American Society of Regional Anesthesia and Pain Medicine August 2016 - 41

PECS Versus PVBS for Perioperative Analgesic Management in
Breast Surgery

he main therapies for
breast cancer treatment
include local and
systemic therapies. Systemic
medical therapy can include
chemotherapy, hormone
therapy, and protein receptor
targeted therapy. Local therapy
includes surgery and radiation
therapy. The majority of women
diagnosed with breast cancer
will have some type of surgery
throughout the course of their
disease.

Besides epidurals and continuous wound infiltration, other choices
for regional techniques include uni- or bilateral PVBs and recently
described pectoral (PEC) I-II and serratus plane blocks.9 The
innervation of the breast involves the thoracic dermatomes of
T2-T6, and, when subpectoral expanders or implants are used,
one must also consider the innervation to the pectorals muscles
(pectoralis major and pectoralis minor).10

PARAVERTEBRAL BLOCKS
PVB for breast surgery is a well-described technique. It can be
performed either with ultrasound (US) guidance or as a landmarksbased technique. The PVB is essentially a nerve block of the
Jeffrey Gonzales, MD
ipsilateral spinal nerve. PVBs can be utilized as an analgesic or
Assistant Professor
anesthetic technique for breast surgery. The technique can involve
Department of Anesthesiology
a single or multiple one-time injections, or continuous catheter
University of Colorado
With the recent changes in the
technique.10 It is possible that the spread of local anesthetic can
Boulder, CO
health care environment, quality
encompass a few levels, both cephalad and caudad from the level
11
improvement and enhanced
Section Editor: Melanie Donnelly, MD of the initial injection. Risks of PVB include failed block, epidural
recovery pathways are becoming
spread, brachial plexus spread, hematoma, vascular puncture,
more important. The main objectives of these pathways revolve
pleural puncture, and pneumothorax. The risk of pneumothorax
around improving outcomes while minimizing risk for patients.
is quoted to be generally less than 0.5%.12 According to ASRA's
According to the National Surgery Quality Improvement Program
evidence-based guidelines for anticoagulated patients, the same
(NSQIP) data, the complication rate after breast surgery is about
precautions should be taken when placing thoracic PVBs as when
6% versus upwards of a 25% risk with colorectal surgery.1
placing an epidural.13
Although the percentage of complications may be significantly
lower in breast surgery, it seems reasonable to approach these
Anatomy. PVBs can be useful because, like epidurals, the
patients with anesthetic plans that offer the best opportunities
innervation of the posterior, lateral, and anterior branches of the
to decrease complications. Since one of the common causes for
intercostal nerve will be covered.8 PVBs can be performed using a
prolonged hospital admission or potential patient dissatisfaction
landmark/loss-of-resistance technique or under direct US guidance.
is acute postoperative pain,
The paravertebral space is a
an approach should greatly
wedge-shaped, anatomical
consider pathways for optimal
compartment that lies
recovery related to pain
adjacent to the vertebral
management.2,3
bodies. Paravertebral
injections are performed
The options for pain
just lateral to the vertebral
management should include
column using the ipsilateral
a multimodal regimen that
transverse process (TP) as a
involves oral and intravenous
boney landmark. The wedge(IV) medications. This approach
shaped paravertebral space
aims to minimize side effects
anatomically consists of
while optimizing outcomes.3,4
an anterior border (parietal
Regional techniques should be considered as part of the analgesic
pleura), posterior border (superior costo transverse ligament), and
regimen as well. The interest in regional techniques-namely,
medial border (intervertebral foramina/transverse process). The
paravertebral nerve blocks (PVBs) and epidurals-stems from the
superior and inferior borders are made up of the corresponding
desire to minimize the risk of chronic pain after breast surgery5,6
heads of the ribs above and below. The space itself contains
as well as taking advantage of possible impacts of this technique
fatty tissue, intercostal nerves, vessels, sympathetic chain, and
on the possibility of cancer recurrence.7,8 Thoracic epidurals may
dorsal rami communicantes. The paravertebral space also may
be considered a valid choice, especially for bilateral procedures.
be divided anteriorly and posteriorly by the endothoracic fascia.
However, many patients are discharged either the day of surgery or The relationship between the spinal nerves and the endothroacic
within 1 day postoperatively, making epidurals a less than optimal
fascia has been evaluated and remains unknown. However, exact
option.
placement of local anesthetic in relation to the endothoracic fascia

"Besides epidurals and continuous wound
infiltration, other choices for regional
techniques include uni- or bilateral PVBs
and recently described pectoral (PEC) I-II
and serratus plane blocks"

American Society of Regional Anesthesia and Pain Medicine
2016

41
3

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2016