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Perioperative Pain Management for Chest Wall Procedures 411
and have contributed to the practice of earlier extubation in patients undergoing
cardiac surgery [4, 5].
In this chapter the techniques, indications, and recent research involving the use of
chest wall fascial plane blocks will be reviewed. These blocks include the Pectoralis
I and II (PECS I and II), Serratus Anterior Plane (SAP), Erector Spinae Plane (ESP),
Transversus Thoracis Plane (TTP), Pectointercostal Fascial Plane (PIF), Retro-
laminar Block (RLB), Midpoint Transverse Process to Pleura (MTP), Rhomboid
Intercostal Block (RIB), and Rhomboid Intercostal Sub-Serratus (RISS) blocks.
2 Anterior Chest Wall Blocks
Pectoralis I (Renamed to Interpectoral Plane Block)
and Pectoralis I (Renamed to Pectoserratus Plane Block)
Technique
The pectoralis I (PECS I) block was originally described by Blanco in 2011 [6].
The PECS I block targets the medial and lateral pectoral nerves by injecting local
anesthetic into the interpectoral fascial plane between the pectoralis major and minor
muscles [7]. A modified version of the PECS I block, also known as a pectoralis II
(PECS II) block, was then later described by Blanco et al. in 2012 [8]. The PECS II
block is a PECS I block with a second deep injection in the fascial plane between
the pectoralis minor and serratus anterior muscles, further targeting the lateral cuta-
neous branches of the intercostal nerves, thoracodorsal nerve, and long thoracic nerve
(Fig. 1)[7].
Fig. 1 Image showing relevant anatomy of the anterior chest wall along with injection site locations
for PECS I, PECS II, and PIF blocks
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412 C. R. Cowart et al.
To perform the PECS I block, position the patient supine with the ipsilateral arm
either at the patient’s side or abducted with their head turned to the contralateral side.
The plane for this block can be found by placing a straight linear array transducer at
the midclavicular parasagittal plane. Identify the pectoralis major and minor muscle,
axillary vessels, and pleura. To identify the second and third ribs, slide the transducer
inferiorly. The image may be optimized by adjusting the ultrasound probe to be
parallel to the deltopectoral groove by rotating the inferior end of the transducer
towardsthe axilla. Insert the needle in-plane or out-of-plane to the ultrasound probe so
that the needle tip is within the interpectoral fascia, deep to the pectoralis major and
superficial to the pectoralis minor muscle. Inject 1–2 mL of isotonic saline into the
interpectoral facia to confirm correct needle placement. After confirming negative
aspiration for blood return, inject the desired local anesthetic within the fascial plane
[7].
To perform the PECS II block, position the patient and ultrasound transducer as
previously described for the PECS I block. The transducer may need to further slide
inferiorly towards the mid-axillary line so that the needle tip can be viewed advancing
through the pectoralis minor muscle into the fascial plane between the pectoralis
minor and serratus anterior muscles. One to two mL of local anesthetic can be injected
to confirm the correct plane, followed by the desired dose of local anesthetic after
negative aspiration. This block can be performed by either injecting first into the
superficial interpectoral fascia then into the deep plane between the pectoralis minor
and serratus anterior, or deep-to-superficial. Injecting deep-to-superficial may be
preferred, as injecting superficial-to-deep has the potential to result in an unclear
ultrasound image of the deep plane by the inadvertent introduction of an air bubble
or the downward displacement of the tissue layers from the previous injection [7].
Indications and Recent Research
The PECS I and II blocks have previously been shown to reduce intraoperative
and postoperative opioid consumption, the need for postoperative rescue analgesia,
postoperativepain scores, and postoperative nausea and vomiting (PONV) in patients
undergoing breast surgery [7]. Multiple studies have been conducted that attempt
to evaluate the optimal timing and indictions where PECS II block administration
optimizes postoperative analgesia.
Ciftci et al. conducted a study in 2021 in which patients undergoing breast augmen-
tation were randomized into a preoperative PECS (pre-group), postoperative PECS
(post-group), or control group. They found that the pre-group had significantly lower
postoperative opioid consumption at 1, 2, 4, 8, 16, and 24 hours along with signif-
icantly lower visual analog scale (VAS) scores at 1, 2, 4, and 8 hours compared to
the post-group. Both groups demonstrated significantly lower cumulative opioid and
VAS scores at all times compared to the control group [9].
