Published: 2021-09-28

Ultrasound guided erector Spinae plane block versus modified pectoral plane block in modified radical mastectomy: a prospective, randomized, single blinded study

Upasana Majumdar, Arun Deka, Jili Basing, Rajib Paul


Background: Modified radical mastectomy (MRM) is the most common surgery for cancer breast that is associated with marked postoperative pain. Effective control of this pain suppresses the surgical stress response and decreases the need for opioids and general anesthetics. This study was aimed to compare ultrasound guided erector spinae block (US-ESP) with modified pectoralis nerve block (US-PECS) in terms of post-operative pain scores as the primary objective, in patients undergoing MRM. The secondary objectives of our study were to compare the time of first rescue analgesic, total analgesic consumption and side-effects between the two groups.

Methods: Group E comprised of patients receiving 20 mL of 0.2% ropivacaine plus 0.5 µ/kg dexmedetomidine and it was injected in‑between erector spinae muscle and transverse process. Group P comprised of patients receiving 30 mL of 0.2% ropivacaine plus 0.5 µg/kg dexmedetomidine divided into 10 mL that was injected between the two pectoralis muscles in the inter-fascial plane and the remaining 20 mL was injected between the serratus anterior and the pectoralis minor muscle.

Results: Demographic profile was comparable between both groups. Both groups offered good analgesia, but PECS group took an upper hand up to the 6th post-operative hour (p<0.05). Beyond the 6th post-operative hour, analgesic efficacy of both groups was comparable

Conclusions: Modified pectoralis nerve block offered better analgesia over the erector spinae block technique up to 6th post-operative hour and it is more effective in terms of total rescue analgesic consumption and the time for request of first rescue analgesic, in patients posted for MRM.


Cancer breast, MRM, Erector spinae block, Modified pectoral nerve block

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Bland KI, Vezedis MP, Copeland EM 3rd. Breast. In: Schwartz SI, editor. Principles of Surgery. 7th ed. New York: McGraw Hill. 1999;576 9.

Fecho K, Miller NR, Merritt SA, Klauber Demore N, Hultman CS, Blau WS. Acute and persistent postoperative pain after breast surgery. Pain Med. 2009;10:708 15.

Gärtner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302:1985 92.

Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: A meta-analysis of randomized controlled trials. Br J Anaesth. 2010;105:842-52.

Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621-7.

Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012;59:470-5.

Kwekkeboom K. Postmastectomy pain syndromes. Cancer Nurs. 1996;19:37-43.

Vecht CJ, van de Brand HJ, Wajer OJ. Post-axillary dissection pain in breast cancer due to a lesion of the intercostobrachial nerve. Pain. 1989;38:171-6.

Altiparmak B, Korkmaz Toker M, Uysal Aİ, Turan M, Gümüş Demirbilek S. Comparison of the effects of modified pectoral nerve block and erector spinae block on postoperative opioid consumption and pian scores of patients after radical mastectomy surgery: A prospective, randomized, controlled trial. J Clin Anesth. 2019;54:61–5.

Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: A randomized clinical trial. Reg Anesth Pain Med. 2015;40:68-74.

Khemka R, Chakrborty A, Agrawal S, Ahmed R. Is COMBIPECS the answer to perioperative analgesia for breast surgery? A double blinded randomized controlled trial. Indian J Anaesth. 2019;63:530-6.

Bakshi SG, Karan N, Parmar V. Pectoralis block for breast surgery: A surgical concern? Indian J Anaesth. 2017;61:851-2.

Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: A randomized controlled trial. Br J Anaesth. 2016;117:382-6.

Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia. 2017;72:452-60.

Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43:567-71.