Pectoral Nerve Blocks

Adequate postoperative pain control is crucial for rehabilitation after open thoracotomy. The aim of this systematic review was to update the previous procedure-specific postoperative pain management recommendations for patients undergoing open thoracotomy. Using previously reported PROSPECT methodology, we performed a systematic review of randomised controlled trials, systematic reviews and meta-analyses evaluating pain interventions for open thoracotomy published between 2015 and 2024. Data extracted from the included studies were evaluated by an expert subgroup that considered the relevance of the studied interventions in clinical practice and their risk/benefit profile. Recommendations were finalised after review and comments by all members of the PROSPECT working group using a modified Delphi approach. The Cochrane Risk of bias tool 2 was used to grade the quality of evidence. Overall, 100 studies were included. Based on the available evidence, either thoracic epidural analgesia or paravertebral blockade should be provided as a first-line analgesic intervention for open thoracotomy. Erector spinae plane, rhomboid intercostal or intercostal nerve blockade could be used as a second-line regional analgesia intervention. In addition, patients should receive basic analgesia consisting of paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2 selective inhibitors. Acupuncture or cryoanalgesia is recommended when regional analgesia cannot be performed, albeit with a low level of supportive evidence. The choice of surgical technique, postoperative physiotherapy and approach to patient education should be based on outcomes other than pain control. In these updated guidelines on pain management after open thoracotomy, the main changes concern the recommendation of either thoracic epidural analgesia or paravertebral blockade as the first-line intervention according to patient and clinician preference, combined with basic systemic analgesia. The use of other regional blocks should be limited to patients who cannot receive thoracic epidural analgesia or paravertebral blockade. The researchers searched through many medical studies done between 2015 and 2024. They found and carefully studied 100 different research papers from trusted medical databases. Experts then worked together to decide which pain treatments were the safest and most effective. When someone has an open thoracotomy, it means they have surgery where doctors open the chest to reach the lungs or heart. After this kind of surgery, people often have a lot of pain. Good pain control is very important so that patients can breathe deeply, move around and get better faster. This study looked at the best ways to manage pain after open thoracotomy. They recommend two main ways to control pain: thoracic epidural analgesia, which delivers medicine near the spinal cord to block pain, and paravertebral blockade, which numbs the nerves next to the spine that send pain signals from the chest. These are the first‐choice treatments because they work best for most patients. If these cannot be used, doctors can try other methods like erector spinae plane block, rhomboid intercostal block or intercostal nerve block. These are called second‐line treatments. Patients should also take basic pain medicines, such as paracetamol and non‐steroidal anti‐inflammatory drugs, or cyclooxygenase‐2 inhibitors to help with general pain and swelling. If regional pain blocks cannot be done, acupuncture or cryoanalgesia (freezing the nerves to stop pain) might help, though there is less scientific proof for these options. The choice of operation, physiotherapy and patient education should focus on things other than pain alone, like recovery and movement.

Although intercostal nerve blocks are sometimes approached with caution due to concerns about potentially high local anesthetic uptake, they remain a valuable tool in specific clinical situations. On the other hand, the erector spinae plane block is currently often favored for its broader coverage and versatility. The hypothesis was that the intercostal nerve block, applied directly by surgeons under direct vision in patients undergoing uniportal video-assisted thoracoscopic surgery, might offer superior analgesia and fewer complications compared to the erector spinae plane block. In this multicenter, double-blind, placebo-controlled randomized trial, 100 patients undergoing uniportal thoracoscopic surgery (wedge excision or lobectomy) within an enhanced recovery program received either a surgical intercostal nerve block under thoracoscopic guidance or an ultrasound-guided erector spinae plane block, followed by 30 ml ropivacaine 0.5% (n = 50) or saline (n = 50). The primary outcome measured was 12-h morphine consumption postextubation. Secondary outcomes included 24-h morphine use, pain severity, rescue analgesia need, postoperative complications, and length of stay. Plasma levels of local anesthetics were also assessed. The intercostal nerve block group had significantly lower mean 12-h morphine consumption compared to the erector spinae plane block group (10.9 mg vs . 17.6 mg; P = 0.0015), as well as lower mean 24-h consumption (18.7 mg vs . 26.7 mg; P = 0.018). Intercostal blocks also led to lower pain scores in the first 2 h postoperatively and a reduced need for rescue analgesia (16% vs . 40%; P = 0.0033). No differences were found in patient satisfaction, complications, or length of stay. Notably, the erector spinae plane block group showed higher systemic absorption of local anesthetics. For uniportal thoracoscopic surgery, intercostal nerve block significantly reduces morphine consumption and systemic anesthetic absorption compared to erector spinae plane block.

The characteristic of thoracolumbar junction syndrome (TLJS( described by Maigne are pain in the iliac crest and tenderness on palpation at the level of the junction between the lower dorsal and the upper lumbar vertebra. It is an often unrecognized and treatable cause of low back pain. TLJS is commonly associated with those who have low back pain, although it does not always present pain in this region. The source of the pain may be due to a disorder, which affects the nerves in the thoracolumbar junction of the spine, but presents usually in the lower abdomen, around the pelvic region, and in the groin. However, while the majority of the stress may be borne by the facet joints between T12 and L1, in reality, any spinal joints between T9 and L2 have the potential to develop lesions and nerve impingements, increasing the risk of referred pain. Lumbar vertebrae are not suited to rotation or twisting like the thoracic vertebrae, are making the site susceptible to problems. Patients with Maigne's syndrome generally respond well to manual techniques. In addition, therapeutic exercises for the spine, anti-inflammatory and analgesic drugs, and nerve block can improve functional outcome.

