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Combined Superficial and Deep Serratus Plane Block With Bupivacaine, Dexamethasone, and Clonidine in the Treatment of a Patient With Postmastectomy Pain Syndrome: A Case Report

Maranto, Christopher J. MD; Strickland, Natalie R. MD; Goree, Johnathan H. MD

doi: 10.1213/XAA.0000000000000792
Case Reports

Postmastectomy pain syndrome poses a significant treatment challenge. We present the case of a 42-year-old woman who presented to our pain clinic with a 16-month history of postmastectomy pain. We performed a combined superficial and deep serratus plane block using bupivacaine, dexamethasone, and clonidine. At 1-month follow-up, the patient had 100% pain relief. At 2-month follow-up, her pain was 5/10. The block was repeated with the same drugs at 3 months with similar pain relief. This case illustrates the utility of a combined superficial and deep serratus plane block in postmastectomy pain syndrome with a possible benefit from added dexamethasone and clonidine.

From the University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Accepted for publication April 3, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Christopher J. Maranto, MD, Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 W Markham St, #515, Little Rock, AR 72205. Address e-mail to

Postmastectomy pain syndrome (PMPS) is reported in approximately 25%–60% of patients after mastectomy and can develop immediately or months to years after surgery.1,2 Like many postsurgical neuropathic pain syndromes, there is no consensus on diagnosis, treatment is very challenging, and currently used regimens of antineuropathic and analgesic medications are often variable and patient dependent.2 The following is a case of a patient with refractory postmastectomy pain who had 1 month of significant pain relief after a combined superficial serratus plane block and deep serratus plane block. While serratus plane blocks are becoming more commonplace for acute postoperative pain, this case report provides a unique example of their use for chronic PMPS.3,4 Furthermore, we elected to use clonidine and dexamethasone as adjuncts to the serratus block.5,6 Despite their limited use in the field of chronic pain, the dramatic pain relief achieved in this particular case suggests that they could be of benefit for chronic neuropathic pain.

Written consent for publication of this case report was given by the patient after review of the case.

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A 42-year-old, 78-kg woman presented to our clinic with severe right-sided axillary and anterolateral chest wall pain. Her invasive micropapillary carcinoma was treated with a bilateral skin-sparing mastectomy, sentinel lymph node biopsy, and placement of tissue expanders 16 months before. She described the pain as a deep ache that was exacerbated with right arm abduction. She rated her pain 10/10 on a numerical pain scale. On physical examination, she had cotton tip allodynia and pinprick hyperalgesia over her right-sided anterolateral chest wall and axilla. Conservative management with lidocaine patches, naproxen 220 mg per os twice a day, gabapentin 100 mg per os thrice a day, desipramine 50 mg per os QHS, and topical ketamine was ineffective. When intercostal nerve blocks at T2-5 under fluoroscopic guidance with bupivacaine provided no temporary relief, her operative surgeon then performed a pectoralis nerve block type 1 (PEC 1 block) under ultrasound guidance using 1% lidocaine, 0.5% bupivacaine, and triamcinolone 40 mg. She experienced 24 hours of relief followed by a severe exacerbation of her pain (Figure 1). The decision was made to perform a combined superficial and deep serratus plane block with bupivacaine, dexamethasone, and clonidine. Clonidine has been demonstrated in a meta-analysis of randomized trials to prolong duration of analgesia from peripheral nerve blockade.5

Figure 1.

Figure 1.

A PEC 2 block was then considered, but we felt that combined superficial and deep block, using the technique of Blanco et al,7 would give better analgesic coverage of the axilla by more reliably blocking the distal thoracic dermatomes. An ultrasound probe was placed in the midaxillary line, and the serratus anterior muscle was identified. Using the long-axis view, a 22-gauge 4-inch needle was then advanced in plane using an inferior to superior approach until the fifth rib was contacted. Ten milliliters of 0.5% bupivacaine, clonidine 50 µg, and preservative-free dexamethasone 5 mg were injected. Under real-time visualization, the injectate was noted to appropriately separate the serratus anterior muscle from the fifth rib. The needle was then withdrawn to the fascial plane between the serratus anterior muscle and the latissimus dorsi muscle. Twenty milliliters of 0.5% bupivacaine, 50 µg of clonidine, and 5 mg of dexamethasone were then injected. Appropriate separation of the serratus anterior muscle from the latissimus dorsi muscle was noted on ultrasound in real time. The needle was then withdrawn without any complications (Figure 2).

Figure 2.

Figure 2.

The patient was monitored for 30 minutes postprocedure, and no hemodynamic instability was noted. The patient was called at 24 hours postprocedure, and she reported 100% pain relief. At 4-week follow-up, her 100% pain relief continued. At 8-week follow-up, patient reported her pain at 5/10. A subsequent block was performed at 12 weeks, using the same medications and dosages (dexamethasone, bupivacaine, and clonidine), achieved similar results.

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While serratus plane blocks are frequently used for acute postoperative pain, this case report provides an example of their use for chronic PMPS.3 While the utility of the superficial versus deep technique is currently being debated, we found that combining both techniques was neither technically difficult nor higher risk than other commonly used techniques like intercostal nerve blocks or deep serratus plane block alone.4,7 Given that this failed therapy with a PEC 1 block, we elected to use a combined superficial and deep serratus anterior plane block. While the PEC 1 block anesthetizes the medial and lateral pectoral nerves, the serratus plane block also blocks the long thoracic nerve and the lateral cutaneous branches of the thoracic intercostal nerves.4,7 Furthermore, the combined superficial and deep approach might improve chances of a more complete blockade than an intercostal nerve block alone. The combined superficial and deep serratus anterior plane blocks block the long thoracic nerve and thoracodorsal nerve.

This case was also unique with respect to the choice of the adjuncts that were used. Although dexamethasone and clonidine are not currently approved by the Food and Drug Administration for perineural injection, both have been shown to prolong peripheral nerve block duration in the acute postoperative period.5,6 Although there are limited data on their use for chronic pain, we chose to add them because we felt that the potential benefit outweighed the risks.

In conclusion, we feel that a combined superficial and deep serratus anterior block could serve as a low-risk treatment option for patients with PMPS. It is easy to perform in an outpatient chronic pain setting. We also feel that with the addition of clonidine and dexamethasone, as presented in this case, this block could have improved therapeutic benefit for these patients in whom other commonly used treatment options have failed.

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Name: Christopher J. Maranto, MD.

Contribution: This author helped care for the patient and write the case report.

Name: Natalie R. Strickland, MD.

Contribution: This author helped care for the patient and revise the case report.

Name: Johnathan H. Goree, MD.

Contribution: This author helped care for the patient and revise the case report.

This manuscript was handled by: Raymond C. Roy, MD.

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