A retrospective cohort study evaluating the PECS II block versus no block on
VAS scores and rescue analgesia usage in patients undergoing robot-assisted trans-
axillary thyroidectomy showed a PECS II block reduced postoperative pain scores at
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Perioperative Pain Management for Chest Wall Procedures 413
10 hours (3.3 ± 2.0 vs. 4.4 ± 2.1; p = 0.017) and 25 hours (2.6 ± 1.3 vs. 3.5 ± 1.7,
p = 0.034); however, there was no statistically significant difference in VAS scores
at 4, 20, 35, and 45 hours or in requirements of rescue analgesia [10].
PECS I (Interpectoral Plane) and PECS II (Pectoserratus Plane)
Summary
The PECS I and II blocks target the medial and lateral pectoral, lateral inter-
costal, long thoracic, and thoracodorsal nerves. They are effective fascial plane
blocks for analgesia after breast surgery, and reduce intraoperative and postoper-
ative opioid consumption, the need for postoperative rescue analgesia, postoperative
pain scores, and PONV.A PECS block administered preoperatively is more effective
at reducing postoperative opioid needs and pain scores in breast surgery. PECS I and
II blocks have indications beyond breast surgery and may also be utilized in surgical
procedures involving the chest wall.
3 Transversus Thoracis Plane Block (Renamed Deep
Parasternal Intercostal Plane Block)
Technique
The transversus thoracis plane (TTP) block was originally described by Ueshima and
Kitamura in 2015 and has since been renamed to the deep parasternal intercostal plane
block [11]. This block targets the anterior cutaneous branches of the second through
sixth intercostal nerves in addition to the sympathetic plexus around the internal
mammary artery by injecting a local anesthetic into the fascial plane between the
internal intercostal and transversus thoracis muscles (Fig. 1)[7].
To perform the deep parasternal intercostal plane block, position the patient either
supine or in a semi-inclined position, depending on which is more comfortable for
the patient. Use a straight linear array ultrasound transducer and place it on the chest
in the parasagittal plane. Use the midclavicular line as a guide and identify the third
or fourth rib space and ribs, pleura, pectoralis major, and intercostal muscles. After
indentifying ribs, scan in a lateral to medial fashion until the probe is located just
lateral to the sternum. Visualizethe transversus thoracis muscle deep to the intercostal
muscles and superficial to the pleura. Identify the internal thoracic artery running
in this plane. Insert the needle in-plane and with a shallow trajectory until the tip is
in the fascial plane between the internal intercostal and transversus thoracis muscle.
Inject 1–2 mL of normal saline to confirm needle tip placement, and then inject a
local anesthetic after negative aspiration for blood [7].
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Indications and Recent Research
The TTP block has previously demonstrated usefulness in providing analgesia for
surgeries involving the sternum and medial chest, including sternotomy for cardiac
surgery and medial breast surgery [7]. Recently, the efficacy of a bilateral TTP block
in cardiac surgery has been thoroughly investigated. A systematic review and meta-
analysis evaluating ultrasound-guided regional anesthesia in patients undergoing
cardiac surgery included patients who received a TTP block. The combination of a
TTP block with a SAP block was also evaluated as an option for patients undergoing
placement of a subcutaneous implantable cardioverter-defibrillator.
In a double-blinded randomized controlled trial (RCT) in patients undergoing
open cardiac surgery, patients who received a bilateral TTP block with 20 mL of 0.4%
ropivacaine at the level between the fourth and fifth ribs consumed less intraoperative
and postoperative sufentanil when compared to control (74 ± 10mcg vs. 125 ±
30mcg, p < 0.01). The block also resulted in lower numeric rating scale (NRS)
scores at 1, 2, 4, 6, and 24 hours after extubation, both at rest and with movement (p
< 0.05) [12].
