Regional anesthesia techniques for breast surgery are an attractive anesthetic option given the evidence for improved overall recovery, the ability to decrease opioid use, and a possible role in decreasing the incidence of chronic postsurgical pain.1,2 Ideally, a regional technique would (1) provide complete coverage of the surgical region and (2) be simple to perform with minimal complications or risk. Paravertebral blockade is a useful technique but may be technically challenging, and some anesthesiologists may avoid this procedure out of concern for complications such as pneumothorax or subarachnoid injection.3,4
The erector spinae block is a novel interfascial plane block first described in 2016 to treat thoracic neuropathic pain.5 Injection of local anesthetic into the plane between the erector spinae muscle and transverse process can penetrate anteriorly to block the spinal nerves, resulting in analgesia of the ipsilateral anterior and posterior chest wall.5 Forero et al6 described thoracic analgesia with coverage of T2–T8 vertebral levels after an erector spinae block performed at the T5 transverse process. Chin et al7 described abdominal analgesia with coverage of T7–T11 dermatomes after blockade at the T7 transverse process. Cadaveric studies have shown extensive spread of contrast from C5 to L2 and intercostal spread after a single injection of 20 mL in the erector spinae plane at the T7 transverse process.8
We report a case of a patient with a history of opioid intolerance who presented for mastectomy and prepectoral tissue expander placement. This case describes the performance of an erector spinae plane block with liposomal bupivacaine in addition to a supplemental T1 paravertebral block for postoperative analgesia. Liposomal bupivacaine is an extended release bupivacaine formulation with approximately a 72-hour duration, and is US Food and Drug Administration–approved for infiltration into the surgical site, which includes field blocks such as transversus abdominis plane (TAP) blocks.9 Liposomal bupivacaine is increasingly being used off-label for peripheral nerve blocks, though its safety profile and efficacy have not yet been fully established.10
This case highlights the possible use of liposomal bupivacaine in this novel plane block to provide extended analgesia and minimize systemic opiate requirements. The patient provided written permission for publication of this report and accompanying images.
A 70-year-old woman (weight 61 kg, height 168 cm, body mass index 22 kg/m2) with a history of hypertension, Raynaud’s syndrome, and right breast multifocal invasive lobular cancer was scheduled for a right nipple-sparing simple mastectomy, axillary lymph node excision, and prepectoral tissue expander placement. As the patient reported previous intractable nausea related to opioid use, our goal was to provide regional analgesia that lasted for an extended duration (ie, >24 hours). We planned to perform an erector spinae plane block with a combination of liposomal bupivacaine and plain bupivacaine as an adjunct to general anesthesia. Additionally, we planned to perform a supplementary T1 paravertebral block with plain bupivacaine to assist with short-term analgesia for the axillary lymph node excision; we chose not to inject liposomal bupivacaine at this site because of the anticipated small incision.
With the patient in the sitting position, a high-frequency linear transducer (BK Medical, Peabody, MA) was placed in a longitudinal orientation 3 cm lateral to the T5 spinous process. The trapezius, rhomboid, and erector spinae muscles were identified. A 10 cm, 21-gauge echogenic block needle (Pajunk, Geisingen, Germany) was inserted cephalad to caudad in-plane until the needle tip was observed deep to the erector spinae muscle and superficial to the T5 transverse process (Figure). Twenty milliliters of plain bupivacaine 0.25% and 266 mg (20 mL) of liposomal bupivacaine (Exparel, Pacira, Parsippany, NJ) were injected into the interfascial plane. This admixture was used to expand the volume to provide sufficient spread, as 266 mg is the maximum dose of liposomal bupivacaine, as well as to provide immediate effect from the plain bupivacaine.11 Subsequently, the linear transducer was moved to the T1 transverse process to identify the paravertebral space, and the 21-gauge echogenic block needle was inserted out-of-plane. At this point, 7 mL of plain bupivacaine 0.25% was deposited into the paravertebral space with observation of anterior displacement of the pleura. The patient then underwent general anesthesia with endotracheal intubation maintained with sevoflurane and a total of 300 μg of fentanyl, 30 mg of ketamine, and 10 mg of dexamethasone over the course of the 8-hour operation.
