SUBMITTED 15 APR 22 1

REVISION REQ. 15 JUN 22; REVISION RECD. 25 JUL 22 2

ACCEPTED 7 SEP 22 3

ONLINE-FIRST: September 2022 4

DOI: https://doi.org/10.18295/squmj.9.2022.057 5

Effect of Erector Spinae Block and PECS Block on Quality of Recovery 7

and Analgesia After Modified Radical Mastectomy 8

A randomised controlled study 9

Md Hammad Mohsin,1 *Reetu Verma,2 Hemlata,2 Dinesh Singh,2 Sarita 10

Singh,2 Kulranjan Singh3 11

1Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, India; 13

Departments of 2Anaesthesiology and 3Endocrine Surgery, King George's Medical University, 14

Lucknow, India. 15

*Corresponding Author’s e-mail: reetuverma1998@gmail.com 16

Abstract 18

Objectives: Postoperative pain after modified radical mastectomy ranges from moderate to 19

severe. Pectoralis block in comparison to Erector Spinae block have been found better in 20

reducing pain scores and reducing consumption of rescue analgesic in postoperative period. 21

This study aimed to compare the effect of Erector Spinae block and Pectoralis block on 22

quality of recovery after Modified Radical Mastectomy using QoR-40 score. Methods: After 23

general anaesthesia, patients were given block according to computer generated 24

randomization. Group-I-Pectoralis block including PEC I AND PEC II(PECS), Group-II-25

Erector spinae block(ESP) and Group III-Control Group (No intervention). Quality of 26

recovery (QoR-40) score was observed on morning of surgery and at 24 hrs. Time to rescue 27

analgesia and total consumption of rescue analgesia in first 24 hrs. were also observed. 28

Results: In the postoperative period at 24 hrs. Global QoR-40 scores were 183.64±6.36 in 29

PECS group, 179.68± 6.38 in ESP group and 171.37±6.88 in control group. (p<0.0001) But, 30

there was no statistically significant difference between QoR score of PECS & ESP group 31

patients(p=0.0551). The total requirement of rescue analgesic was significantly lesser in 32

PECS group (137.28±31.46 mg) in comparison to ESP Group(189.46±42.98mg) and control 33

mailto:reetuverma1998@gmail.com

group (229.57±46.80 mg). (p<0.0001). Time to first rescue analgesia was significantly higher 34

in PECS group (6.53±2.78 hrs) in comparison to ESP (4.05±2.91 hrs) and control group 35

(2.15±1.51 hrs). (p<0.0001) Conclusion: Both Erector Spinae block and Pectoralis block are 36

effective for improving QoR score and reducing consumption of rescue analgesic after 37

modified radical mastectomy. 38

Keywords: breast surgery, cancer, postoperative recovery, postoperative pain 39

Advances in Knowledge 41

 Both Erector Spinae Block and PECS block have been shown very promising 42

results in providing postoperative analgesia after breast surgery. Our study based 43

on these blocks helped us to get more data and knowledge as well as getting 44

accustomed about these blocks. 45

Application to Patient Care 47

 These blocks providing post-operative analgesia resulted in patients being more 48

comfortable post operatively, having a better feel of general over all wellbeing as 49

well as better post operative outcomes. 50

Introduction 52

In year 2020 female breast cancer was diagnosed as most common cancer worldwide.1,2 53

Radical or Modified Radical Mastectomy (MRM) is main treatment option for locally 54

advanced lesions of breast.3 MRM is usually done under general anaesthesia. Incidence 55

of severe post-operative pain on the first post-operative day after MRM has been 56

reported to be 60%.4 Poor management of pain in the postoperative period may produce 57

various acute and chronic detrimental effects.5,6 So, adequate control of pain in 58

postoperative period is very important to alleviate these detrimental effects. Also, getting 59

adequate pain management is fundamental right of every patient. 7 Moreover, adequate 60

control of pain in postoperative period can also have an impact on quality of recovery of 61

patients.8 QoR-40 score is a global score for assessing the status of recovery after 62

anaesthesia and surgery. It includes 40 questions covering five domains: patient’s 63

psychological support, emotional status, physical comfort, physical independence in 64

doing his work and severity of pain. In a number of surgical settings, the QoR-40 score 65

has been shown to be a valid, and sensitive method, for measuring the dynamic and 66

multidimensional process of post-operative recovery.9-11 Nair et al., in their study found 67

that patients who received regional blocks during breast surgery had higher 68

postoperative QoR scores.11 Yao Y et al. also observed that preoperative ESP block 69

improves postoperative QoR score and postoperative analgesia in patients undergoing 70