A systematic review and meta-analysis evaluatingthe effects of ultrasound-guided
regional anesthesia versus placebo in patients undergoing cardiac surgery requiring
median sternotomy included five studies investigating the TTP block. Collectively,
the TTP block resulted in less opioid consumption compared to no block (MD −
10.71 mg, 95% CI −17.08 to −4.33). However, these studies collectively did not
show a significant difference in pain scores at 12 and 24 hours after surgery, time to
extubation, and ICU length of stay (LOS) when compared to no block [13].
Investigationscombining the TTP block with other regional anesthesia techniques
have also been conducted. Shariat et al. conducted a small, randomized study with
22 patients comparing the combination of a TTP and SAP block with 0.25% bupi-
vacaine (10 mL and 20 mL, respectively, totaling 30 mL) versus surgical site local
anesthetic infiltration with 30 mL of 0.25% bupivacaine in patients undergoing place-
ment of a subcutaneous implantable cardioverter defibrillator (S-ICD). It showed that
patients who received a combination TTP-SAP block required less total intraoper-
ative fentanyl compared to surgical site local anesthetic infiltration (45 mcg vs. 90
mcg, p < 0.026) [14].
TTP (Deep Parasternal Intercostal Plane) Summary
The TTP block targets the anterior cutaneous branches of the second through sixth
intercostal nerves in addition to the sympathetic plexus around the internal mammary
artery. It has been shown to provide beneficial analgesia in cardiac and medial
breast surgery. A bilateral TTP block may result in less intraoperative and post-
operative opioid requirements and lead to lower pain scores in open cardiac surgery.
However, a TTP block has not shown reductions in time to extubation or intensive
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Perioperative Pain Management for Chest Wall Procedures 415
care unit LOS. Combining a TTP block with an SAP block can provide adequate
analgesia for patients undergoing S-ICD placement and can reduce total intraop-
erative fentanyl required compared to those who received only surgical site local
anesthetic infiltration.
4 Pectointercostal Fascial Plane Block (Renamed
Superficial Parasternal Intercostal Plane Block)
The pectointercostal fascial plane (PIF) block is a potentially safer alternative to the
TTP block. The PIF block is performed by injecting local anesthetic in the fascial
plane between the pectoralis major and the intercostal muscles directly superficial
to the site of injection for a TTP block. Despite being a more superficial block, this
technique still manages to anesthetize the anterior branches of the intercostal nerves
that are present within the intercostal muscles (Fig. 1)[15]. By utilizing the PIF block,
the proceduralist can theoretically decrease overall risk associated with vascular and
pericardial puncture, pneumothorax, and local anesthetic systemic toxicity, when
compared to TTP.
5 Lateral Chest Wall Blocks
Serratus Anterior Plane Block
Technique
The serratus anterior plane (SAP) block was initially described by Blanco et al. in
2013 [16]. This block targets the long thoracic, thoracodorsal, intercostobrachial,
and lateral intercostal nerves by injecting local anesthetic either into the superficial
plane created by the latissimus dorsi, teres major, and serratus anterior muscles or
into the deep plane created by the serratus anterior and intercostal muscles between
the fourth and fifth ribs (Fig. 2)[7].
To perform the SAP block, position the patient supine with their ipsilateral arm
abducted. Alternatively, the patient can be placed in the lateral decubitus position
with the operative side facing up and the patient’s arm flexedforward. Using a straight
linear array transducer place the probe in the parasagittal plane inferior to the clavicle.
Identify the fourth rib by translating the probe inferiorly. Slide the probe laterally
and rotate the inferior end into the midaxillary-to-posterior axillary line to identify
the latissimus dorsi and serratus anterior muscles. Insert the needle either in-plane or
out-of-plane until the needle tip is within the fascial plane either superficial or deep
to the serratus anterior muscle. Inject 1–2 mL of normal saline to confirm the correct
placement, followed by local anesthetic after negative aspiration for blood [7].
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416 C. R. Cowart et al.
Fig. 2 Image showing relevant anatomy of the lateral chest wall
Indications and Recent Research
The SAP block has displayed efficacy in reducing VAS scores, opioid requirements,
and PONV in patients undergoing thoracic surgery [7]. The efficacy and safety profile
of the SAP block in pediatric patients undergoing thoracic surgery has been recently
studied. The use of a continuous SAP block catheter has also been investigated for
patients undergoing video-assisted thoracic surgery (VATS) procedures. In efforts
to determine which approach provided more effective analgesia in breast surgery, a
comparison study of a superficial versus deep SAP technique was performed. The
combination of a SAP with a PECS II block in minimally invasive cardiac surgery
and comparisons of the SAP block versus an intercostal nerve block for thoracic
surgery also have been evaluated.
