A Comprehensive Review on Rhomboid Intercostal Block as Postoperative Analgesia in Breast Surgery

Background and Aims:The rhomboid intercostal plane block (RIB) is a regional anaesthesia technique that has shown promising results in breast and thoracic surgeries. This systematic review and meta-analysis evaluated the efficacy and safety of RIB in breast surgery.Methods:The study was conducted as per PRISMA guidelines and registered in PROSPERO (CRD420251089477). Randomised controlled studies in which RIB was compared with other regional blocks or a control group for postoperative analgesia in breast surgeries were included in this study. Databases searched included PubMed, EMBASE, the Cochrane Library, Web of Science, Directory of Open Access Journals, and Google Scholar. The primary outcome was 24 h opioid consumption; secondary outcomes were duration of analgesia, pain scores, and complications. Data extraction and Risk of Bias assessment were performed independently by two reviewers. Continuous data were pooled as mean difference (MD) and dichotomous data as risk ratio with 95% confidence intervals (CIs). Analyses were conducted using Python (v3.11.13) and RevMan (v5.4).Results:Ten randomised controlled trials (n = 777) were included in this meta-analysis. The risk of bias was low in 70% of studies, and none were at high risk. RIB reduced 24 h opioid consumption compared to control (no block) (SMD: –3.68; 95% CI: 5.13, 2.23; P < 0.00001) and serratus anterior plane block (SAPB) (SMD: –0.93; 95% CI: 1.65, −0.21; P = 0.01). There was no difference between RIB and pectoral nerve block or erector spinae plane block in terms of postoperative analgesic consumption. The duration of analgesia was significantly longer with the rhomboid intercostal block (RIB) compared to no block (MD: 8.84 h; 95% CI: 8.02, 9.66; P < 0.00001). The duration of analgesia was comparable between RIB and SAPB. Meta-analysis of postoperative pain scores was not feasible due to the limited number of studies. No block-related complications were reported in any of the studies. RIB reduced postoperative nausea and vomiting compared to control (no block), but not significantly when compared to other blocks.Conclusion:RIB, as part of multimodal analgesia, significantly reduces opioid consumption compared with no block. RIB is a safe and effective alternative to established regional anaesthesia techniques for postoperative analgesia in breast surgeries.

<h3></h3> Thoracic epidural analgesia (TEA) and paravertebral block (PVB) were still the gold standards for postoperative analgesia after thoracic and abdominal surgeries. Techniques of TEA and PVB changed to become...

SP30 Statistically significant but clinically insignificant: no use for ESP block

BACKGROUND: Prior research has suggested that the rhomboid intercostal block (RIB) may contribute to postoperative analgesia after surgeries of the chest and breast OBJECTIVE: To explore the effectiveness and safety of RIB for postoperative analgesia, as well as whether RIB is superior to other types of nerve blocks. STUDY DESIGN: A systematic review and meta-analysis. SETTING: Querying electronic databases, including the Cochrane Library, PubMed, Embase, and Web of Science, was part of the process in searching for eligible clinical trials for this meta-analysis and systematic review. METHODS: The Cochrane Collaboration’s tool for quality evaluation was utilized in assessing the bias risk in the selected randomized controlled trials (RCTs). meta-analysis was facilitated through the utilization of Review Manager 5.3. The determination of the evidence’s quality adhered to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: After the inclusion and exclusion criteria were established, the incorporation of 8 RCTs, encompassing 714 patients, took place. During the first 24 hours after the operation, patients in the RIB group exhibited lower pain scores and less opioid consumption than did those in the no-block group. Furthermore, a decrease in the incidence of postoperative vomiting and nausea was noted in the RIB group. Nevertheless, when comparing outcomes, it was revealed that the RIB group and the other nerve block group did not differ significantly. LIMITATIONS: No subgroup analysis to investigate the sources of heterogeneity was performed. The number of studies in this meta-analysis of RIB compared to those that focus on other types of nerve block is relatively small. The optimal concentrations and volumes of local anesthetics were not evaluated. CONCLUSIONS: RIB may be a new option for pain relief after chest and breast surgery. KEY WORDS: Rhomboid intercostal block, pain score, opioid consumption