MRM.12 Sinha C et al compared PECS block and ESP after MRM and observed that 71

PECS block patients had lower pain scores and consumptions of analgesics in the 72

postoperative period in comparison to ESP block.13 So we hypothesized that PECS 73

block patient would also have better quality of recovery in comparison to ESP, and this 74

study was done to compare the effect of ESP block and PECS block on post-operative 75

quality of recovery after MRM using QoR-40 score. The primary objective of the study 76

was to compare the Quality of Recovery Score (QoR-40) at 24 hrs. after surgery. The 77

secondary objectives were total consumption of analgesics in the first 24hrs, time to 78

rescue analgesia, postoperative VAS score and to compare intraoperative hemodynamic. 79

Methods 81

This randomized control study was conducted adhering to the Helsinki declaration, 82

CONSORT recommendations for RCT from 20/12/2020 to 20/12/2021 after approval from 83

the institutional ethical committee (***) and after clinical trial registry (***) in department of 84

anaesthesia. 85

This study included patients between 18-60 years female with ASA grade I &II, who 87

were planned for unilateral modified radical mastectomy for breast cancer. Written 88

informed consent was obtained from all patients. Exclusion criteria were patient refusal, 89

endocrine disorders (including I and II type of Diabetes Mellitus), any coagulation 90

disorders, cognitive inability to understand QoR-40 questionnaire and allergies to local 91

anaesthetics. 105 patients were assessed for eligibility. (Figure 1) Patients were 92

randomly allocated to one of the following three groups using computer-generated 93

random numbers. Group-I-Pectoralis block (PECS block), Group-II-Erector spinae block 94

(ESP block) & Group III-Control Group. QoR-40 score was noted on the morning of 95

surgery in each patient. After taking the patients in operation theatre, monitors were 96

attached. The patients were monitored for heart rate, BP (SBP, DBP & MAP), SpO2, and 97

ECG. After that intravenous line was taken in arm contralateral to surgery planned and 98

an intravenous fluid was started. Preoxygenation was done for 3 mins and after that 99

patient were induced with injection fentanyl 1ug/kg, injection propofol 2-2.5 mg/kg and 100

after confirming adequate bag and mask ventilation injection vecuronium 0.1mg/kg was 101

given. After three minutes, either second generation supraglottic airway device or 102

endotracheal tube was inserted. After confirmation of adequate ventilation by 103

auscultation and capnography patients were put on volume-controlled ventilation mode. 104

Anaesthesia was maintained with O2: N20(50:50) and sevoflurane. After that patient 105

received respective block according to randomization. 106

107

The blocks were performed with Stimuplex® needle A100 (0.80 x 100mm (21G x 4”) 108

and Toshiba USG machine with a high frequency linear probe 38mm, 6-13 MHz. Hydro 109

dissection (saline) was used to identify the correct position and plane before injecting the 110

local anesthetic. 111

Pectoralis Block 112

The patient was positioned supine, with the arm ipsilateral to surgery site abducted to 90 113

degrees. The skin was prepared with 10% betadine solution. The sterile USG probe was 114

put longitudinally at the mid clavicular level just below clavicle and was adjusted to 115

identify axillary artery and vein. After that caudal edge of probe was turned laterally and 116

USG probe was moved downwards to identify third rib, fourth rib, pectoralis major 117

muscle, pectoralis minor muscle and serratus anterior muscle. The needle was introduced 118

through an in-plane technique from cranial edge of probe and advances to lie in 119

interfascial plane between pectoralis minor and serratus anterior muscle and 20 ml of 120