A double-blinded RCT performed by Gado et al. investigated the effective-
ness and safety of SAP blocks in pediatric patients undergoing thoracotomies. The
study demonstrated that pediatric patients undergoing unilateral thoracotomies who
received a post-induction SAP block required lower intraoperative (2.1 ± 0.8 mcg/
kg vs. 6.9 ± 3.0 mg/kg, p < 0.001) and postoperative fentanyl (4.0 ± 1.5mcg.kg vs.
6.3 ± 1.5 mcg/kg, p < 0.001) compared to the control, with no significant difference
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Perioperative Pain Management for Chest Wall Procedures 417
in complication rates. There also was a lengthened time to first rescue analgesia in
the SAP block group compared to the control (226.6 ± 73.7 min vs. 64.3 ± 35.8 min,
p < 0.001) [17].
Gao et al. performed a RCT comparing a continuous SAP block versus an I V
sufentanil PCA on the pulmonary function in patients undergoing VATS for lung
cancer. Both groups had a substantial decrease in their forced expiratory volume in
one second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio after their
procedures (p < 0.001). However, patients who received a continuous SAP demon-
strated higher postprocedural FEV1, FVC, and FEV1/FVC compared to those with
only an opioid PCA (p < 0.001). When a subset analysis comparing segmentectomy/
lobectomy versus wedge resection was performed, the continuous SAP block group
still demonstrated higher postprocedural FEV1, FVC, and FEV1/FVC (p < 0.05)
[18].
As the SAP block has been described to be performed within both a superficial
or deep plane, investigators have set out to examine if there is a superior approach.
Edwards et al. conducted a randomized trial with 66 patients comparing a superficial
versus a deep SAP block in women undergoing mastectomy. They determined that
those who received a deep SAP block required 30% less oral morphine equivalents
in the first 24 postoperative hours compared to those who received a superficial block
(113.5 mg vs. 147.0 mg, p = 0.009) [19].
The SAP block has also been combined with a PECS II block. Torre et al.
performed a retrospective cohort study evaluating the combination of a SAP with
a PECS II block versus IV opioids alone on postoperative analgesia in patients
who underwent mini-thoracotomy for aortic, mitral, or tricuspid valve replacement
or atrial myxoma resection. The study revealed critical care pain observation tool
(CPOT) scores at 6, 12, and 24 hours after minimally invasive cardiac surgery were
lower in the regional group compared to the IV opioids group (p = 0.0002; p =
0.0088; p < 0.0001). The block group also consumed less postoperative sufentanil
and morphine (p < 0.0001); however,there was not a significant difference in tramadol
consumption [20].
When the SAP was compared to an intercostal nerve block in a prospective,
double-blinded randomized feasibility trial in patients undergoing VATS there
was no statistically significant difference in intraoperative opioid and nonopioid
consumption, time to first analgesic request or VAS scores [21].
SAP Summary
The SAP block targets the long thoracic, thoracodorsal, intercostobrachial, and lateral
intercostal nerves. It is an effective block in thoracic surgery, as it reduces postop-
erative pain scores, postoperative opioid needs, and PONV. It can also increase the
time until first rescue anesthesia in pediatric patients undergoing unilateral thoraco-
tomies. A continuous SAP block can improve FEV1, FVC, and FEV1/FVC ratios in
patients undergoing VATS for lung cancer. Patients who receive a deep SAP block
may require less postoperative morphine compared to those who receive a superficial
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418 C. R. Cowart et al.
SAP block. A SAP block can be combined with a PECS II block, and the combination
can reduce postoperative pain scores and opioid consumption in patients undergoing
minimally invasive cardiac surgery. Patients who receive a SAP block have similar
intraoperative opioid needs, time to first analgesic request, and postoperative pain
scores as those who receive intercostal nerve blocks for VATS.