ABSTRACTBackground:Effective management of postoperative pain (PSP) following breast surgeries is essential to improving recovery and preventing chronic pain syndromes. While the thoracic paravertebral block (TPVB) is the established standard for analgesia in breast surgeries, the erector spinae plane block (ESPB) has recently emerged as a simpler and safer alternative.Aim:To compare the efficacy of ultrasound-guided erector spinae block (ESPB) versus paravertebral block (TPVB) for postoperative analgesia in breast surgeries.Methods:A prospective randomized study was conducted on 60 patients undergoing elective breast surgeries at Vinayaka Missions Kirupananda Variyar Medical College and Hospitals, Salem. Patients were randomized into two groups: Group A (ESPB, 0.125% ropivacaine + dexmedetomidine) and Group B (TPVB, 0.125% ropivacaine + dexmedetomidine). Pain was assessed using the Visual Analog Scale (VAS) over 24 hours post-surgery. Secondary outcomes included hemodynamic stability, duration of sensory blockade, rescue analgesic requirements, and complications. Data were analyzed using EPI 2010 software.Results:Baseline hemodynamic parameters were comparable between the groups, except for higher systolic blood pressure (142.1 ± 3.8 mmHg vs. 136.5 ± 7.8 mmHg, P < 0.001) and VAS scores (4.5 ± 0.9 vs. 3.5 ± 0.8, P < 0.001) in Group B. Postoperatively, VAS scores were significantly lower in Group A from the 4-hour mark onwards (P < 0.006), indicating superior analgesic efficacy. Hemodynamic parameters, including heart rate and diastolic blood pressure, remained stable and comparable between the groups. No significant complications were observed in either group.Conclusion:Ultrasound-guided ESPB provides superior postoperative analgesia compared to TPVB, with consistent pain relief and similar hemodynamic stability. Its simplicity and safety profile make ESPB a promising alternative for pain management in breast surgeries. Further studies are warranted to validate these findings and optimize analgesic protocols.

Comparison of the Effects of Combined Rhomboid Intercostal and Sub-Serratus Plane Block versus Rhomboid Intercostal Block on Postoperative Analgesia in Patients Undergoing Video-Assisted Thoracoscopic Surgery for Wedge Resection.

The rhomboid intercostal block and the rhomboid intercostal subserratus block are novel blocks. These provide effective postoperative analgesia for a myriad of indications. It surpasses previous blocks by being away from the surgical site which soothes any fear of the surgeon – a possibility of infection at the site and also difficulty of postoperative catheter maintenance. The landmarks of this block are very lucid and understood easily. It is relatively a very safe block with rib acting as a safe barrier as well as a landmark. The catheter of the site does not interfere with patients’ routine activity, thus increasing overall patient satisfaction. The authors discuss five cases in which RISS proved immensely effective in relieving pain from rib fractures and postoperative. Furthermore, details of the block including anatomical site, dermatomal coverage, and USG images are discussed. It has proved to be a boon for all patients offering an excellent analgesia. Rhomboid intercostal subserratus plane block is an excellent option for providing adequate postoperative analgesia for thoracoabdominal surgeries as well as patients with multiple rib fractures. More reporting of cases and randomized trials are needed to confirm the same.

