, dissemination of the local anesthetic is possible from the injection site far from its target, leading to serious complications.
Total spinal block with subarachnoid spread has been reported after intercostal block for thoracotomy. Lekhak and colleagues described total spinal block after insertion of a paravertebral catheter. Naja. Z et al. report a higher probability of vascular puncture and pneumothorax in the paravertebral bilateral block than in the unilateral block.
Other authors have cited inadvertent vascular puncture (6.8%), hypotension (4%), epidural or intrathecal spread.
Pulmonary hemorrhage has also been reported in patients who underwent thoracic surgery and who underwent paravertebral block.
Finally, Burlacu et al. (2005) and Crawley S M also reported an ipsilateral Horner syndrome after unilateral paravertebral anesthesia for breast cancer surgery by diffusion to the ipsilateral stellate ganglion.
These complications should raise awareness of the anesthesiologist and emphasize the importance of understanding anatomy before any regional anesthesia act or procedure.
Breast cancer surgery with breast reconstruction is a relatively heavy surgery that can lead to complications and nerve damage manifested by acute postoperative pain, including phantom breast pain, intercostobrachial neuralgia, or even neuropathic pain.
In some breast clinic centers, chronic pain symptoms at the operative site and ipsilateral upper limb may persist for up to 1 year after breast surgery or longer. Studies have reported a correlation of chronic pain to the extent of the invasiveness of surgical procedures: 49% for a mastectomy with reconstruction, 31% for mastectomy, and 22% for breast reduction.
The factors influencing this transition to chronicity are linked to the intensity of the acute postoperative pain, the type of operation performed with total lymph node dissection, the involvement of regional lymph nodes, and the per- and post-operative radiotherapy.
In the literature, several authors have demonstrated the impact and positive effect of locoregional anesthesia in breast surgery on the incidence of chronic pain, which allows a decrease in morbidity and, therefore, a reduction in the length of hospital stay due to a decrease in opioid needs. Aside from the beneficial effects on pain, some authors (Exadaktylos AK et al.) study the impact of regional anesthesia techniques during breast surgery on long-term oncological results. Thus an association between women who received regional paravertebral anesthesia and a significant decrease in the recurrence rate was demonstrated.
In fact, postoperative morbidity after cancer surgery can delay oncological treatment with adverse effects on cancer recurrence. Several studies have shown that regional anesthesia suppresses surgical stress response and reduces immunosuppression during the perioperative period because of reduced consumption of volatile anesthesia and opioids. It allows the immune system to eliminate residual cancer cells.
Randomized controlled trials (Wang L et al.) have shown a significant reduction in NK and T cell activity in patients who received locoregional anesthesia combined with general anesthesia. The effects of this regional anesthesia on tumor mediators are still poorly understood. uncontrolled pain in animals is known to suppress NK cells and promote metastasis.
Enhancing Healthcare Team Outcomes
In today's healthcare environment, breast reconstruction surgery must be performed in specialized breast clinics with multimodal pain management to reduce acute postoperative pain and its progression to chronicity. This also implies collaboration between inter-professional and multidisciplinary teams. The choice of the locoregional anesthesia technique in this surgery must take into account various factors, in particular, the opinion of the patient, the surgeon, and the preferences of the anesthesiologists who must be able to perform the nerve block without difficulty for patient safety it is advisable to follow specific guidelines and protocols to conduct adequate regional anesthesia procedures.
Nursing, Allied Health, and Interprofessional Team Interventions
To perform locoregional anesthesia safely qualified nursing team for the operating room and postoperative recovery is required. The nurses should be trained in post-anesthesia care units (PACU) and monitoring recovery from anesthesia and the success of analgesia.
Nursing, Allied Health, and Interprofessional Team Monitoring
Nerve blocks must be performed in a center equipped with vital sign monitoring devices for optimal monitoring of vital parameters and management of complications related to the toxicity of local anesthetics and nerve block and access to anesthesiologists for vigilant identification and treatment if complications arise.
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FIG 1. Anatomy of the thoracic paravertebral space, chest cavity and intercostal nerves.
Manoj K et al . NYSO RA courses
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Fig 2 : Anatomy of the intercostal nerve
Anthony M. et al . NYSO RA .courses
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Fig 3 : Longitudinal view at transverse process. ST - subcutaneous tissue , 1 (TZ) - Trapezius, 2(RM) - Rhomboid Major, 3(ES) - Erector Spinae, 4 - Transverse process, [S] - Superficial needle approach, [D] - Deep needle approach
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