Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery: A Systematic Review and Meta-analysis

• Published in: Anesthesiology (Philadelphia) 2019-09, Vol.131 (3), p.630-648
• Main Authors: Hussain, Nasir, Brull, Richard, McCartney, Colin J L, Wong, Patrick, Kumar, Nicolas, Essandoh, Michael, Sawyer, Tamara, Sullivan, Timothy, Abdallah, Faraj W
• Format: Article
• Language: English
• Subjects: Analgesia - methods; Breast Neoplasms - surgery; Female; Humans; Nerve Block - methods; Pain, Postoperative - drug therapy; Pectoralis Muscles - drug effects
• ISSN: 0003-3022; 1528-1175
• DOI: 10.1097/ALN.0000000000002822

WHAT WE ALREADY KNOW ABOUT THIS TOPICPectoralis-II block is a potential alternative to paravertebral blocks to provide regional analgesia for breast cancer surgery WHAT THIS ARTICLE TELLS US THAT IS NEWThis meta-analysis includes 14 randomized trials comparing pectoralis-II block with paravertebral blocks and found that there were no differences in pain scores or opioid consumption between the two groups in patients having surgery for breast cancerPectoralis-II blocks were noninferior to paravertebral blocks in reducing pain intensity and morphine consumption for the first 24 h after surgery and both were superior to systemic analgesia alone BACKGROUND:Thoracic paravertebral block is the preferred regional anesthetic technique for breast cancer surgery, but concerns over its invasiveness and risks have prompted search for alternatives. Pectoralis-II block is a promising analgesic technique and potential alternative to paravertebral block, but evidence of its absolute and relative effectiveness versus systemic analgesia (Control) and paravertebral block, respectively, is conflicting. This meta-analysis evaluates the analgesic effectiveness of Pectoralis-II versus Control and paravertebral block for breast cancer surgery. METHODS:Databases were searched for breast cancer surgery trials comparing Pectoralis-II with Control or paravertebral block. Postoperative oral morphine consumption and difference in area under curve for pooled rest pain scores more than 24 h were designated as coprimary outcomes. Opioid-related side effects, effects on long-term outcomes, such as chronic pain and opioid dependence, were also examined. Results were pooled using random-effects modeling. RESULTS:Fourteen randomized trials (887 patients) were analyzed. Compared with Control, Pectoralis-II provided clinically important reductions in 24-h morphine consumption (at least 30.0 mg), by a weighted mean difference [95% CI] of −30.5 mg [−42.2, −18.8] (P < 0.00001), and in rest pain area under the curve more than 24 h, by −4.7cm · h [−5.1, −4.2] or −1.2cm [−1.3, −1.1] per measurement. Compared with paravertebral block, Pectoralis-II was not statistically worse (not different) for 24-h morphine consumption, and not clinically worse for rest pain area under curve more than 24 h. No differences were observed in opioid-related side effects or any other outcomes. CONCLUSIONS:We found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively whe