Blanco has introduced an inter-fascial plane pectoralis nerve (PECs) block 1 and 2 in 2011 for analgesia after breast and other chest wall surgeries.[1] It has also some advantages over thoracic paravertebral block (TPVB) and epidural block. Unlike TPVB and epidural blockade, this is not associated with sympathetic blockade-induced haemodynamic changes. In TPVB, medial pectoral, lateral pectoral, long thoracic and thoracodorsal nerves are not blocked. Hence, there are chances of lack of adequate analgesia in breast surgeries involving axillary dissection.[2] Several studies and case reports have established its role for postoperative analgesia, as well as for intraoperative and postoperative anesthesia with sedation without general anaesthesia for breast surgeries.[234] Though introduction of ultrasound has increased the accuracy and safety of regional anaesthesia, availability of ultrasound(US) machine and need of certain amount of training in smaller settings is still a limitation. In some situations, like carcinoma breast with invasion in the underlying muscle layers or with ulcerative/fungating mass, understanding clear sono-anatomy or placement of probe is a major challenge. In patients with deranged coagulation profile, regional blocks are associated with some known risks. Here we are presenting three cases of successful pain management by direct PEC block where USG-guided PEC block was not feasible. Our first case was a 52 years old female, posted for modified radical mastectomy (MRM) with a large fungating ulcerative breast lesion with local invasion making the pectoral, clavipectoral fascia, and serratus anterior muscle difficult to appreciate in sono-anatomy. Our second patient was a 56 years old female, known case of coronary artery disease (CAD) with drug eluting stent in situ, on anticoagulation with mildly elevated international normalised ratio (INR = 1.92) posted for MRM; so we planned to avoid any regional block. Our third patient was a 33 years old female with huge phyllodes tumor of breast, posted for mastectomy. Written informed consent was obtained from all three patients. They were educated about 11 points numerical pain score (NRS) before surgery. They received standard uniform general anaesthesia for surgical procedure with fentanyl (2 μg/kg) at the time of induction and injection paracetamol (15 mg/kg) intraoperatively. We had decided to administer injection tramadol (100 mg) as postoperative rescue analgesia only after patient's demand (NRS >3). In all these above-mentioned patients, we had decided to administer direct PEC block postoperatively by instillation of 10 ml of 0.5% levobupivacaine with dexmedetomidine (1 μg/kg) in the fascial plane between pectoralis major and minor and 10 ml of 0.5% levobupivacaine with dexmedetomidine (1 μg/kg), between pectoralis minor and superficial border of serratus anterior muscle after resection of breast tissue and achieving haemostasis under vision, taking all aseptic and antiseptic precautions with the help of surgeons. This provides analgesia by blocking the pectoral, intercostobrachial, 3rd–6th intercostal and thoraco-dorsal nerves.[5] Perineural dexmedetomidine as adjuvant to local anaesthetics has shown to shorten the onset and prolong the duration of sensory and motor blockade.[6] We decided against putting catheter for prolongation of analgesia because of high chances of catheter blockade because of blood collection, dislodgement, and high chances of infection because of presence of catheter in close proximity of operated site. We found satisfactory analgesia (NRS <4) for 10–14 h postoperatively without any side effects [Table 1]. Patients demanded rescue analgesia only after 10, 12.5, and 14 h, respectively. Thus, we want to convey that, on the background of better understanding of the nerve supply of chest wall, direct PEC block can be used as an effective, simple, safe, and less time-consuming alternative technique for postoperative analgesia after breast surgeries.Table 1: NRS at various time intervalsDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

BackgroundEffective management of postoperative pain remains a significant challenge after breast surgery. Among the available strategies, regional nerve blocks play a key role in alleviating surgical pain in these patients. This study was aimed to evaluate and compare the analgesic efficacy of two regional techniques—erector spinae plane block (ESPB) and serratus posterior superior intercostal plane block (SPSIPB)—in patients undergoing breast surgery.MethodsThis study included 50 female patients aged 18 to 65 years, classified as ASA physical status I-III, with a body mass index ranging from 18 to 35 kg/m², who were scheduled to undergo unilateral breast cancer surgery. Based on random group allocation, either ESPB or SPSIPB was administered before the induction of general anesthesia. Postoperative analgesia was provided using a tramadol-based patient-controlled analgesia (PCA) system. Pain intensity was assessed with the visual analog scale (VAS) at specific predetermined time points: immediately postoperatively (0 h), and at 1, 4, 8, 12, and 24 h. The primary outcome was postoperative pain intensity assessed using the VAS at predetermined time points. Secondary outcomes included total opioid consumption via PCA, requirement for rescue analgesia, incidence of postoperative nausea/vomiting (PONV), block performance time, side effects, and patient satisfaction.ResultsThere were no significant differences in VAS scores at rest or during coughing between the two groups at any of the assessed postoperative time points (0, 1, 4, 8, 12, and 24 h) (p > 0.05). A statistically significant difference in postoperative tramadol consumption was observed between the groups, with the ESPB group receiving 137.6 ± 124 mg and the SPSIPB group receiving 82.4 ± 102 mg via PCA, corresponding to an average reduction of 55.2 mg in the SPSIPB group (p = 0.044). The difference in consumption was due to the difference in consumption between 4 and 8 h. In the ESPB group, the average tramadol consumption during this period was 75.2 mg, while in the SPSIPB group, it was 36.8 mg (p = 0.007). No significant differences were found between the groups regarding PONV, side effects, patient satisfaction, and duration of blocks.ConclusionsThe SPSIPB may provide postoperative analgesia that is comparable in efficacy to the ESPB technique in breast surgery. Based on the findings of this study, SPSIPB provided postoperative analgesia comparable to ESPB and was associated with lower opioid consumption within the first 24 h after surgery. Furthermore, the ESPB group experienced pain relief earlier after surgery compared to the SPSIPB group, while pain relief in the SPSIPB group occurred later and lasted longer.