.25% bupivacaine was administered (PECS II). After giving PECS II block, the needle 121

was withdrawn slowly and adjusted to lie between pectoralis major and minor muscle 122

and after confirmation by hydro dissection, 10 ml of 0.25% bupivacaine was deposited 123

there (PECS I). 124

125

Erector Spinae Block 126

The patient was placed in lateral decubitus position and, following aseptic precautions, 127

sterile USG probe was put longitudinally paramedian to thoracic spine and T4 transverse 128

process was identified. Superficial to transverse process erector spinae, rhomboid major 129

and trapezius muscles were identified. The needle was introduced through an in-plane 130

cephalocaudal approach till the needle tip contacts the transverse process and after 131

confirmation of correct plane by hydro dissection 20ml of 0.25% bupivacaine was given 132

superficial to the transverse process and beneath the erector spinae muscle. 133

134

This study was double blinded as the patients were not aware of the intervention, they had 135

received and the observer who observed the patient and collected data was also not aware of 136

intervention each patient has received. 30 minutes before completion of surgery each patient 137

was given PCM 1gm i.v. and thereafter 1gm i.v. at every 6 hours. If any patient had VAS 138

score > 3 in postoperative period, rescue analgesic injection of Tramadol (100mg) i.v. was 139

given. Time duration between two injection of tramadol was kept >4 hrs. Hemodynamic 140

variables (Heart Rate, MAP, SBP, DBP, & SPO2) were recorded before surgery and after that 141

every 15 minutes till completion of surgery. Time to rescue analgesia and total consumption 142

of rescue analgesia in 1st 24 hrs. were also observed. Quality of recovery (QoR-40) score was 143

observed again at 24 hrs. QoR-40 questionnaires were filled by observer who verbally 144

translated the questionnaire to patients into the regional language. 145

146

Statistical analysis 147

Sample size is calculated on the basis of pilot study done on 10 patients in which SD was 148

7.12 for QoR-40 in control group. Assuming a difference of 10 would be clinically 149

significant, minimum sample size was calculated to be 28 in each group. We took 30 patients 150

in each group with the possibility of loss to follow up. Statistical analysis was performed 151

using SPSS software (15.0 version). The continuous variables were evaluated by mean and 152

standard deviation.. The dichotomous variables were presented in number and were analysed 153

using Chi-square or Fisher Extract test. To compare the means between the two groups, 154

Student t-test and for comparing three groups ANOVA tests were used. A p-value of < 0.05 155

was regarded as significant. 156

157

Results 158

In our study all groups had comparable demographic profile. (Table No.1) On 159

comparing mean average global QoR-40(0-200) score preoperatively, there was no 160

statistically significant difference between three groups (p =0.8360). At 24 hrs there 161

was a significant difference between three groups. In our study at 24 hours, Global 162

QoR-40(0-200) score was highest in PECS group followed by Erector Spinae group 163

and control group patients. The difference between three groups were statistically 164

significant(p<0.0001). But difference between PECS & Erector Spinae group patients 165

was not significant statistically(P=0.0551). (Table No.2) 166

167

The requirement of rescue analgesic was significantly lower in PECS group in comparison to 168

Erector Spinae Group and Control group patients(p<0.0001). Time to first rescue analgesic 169

was significantly higher in PECS group in comparison to other two groups. (Table 3) 170

The gradual increase in VAS score was observed in all the three groups after surgery. VAS 171

score was lowest in PECS group. The difference between groups was statistically significant 172

at 6 hours, 12 hours and 24 hours. (Table-4) 173

174

There was no clinically significant difference between haemodynamic in three groups 175

intraoperatively. (Fig 2,3) 176

177

Discussion 178

After MRM, patients report moderate to severe postoperative pain and various drugs and 179

regional analgesic techniques are being used for providing postoperative pain relief. Opioids 180

are the drugs which are most commonly used for providing postoperative analgesia but using 181

opioid in cancer patients is related to suppression of cellular immunity and increase in cancer 182

recurrence.14 NSAIDs are the other class of drugs which are also commonly used for 183

postoperative analgesia but their efficacy is limited to mild to moderate pain. Also, patients 184

with MRM has high incidence of postoperative nausea and vomiting and using opioids and 185

NSAIDs may increase the incidence of PONV.15 Transdermal patch is a non-invasive 186

method of providing postoperative analgesia and they have been found very effective in 187

reducing pain scores in postoperative period in various other surgeries. But transdermal 188

patches generally contain opioids and NSAIDs which can again increase the incidence of 189

nausea and vomiting after MRM surgery. So, regional analgesia is best modality for 190

providing postoperative analgesia in MRM patients. Further, it has also been found that using 191

regional analgesia also decreases the incidence of chronic pain. 16 192

193

Among, regional analgesia thoracic epidural and paravertebral blocks are still gold 194

standard analgesic techniques.17-19 But, sometimes it may be difficult to give thoracic 195

epidural and paravertebral block and they are also associated with complications such 196

as pneumothorax, vascular puncture, or nerve injury. So, there is always a need to find 197

alternatives to these blocks, which are easy to give, having a higher safety profile and 198

can provide equivalent pain relief. Both PECS block and ESP block are blocks which 199

are easy to perform and with very less complications in expert hands. They also reduce 200

the requirement of analgesia in postoperative period with decrease in pain scores. 20,21 201

