The Analgesic Efficacy of Pecto-Intercostal Fascial Block Combined with Pectoral Nerve Block in Modified Radical Mastectomy: A Prospective Randomized Trial

Background: Pectoral nerve (Pecs) block is one of the most promising regional analgesic techniques for breast surgery. However, Pecs II block may not provide analgesia of the medial aspect of the breast or the entire nipple-areolar complex. Objectives: The aim of the present study was to investigate the efficacy of combining the pectointercostal fascial block (PIFB) and Pecs II block for perioperative analgesia following modified radical mastectomy (MRM). Study Design: A prospective randomized study. Setting: An academic medical center. Methods: Sixty women undergoing unilateral MRM were randomly divided into 2 groups. The Pecs II group received Pecs II block using 20 mL bupivacaine 0.25% between the serratus anterior and the external intercostal muscles, and 10 mL bupivacaine 0.25% between the pectoralis major and minor muscles, together with sham PIFB using 15 mL normal saline solution in the interfascial plane between the pectoralis major muscle and the external intercostal muscle. PIFB-Pecs II group received the same Pecs II block combined with PIFB using 15 mL bupivacaine 0.25%. Results: The median (interquartile range [IQR]) time to the first morphine dose was significantly longer in the PIFB-Pecs II group (327.5 [266.3–360.0] minutes) than the Pecs II group (196 [163.8– 248.8] minutes) (P < 0.001, 95% confidence interval [CI] 79.98, 150.00).The median (IQR) cumulative morphine consumption was higher in the Pecs II group (14.0 [11.0–18.0] mg) than the PIFB-Pecs II group (8.0 [7.0–9.0] mg) (P < 0.001; CI, 4.0–8.0). Intraoperative consumption of fentanyl was significantly lower in PIFB-Pecs II group with a median (IQR) of 0 (0–15 μg) than the Pecs II group median 57.5 (0–75 μg) (P = 0.022, CI; 0–60). The Visual Analog Scale scores for the first 12 postoperative hours were lower in the PIFB-Pecs II group than the Pecs II group at rest and on moving the ipsilateral arm (P < 0.001). The dermatomal block on the lateral chest wall was comparable between the 2 studied groups. PIFB-Pecs II provided extensive sensory block on the anterior chest wall, whereas Pecs II block failed to achieve any sensory block. Limitations: This study was limited by its small sample size. Conclusions: The combination of Pecs II and PIFB provide better perioperative analgesia for MRM than Pecs II alone. Key Words: Pectoral nerves, postoperative pain, modified radical mastectomy