The Use of Erector Spinae Plane Block and Pecto-Intercostal Fascial Block for an Opioid-Free Breast Surgery

Abstract

Dear Editor, The erector spinae plane block (ESP) is the injection of drugs deep into the erector spinae muscle above the vertebral transverse process; it has been used in various surgical settings to provide analgesia, for thoracic and breast surgery, it is performed at T5 level (1, 2). Sometimes, ESP is not able to block the anterior cutaneous branches of the intercostal nerves and does not provide adequate anaesthesia near the sternum and in the inner quadrants; thus, new blocks have been developed to fix this problem, for example, pecto-intercostal fascial block (PIFB) that consists of the injection of a local anaesthetic between the major pectoral muscle and superficial to internal intercostal muscles (3). An 87-year-old woman (height: 162 cm, weight: 70 kg) previously presented for a right breast internal quadrantectomy was scheduled for a right mastectomy with sentinel lymph node resection. To provide perioperative analgesia in the whole area, we decided to perform a right ESP and PIFB by injecting ropivacaine 0.5%; we used 20 mL for the ESP performed at right T5 level and 10 mL for the PIFB performed between the third and the fourth rib 2 cm lateral from the right edge of the sternum. Surgeons performed a wide skin incision from the right axillary line to the sternum, and the total surgical time was 180 min. The patient did not require further analgesic; thus, we were able to perform an opioid-free anaesthesia. The numerical rating score at the end of surgery was 0. During the uneventful postoperative course, the patient required only acetaminophen 1000 mg at 8, 16, and 24 h after the end of surgery. This case has demonstrated that ESP and PIFB can be useful to obtain a complete analgesia for mastectomy and sentinel lymph node resection. We obtained consent from the patient for the procedure and publication.