Breast cancer is one of the most common malignant tumours among women. In this study, we compared the analgesic efficacy of ultrasound (US)-guided rhomboid intercostal nerve block, erector spinae plane (ESP) block and serratus plane block (SAB) after modified radical mastectomy (MRM) of unilateral breast cancer. This study involved a double-blind clinical trial that was carried out in the Affiliated Hospital of Jiaxing University on 23 September 2020. The inclusion criteria were the following: The American Society of Anesthesiologists (ASA) grade needed to be 1-2, the patients needed to be between 18 and 80 years old, and MRM needed to be proposed in our hospital. The exclusion criteria were patients with contraindications related to nerve block. Ninety patients were randomly divided into three groups receiving US-guided SAB, ESP block and rhomboid intercostal block (RIB). All groups received 20 mL 0.5% ropivacaine. Within 24 hours after the operation, the patients received an intravenous injection of tramadol 1-2 mg/kg in the surgical ward for pain relief. The dosage of tramadol 24 hours after the operation in the RIB (269.67 ± 48.75 mg) and ESP block groups (273.67 ± 36.90 mg) was significantly lower than that in the SAB group (314.33 ± 18.88 mg) (P < .001). There was no statistical difference in tramadol consumption between the ESP block and RIB groups within 24 hours (P = .676). The numerical rating scale (NRS) scores in the ESP block and RIB groups at 0.5, 1, 3, 6, 12, 18 and 24 hours after the operation once patients were active were significantly lower than that in the SAB group (P < .05 for all comparisons); however, the NRS scores of the RIB and ESP block groups did not differ significantly within 24 hours after surgery when patients were active. US-guided rhomboid intercostal block (US-RIB) and ESP block can effectively reduce the dosage of tramadol within 24 hours after MRM, and they can effectively relieve pain within 24 hours after MRM compared with SAB.

The objective of this study was to examine the hypothesis that the opioid consumption of patients who receive a rhomboid intercostal block (RIB) or a pectoral nerve (PECS) block after unilateral modified radical mastectomy (MRM) surgery is less than that of patients who receive local anesthetic infiltration. Eighty-one female patients aged 18-70years who underwent unilateral MRM surgery with general anesthesia were randomly allocated to three groups. The first group received an RIB with 30ml of 0.25% bupivacaine on completion of the surgery, and the second received a PECS block with the same volume and concentration of local anesthetic. In the third (control) group, local infiltration was applied to the wound site with 30ml of 0.25% bupivacaine at the end of the surgery. The patients' total tramadol consumption, quality of recovery (QoR), postoperative pain scores, and sleep quality were evaluated in the first 24h postoperatively. Both the RIB (58.3 ± 22.8mg) and PECS (68.3 ± 21.2mg) groups had significantly lower tramadol consumption compared to the control group (92.5 ± 25.6mg) (p < 0.001 and p = 0.002, respectively). Higher QoR scores were observed in the RIB and PECS groups than the control group at 6h post-surgery. The lowest pain values were observed in the RIB group. The sleep quality of the patients in the RIB and PECS groups was better than that of the control group (p < 0.001). Compared to local anesthetic infiltration, the RIB and PECS blocks applied as part of multimodal analgesia in MRM surgery reduced opioid consumption in the first 24h and improved the quality of recovery in the early period.