Breast cancer surgery results in significant postoperative pain. Pectoral nerve blocks (PECS I and II) may lessen the use of opioids during surgery and enhance pain management. This systematic review and meta-analysis assessed the efficacy of PECS blocks compared with placebo in breast cancer surgery. The Cochrane Collaboration, PubMed, CINAHL, Google Scholar, and grey literature were all thoroughly searched. We only included randomized controlled trials (RCTs) that compared PECS I or II blocks to a placebo. Mean differences (MD) and risk ratios (RR) were calculated for primary and secondary outcomes. Meta-analysis was conducted using RevMan 5.4, and evidence was appraised using the GRADE system. Twenty-two RCTs were included. PECS blocks significantly decreased pain scores up to 48 hours after surgery during activity (MD, -1.66) and at rest (MD, -1.38). Additionally, they decreased the use of opioids during surgery (MD, -5.28) and after surgery (MD, -9.82), extended the time until first rescue analgesia (MD, 4.95 hours), and decreased PONV (RR, 0.48) with no effect on chronic pain (RR, 0.40). PECS blocks support their role in multimodal analgesia by improving postoperative pain control, lowering the need for opioids, and promoting recovery following breast cancer surgery.

Multimodal analgesic strategy is pivotal for enhanced recovery after surgery. The objective of this trial was to assess the effect of subanesthetic esketamine vs. placebo combined with erector spinae plane block (ESPB) vs. intercostal nerve block (ICNB) on postoperative recovery following thoracoscopic lung resection. This randomized, controlled, 2&#xd7;2 factorial trial was conducted at a university hospital in Suzhou, China. One hundred adult patients undergoing thoracoscopic lung surgery were randomized to one of four groups (esketamine-ESPB, esketamine-ICNB, placebo-ESPB, and placebo-ICNB) to receive i.v. esketamine 0.3&#xa0;mg/kg or normal saline placebo combined with ESPB or ICNB using 0.375% ropivacaine 20&#xa0;ml. All patients received flurbiprofen axetil and patient-controlled fentanyl. The primary outcome was quality of recovery (QoR) at 24&#xa0;h postoperatively, assessed using the QoR-15 scale, with a minimal clinically important difference of 6.0. The median age was 57 years and 52% were female. No significant interaction effect was found between esketamine and regional blocks on QoR ( P =0.215). The QoR-15 score at 24&#xa0;h was 111.5&#xb1;5.8 in the esketamine group vs. 105.4&#xb1;4.5 in the placebo group (difference=6.1, 95% CI: 4.0-8.1; P <0.001); 109.7&#xb1;6.2 in the ESPB group vs. 107.2&#xb1;5.6 in the ICNB group (difference=2.5, 95% CI: 0.2-4.9; P =0.033; not statistically significant after Bonferroni correction). Additionally, esketamine resulted in higher QoR-15 scores at 48&#xa0;h (difference=4.6) and hospital discharge (difference=1.6), while ESPB led to a higher QoR-15 score at 48&#xa0;h (difference=3.0). For patients undergoing thoracoscopic lung resection, subanesthetic esketamine improved QoR after surgery, while ICNB can be used interchangeably with ESPB as a component of multimodal analgesia.

First discussed by Dr. Robert Maigne in the late 1980s, Maigne Syndrome is an often unrecognized and treatable cause of low back pain. It can be separated into two distinct entities. The central variant is a result of nerve afferent input secondary to changes of facet joint arthropathy at the thoracolumbar junction. The peripheral variant is a result of impingement of the medial branch of the superior cluneal nerve, which arises from the posterior rami of the lower thoracic and upper lumbar nerve roots, and results in similar clinical symptoms and signs. To review the current literature for a comprehensive description of Maigne Syndrome, its diagnosis and management. Evidence was gathered using two main medical databases, namely PubMed and Google Scholar. Search terms included 'Maigne's Syndrome', 'Maigne facet', 'thoracolumbar junction syndrome', 'cluneal nerve entrapment', 'posterior iliac crest trigger point', 'pseudosciatica', as well as various permutations of these terms. The initial search generated 52 articles. These were screened, and duplicate and irrelevant articles were removed. Using the remaining articles, and with evaluation of their cited references, we selected 28 articles for review. Most of these consisted of case reports, many of which were published in rehabilitation, chiropractic and medical journals. The papers explored topics such as anatomy, cluneal nerve imaging, and treatment of nerve entrapment and facet related back pain syndromes, and have been included in this review, which is, to the best our knowledge, the most comprehensive description of Maigne Syndrome to date. The keys to the diagnosis of Maigne Syndrome include an awareness of the mechanical causes of back dominant pain, an understanding of the relevant anatomy, a specific clinical examination, and focused radiological guided anesthetic blocks. Treatment is available, and as in all back-pain etiologies, is most effective in the early stages of the disease.