202

Quality of recovery of any patient after surgery may be related to quality of 203

perioperative analgesia. Myles PS et al in their study observed that patient’s quality of 204

recovery after anaesthesia and surgery can be assessed effectively by using QoR-40 205

score.10 206

207

In our study at 24 hours, the Global QoR-40 score was 183.64±6.36 in PECS group, 179.68± 208

6.38 in ESP group, and 171.37±6.88 in control group and the inter mean difference between 209

groups was statistically significant at 24 hours global QoR-40(0-200) (p<0.0001). However, 210

the difference between PECS group and ESP group was statistically insignificant. Kamiya Y 211

et al studied the effect of PECS block on postoperative pain and QoR score in breast cancer 212

surgery patients and observed that pain score in PECS group was lower than control group 213

till 24 hrs. 22 But there was no statistically significant difference between requirement of 214

rescue analgesic and QoR-40 score in their study. In our study, we reported a significant 215

difference between PECS and control group in requirement of rescue analgesic and QoR 216

score. It may be because of that for PECS II block Kamiya Y,. et al injected the drug deep to 217

serratus anterior muscle and in our study drug was administered superficial to serratus 218

anterior muscle. 219

220

In a study conducted by Yao Y et al,. it was also found that ESP block improves pain score 221

QoR score in the postoperative period.12 222

223

Similar to our study Sinha et al,. also observed that PECS block administered prior to MRM 224

leads to decreased requirement of postoperative analgesics in first 24 hours. The mean 225

duration of analgesia was 7.26 ±0. 69 hrs in patients with PECS block and 5.87 ±1.47 hrs in 226

individuals with ESP block.13 227

228

Similar to our study Altiparmak B et al, also observed that PECS group patients had lower 229

consumption of tramadol in postoperative period. In their study consumption of tramadol was 230

132.78 ± 22.44 mg in PECS group and 196 ± 27.03 mg in ESP group (p = 0.001).23 231

232

Gad M et al also observed that patients in PECS group had lower consumption of morphine 233

in postoperative period in comparison to ESP block patients.24 234

235

Regarding complications, we have not encountered any procedure related complications in 236

any of group which is similar to other studies. 237

238

The limitation of our study is that we used original version of QoR-40 score which is in 239

English and score was filled by clinician verbally translating it into regional language. So it 240

might have affected the interpretation of score. Other limitations of our study were its small 241

sample size and single-centric approach. Another limitation was that the block was given 242

after inducing the patients so we could not access the level of sensory block. 243

244

Conclusion 245

To conclude, both Erector Spinae and Pectoralis blocks in comparison to control group are 246

effective for improving postoperative quality of recovery after modified radical mastectomy. 247

But, in Pectoralis blocks group time to first rescue analgesic was higher and requirement of 248

rescue analgesic was lesser in comparison to Erector Spinae Block. As our study is single 249

centred, a multicentric study with large sample size is required for generalizability of results. 250

251

Conflicts of Interest 252

The authors declare no conflict of interests. 253

254

Funding 255

No funding was received for this study. 256

257

Author Contributions 258

Collection of data and drafting the manuscript was done by MHM. Analysis and 259

interpretation of data were handled by MHM and RV. RV, H, DS, SS and KS contributed to 260

the concept and design as well as the critical revision of the manuscript. All authors approved 261

the final version of the manuscript. 262

263

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Figure 1: Consort flow chart 335

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Assessed for eligibility (n= 105 )

Randomized(n=90)

Excluded(n=15)

Not meeting exclusion criteria(n=10)

Declined to participate(n=5)

Allocated to PECS Block(n= 30 )

Received PECS Block (n= 30 )
Did not receive PECS Block (n= 0)

Allocated to Erector Spinae Block(n=
30 )

Received Erector Spinae block (n=
30 )

Did not receive Erector Spinae Block
(n= 0 )