Breast-conserving surgery is a common breast operation type in the world. Patients may feel severe postoperative pain after the surgery. Several regional anesthesia methods are used for postoperative pain control as a part of multimodal analgesia management after breast surgery. Erector spinae plane block (ESPB) and rhomboid intercostal plane block (RIB) are commonly used techniques for this purpose. The studies that compare these methods are limited. Therefore, we aimed to compare the efficacy of ESPB and RIB. This prospective, randomized study included sixty female patients with ASA class I-II physical status in the study. All patients underwent general anesthesia. We performed the blocks at the end of the surgery before extubation. Participants were randomized into two groups between the operation: the Group ESPB (n=30) and the Group RIB (n=30). We performed 30 ml volume of 0.25% bupivacaine for the blocks. 400 mg ibuprofen 3x1 was ordered postoperatively, and a fentanyl PCA device (2 ml bolus, 0 ml infusion, 20 min lock time, 4 hour limit) was attached intravenously to the participants. If the pain score was ≥4, meperidine (0.5 mg/kg) was performed. There were no differences in terms of demographical data. The postoperative opioid use, pain scores, adverse events, and the need for rescue analgesia were similar between groups. Both RIB and ESPB are effective regional anesthesia techniques following breast surgery. They are simple and safe methods. Anesthesiologists may prefer one or the other based on their clinical experience.

Background and objectivesMastectomy has many potential sources of pain. Rhomboid intercostal block (RIB) is a recently described plane block. The primary hypothesis of the study is that ultrasound-guided RIB combined...

BackgroundRegional anesthesia have been successfully performed for pain management in breast cancer surgery, but it is unclear which is the best regional anesthesia technique. The aim of the present network meta-analysis was to assess the analgesic efficacy and disadvantages of regional anesthesia techniques.MethodsMultiple databases were searched for randomized controlled trials (RCTs). The association between regional anesthesia and analgesic efficacy was evaluated by Bayesian network meta-analysis.ResultsWe included 100 RCTs and 6639 patients in this study. The network meta-analysis showed that paravertebral nerve block, pectoral nerve-2 block, serratus anterior plane block, erector spinae plane block, rhomboid intercostal block, and local anesthetic infusion were associated with significantly decreased postoperative pain scores, morphine consumption and incidence of postoperative nausea and vomiting compared with no block. Regarding the incidence of chronic pain, no significance was detected between the different regional anesthesia techniques. In the cumulative ranking curve analysis, the rank of the rhomboid intercostal block was the for postoperative care unit pain scores, postoperative 24-hour morphine consumption, and incidence of postoperative nausea and vomiting.ConclusionRegional anesthesia techniques including, paravertebral nerve block, pectoral nerve-2 block, serratus anterior plane block, erector spinae plane block, rhomboid intercostal block, and local anesthetic infusion, can effectively alleviate postoperative acute analgesia and reduce postoperative morphine consumption, but cannot reduce chronic pain after breast surgery. The rhomboid intercostal block might be the optimal technique for postoperative analgesia in breast cancer surgery, but the strength of the evidence was very low.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/(PROSPERO), identifier CRD 42020220763.

Background: Breast surgery is an exceedingly common procedure and is associated with an increased incidence of acute and chronic pain in 25–60% of cases. Regional anesthesia techniques may improve postoperative analgesia for patients undergoing breast surgery. Objective: This study aimed to compare the efficacy and safety of an ultrasound-guided Pecs II block versus TPVB for postoperative analgesia after breast surgeries. Patients and Methods: The present study was conducted on sixty female patients ASA I-II, their ages ranged from 18- 65 years old scheduled for unilateral breast surgery. The patients were allocated randomly into two groups (n=30) according to type of regional anesthesia administrated. (PECS block or TPVB). Results: The results demonstrated that PECS block caused hemodynamic stability, decreased the intensity of postoperative pain, reduced postoperative analgesic requirement, prolonged the time needed for first request of analgesia and decreased PONV. Therefore it can be considered as quite safe procedure and effective as well for intraoperative and postoperative pain control in breast surgeries. Conclusion: PECS blocks can produce excellent pain relief during the first twelve postoperative hours. They hold great promise due to their simplicity, easy-to-learn techniques and relative lack of contraindications and complications. It maintained hemodynamic stability. Also, it produced low pain scores and less total (morphine) consumption in the early postoperative period after unilateral breast cancer surgery.