Postoperatively, the patient did well and reported minimal pain until discharge on postoperative day 3 (Table). She received a total of 20 mg of oxycodone throughout her 4-day hospitalization as well as acetaminophen (total of 7 doses of acetaminophen 650 mg on an as needed basis), noting solely axillary discomfort. Of note, the patient did not receive liposomal bupivacaine in the paravertebral block, as we expected mild pain from the scheduled axillary lymph node excision. Her operative course was complicated by axillary vein injury requiring repair which resulted in a more extensive axillary exposure and more postoperative discomfort than anticipated. She denied pain in the anterior chest. On further follow-up, the patient reported minimal discomfort for 2 weeks postoperatively. The patient did not require any opiates after discharge, with her postoperative pain controlled with acetaminophen and ibuprofen alone.
Fascial plane blocks, such as TAP or pectoralis I and II blocks, have increased in popularity because of their ease of placement, efficacy, and a perception that they may confer a lower risk of complications than neuraxial or paravertebral techniques.12 In this case, we performed both an erector spinae plane block and a supplemental paravertebral block with the goal of ensuring adequate axillary analgesia. Future evaluation would be helpful to determine if 40 mL of local anesthetic is adequate to ensure coverage of the T1 and T2 dermatomes, which would allow us to use an erector spinae plane block alone.
Erector spinae plane block has enjoyed some early success for a variety of chest or abdominal wall indications,3,4 but the duration of action is limited to 12–24 hours with traditional local anesthetics. Liposomal bupivacaine has been used to provide effective long-acting analgesia and opioid reduction in both TAP and pectoralis I and II infiltration, by slowly releasing bupivacaine HCl from lipid microsomes over 72 hours.13,14
This is the first report to our knowledge of the use of liposomal bupivacaine in an erector spinae plane block. Due to our patient’s previous negative experiences with strong opioids, our clinical challenge was to provide a long-lasting nonopioid solution to postoperative chest wall and axillary pain. A paravertebral or erector spinae catheter technique may have been an acceptable option, but practical postoperative management considerations precluded this technique because the patient was initially scheduled as an outpatient. Erector spinae plane block was instead chosen for its simplicity and effectiveness, as we had achieved good results for other breast/chest wall procedures. To extend our single-injection block as long as possible, we chose to use liposomal bupivacaine as an adjunct with the plain 0.25% bupivacaine. This combination resulted in a short latency and prolonged duration of action compared with bupivacaine alone,11 and in our case resulted in early as well as sustained pain control and opioid minimization. Single-injection regional techniques that utilize liposomal bupivacaine or other novel long-acting local anesthetics may be particularly useful in patients with intolerance to opiates. Similarly, these techniques are becoming more popular in the setting of enhanced recovery after surgery programs, where the goals of early ambulation and freedom from drains, catheters, and tubes suggest that a shift away from catheter techniques may be imminent. The erector spinae plane block is an attractive alternative to paravertebral or intercostal nerve blockade given a possibly enhanced safety profile with minimal risk of pneumothorax if performed under continuous ultrasound guidance.15 Further prospective studies comparing this technique with paravertebral block and surgical infiltration are indicated.
Name: Amanda Kumar, MD.
Contribution: This author helped perform the block and write the manuscript.
Name: Alina Hulsey, MD.
Contribution: This author helped perform the block, compile patient opioid use, and write the manuscript.
Name: Hector Martinez-Wilson, MD, PhD.
Contribution: This author helped supervise performance of the block and write the manuscript.
Name: James Kim, MD.
Contribution: This author helped write the manuscript.
Name: Jeff Gadsden, MD.
Contribution: This author helped perform the literature review and write the manuscript.
This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.
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