Lost to follow-up (n= 0)
Discontinued intervention (n= 0 )

Analysed (n= 30 )

Excluded from analysis (n= 0 )

Allocated to control group (n= 30

No intervention (Control Group)
(n= 30 )

Analysed (n= 30 )

Excluded from analysis (n= 0 )

Lost to follow-up (n= 0)

Analysed (n= 30 )

Excluded from analysis (n= 0 )

Table 1: Demographic Profiles 369

Group-I(PECS

group) [n=30]

Group-II(ESP

group) [n=30]

Group-

III(Control

Group) [n=30]

p-value

Age(in years) 43.52±9.6 42.26±7.64 44.13±8.9 F=0.3563

p=0.7013#

Weight (in

kg)

59.4±9.1 57.2±5.28 56.71±8.1 F=1.048

p=0.3551#

Height (in

cms)

162.6±7.6 159.0±46.5 156.21±3.9 F=0.4132

p=0.66283#

BMI(kg/m2) 22.5±3.8 23.9±3.6 22.0±3.1 F=1.118

p=0.21963#

ASA I:II 24:6 26:4 25:5 X=0.48

p=0.7866#

Duration of

Anaesthesia(in

minutes)

86.8±18.1 89.4±19.4 87.7±17.5 F=0.1553

p=0.8564#

*p value< 0.05= significant, #p value> 0.05= non-significant 370

371

Table 2: Tabular presentation of mean global QoR-40(0-200) of Group-I, Group-II and 372

Group-III patients 373

Global QoR-40

(0-200)

Group-I(PECS

group) [n=30]

Group-II(ESP

group) [n=30]

Group-

III(Control

Group) [n=30]

p-value

Pre-OP 186.63±7.78 185.53±6.73 186.34±7.56 F=0.1795

p=0.8360
¥p=0.8322, €p=0.9873,£p=0.9051

At 24 hrs 183.64±6.36 179.68± 6.38 171.37±6.88 F=27.47

p<0.0001*
¥p=0.0551,€p<0.0001*,£p<0.0001*

*p value< 0.05= significant, #p value> 0.05= non-significant 374

¥Group-I Vs Group-II, € Group-I Vs Group-III, £ Group-II Vs Group-III 375

376

377

378

379

380

381

382

383

Table 3: Time to first rescue analgesic requirement and total rescue analgesic in first 24 hrs 384

Group-

I(PECS

group) [n=30]

Group-II(ESP

group) [n=30]

Group-

III(Control

Group)

[n=30]

p-value

Time to first rescue

analgesics

requirement(hrs)

6.53±2.78 4.05±2.91 2.15±1.51 F=23.5

p<0.0001*

¥p=0.0006*,€p<0.0001*,£p=0.0108*

Total rescue analgesics

requirement (in mg) in first

24 hrs

137.28±31.46 189.46±42.98 229.57±46.80 F=38.34

p<0.0001*

¥p<0.0001*,€p<0.0001*,£p=0.0008*

*p value< 0.05= significant, #p value> 0.05= non-significant, 385

¥Group-I Vs Group-II, € Group-I Vs Group-III, £ Group-II Vs Group-III 386

387

Table 4: Tabular presentation of mean VAS score of Group-I, Group-II and Group-III 388

patients 389

VAS Score Group-

I(PECS

group)

[n=30]

Group-

II(ESP

group)

[n=30]

Group-

III(Control

Group)

[n=30]

p-value

At 1 Hour

0±0 0±0 0±0 ---

At 2 Hour

0±0 0±0 0±0 ---

At 4 Hour 0.52±0.37 0.54±0.82 0.59±0.21 F=0.1371

P=0.8721

At 6 Hour 1.04±0.19 2.01±0.54 4.13±1.45 F=92.48

P<0.0001*

At 12 Hour 1.44±0.54 2.28±0.90 4.80±1.09 F=120.2

P<0.0001*

At 24 Hour 2.10±1.14 3.41±1.19 4.94±1.95 F=27.9

P<0.0001*

*p value< 0.05= significant, #p value> 0.05= non-significant, 390

¥Group-I Vs Group-II, € Group-I Vs Group-III, £ Group-II Vs Group-III 391

392

393

394

395

396

397

398

399

Figure 2: Mean Pulse Rate in beats per minute between three groups 400

401

402

Figure 3: Mean Arterial Pressure in mm of Hg between three groups 403