Analgesic Efficacy of Combined PECS II and PIP Block Versus Thoracic Paravertebral Block Post-Mastectomy

Breast cancer surgery, particularly mastectomy with or without axillary lymph node dissection (ALND), is associated with significant acute postoperative pain. Inadequate pain control in the immediate postoperative period can prolong hospital stay, delay functional recovery, and increase the risk of persistent post-mastectomy pain syndrome. While Thoracic Paravertebral Block (TPVB) has long been considered a gold standard for unilateral thoracic surgery analgesia, its technical difficulty and risk of serious complications such as pneumothorax and systemic toxicity prompt the search for safer alternatives.

The PECS II block targets the lateral and medial pectoral nerves, intercostobrachial nerve, and lateral cutaneous branches of intercostal nerves T2-T6. However, it may not consistently cover the anterior cutaneous branches near the sternum. Combining the PECS II block with a Superficial Parasternal Intercostal Plane (PIP) block aims to provide complete coverage of both the lateral and anterior thoracic wall, potentially offering comparable or superior analgesia to TPVB with a lower complication profile.

In this single-blind randomized controlled trial conducted at Dharmais Cancer Hospital, eligible female patients scheduled for mastectomy are randomized into two parallel groups:

• Intervention Group: Receives an ultrasound-guided combination of PECS II block (25 mL 0.25% Bupivacaine) and Superficial PIP block (10 mL 0.25% Bupivacaine) prior to surgical incision.
• Control Group: Receives an ultrasound-guided Thoracic Paravertebral Block at T4 and T6 levels (10 mL total of 0.25% Bupivacaine).

Standardized general anesthesia and intraoperative monitoring (including hemodynamics and qNOX index for depth of analgesia) are maintained for all subjects. Postoperatively, patients receive standard oral paracetamol and IV ketorolac, supplemented with IV Morphine via a Patient-Controlled Analgesia (PCA) device.

Study endpoints include Numeric Rating Scale (NRS) pain scores evaluated at rest and movement at 0, 6, 12, and 24 hours post-surgery; quality of recovery measured via the QoR-15 questionnaire at 24 hours; time to first PCA activation (duration of analgesia); total 24-hour morphine consumption; and monitoring for complications including local anesthetic systemic toxicity (LAST), hematoma, and pneumothorax.

Inclusion criteria

• Female patients aged 18 to 60 years.
• Scheduled for breast cancer surgery (mastectomy with or without axillary lymph node dissection [ALND]).
• American Society of Anesthesiologists (ASA) physical status I to III.
• Provided signed written informed consent to participate in the study.

Exclusion criteria

• Patient refusal to participate in the study.
• Known allergy to local anesthetics or study medications (e.g., bupivacaine, ketorolac, morphine).
• Coagulation disorders or coagulopathy.
• Mastectomy procedure with immediate breast reconstruction.
• Pre-existing chronic cancer pain with active usage of strong opioids (e.g., morphine, fentanyl).
• Cognitive impairment or inability to comprehend the pain assessment scale (NRS).
• Pregnancy.
• Active infection at the planned regional block injection site.