6 Posterior Chest Wall Blocks
Erector Spinae Plane Block
Technique
The erector spinae plane (ESP) block was first described by Forero et al. in 2016 [22].
This block targets the dorsal rami of spinal nerves by placing local anesthetic into the
posterior chest wall fascial plane between the anterior surface of the erector spinae
muscle and the posterior surface of the transverse process of the thoracic vertebrae
(Fig. 3)[7]. There has also been shown to be variable and inconsistent anesthetic
spread to the ventral rami of spinal nerves via the paravertebral space.
To perform the ESP block, place the patient into the lateral, sitting, or prone
position. Use a straight linear or curvilinear array ultrasound transducer dependent
on body habitus. Identify the target vertebral level by either counting inferiorly from
the C7 spinous process or by using the ultrasound probe to scan inferiorly from the
Fig. 3 Image depicting relevant anatomy of the posterior chest wall along with injection site loca-
tions of the retrolaminar block (RLB), erector spinae block (ESP) and paraspinal intercostal plane
block (PIP)
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Perioperative Pain Management for Chest Wall Procedures 419
first rib. Place the transducer in the parasagittal plane approximately 2–3 cm lateral
to the spinous process at the desired vertebral level. You can recognize the transverse
processes by their “squared-off” appearance versus the “rounded” appearance of the
ribs. There will also be a pleural line deep to the ribs. Identify the fascial plane
between the anterior surface of the erector spinae muscle and the posterior surface
of the transverse processes. Insert the needle either in-plane or out-of-plane to the
ultrasound probe. Inserting the needle in-plane and with a shallow trajectory may
enhance the ability to effectively open the desired fascial plane or place a catheter.
Pass the needle tip into the described fascial plane by skimming off the edge of the
desired transverse process and confirm by injecting 1–2 mL of normal saline. Then
inject the desired local anesthetic after checking negative aspiration for blood [7].
Indications and Recent Research
The ESP block has been used for analgesia in rib fractures, back surgery, and chest
wall procedures including cardiac surgery. The ESP block has previously been shown
to reduce VAS scores, intraoperative fentanyl, and postoperative rescue analgesia in
epigastric hernia cases. It has demonstrated a reduction in NRS scores as well as
opioid rescue analgesia in cardiac surgery and has been associated with improved
inspiratory capacity in patients with rib fractures [7]. Further evaluation of the ESP
block through systematic reviews and meta-analyses evaluated the effectiveness of
the block in cardiac and breast surgery. Additionally, trials comparing the ESP to
other techniques, including the PECS II, SAP, thoracic PVB, and intercostal nerve
blocks in breast and thoracic surgery have been performed.
Another systematic review and meta-analysis with 861 total patients conducted
by Leong et al. compared the ESP to the PECS, PVB, and a control in patients
undergoing breast surgery. 147 total patients were in the ESP versus PECS block
analysis which revealedthat the ESP group required a greater amount of postoperative
oral morphine equivalents (MD 14.00 mg, 95% CI 3.91–24.06, p = 0.007). 155
total patients were in the ESP versus PVB analysis where there was no significant
difference in postoperative oral morphine equivalents consumed (MD −2.15 mg,
95% CI −4.97 to 0.67, p = 0.14). Finally, a total of 214 patients were identified in
the ESP versus control analysis. There was a significant difference in postoperative
oral morphine equivalents consumed in this arm (MD −21.55 mg, 95% CI −23.57
to −10.52, p = 0.0001) [23].
Comparisons of ESP blocks to other regional anesthesia techniques have been
conducted. A single-blinded RCT compared an ESP block with 0.25% bupivacaine
versus PECS II block with 0.25% bupivacaine versus control on postoperative opioid
consumption, acute pain, and chronic pain in women undergoing segmental mastec-
tomy with sentinel lymph node biopsy. A total of 95 patients were randomized into
the three groups and it was found there was comparable postoperative morphine
consumption between the ESP, PECS II and control group, with the control having
the highest consumption (4 vs. 3 vs. 5 mg respectively, p < 0.001); statistically, yet
not clinically significant. Intraoperative remifentanil consumption was also similar
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420 C. R. Cowart et al.
between the ESP and PECS II blocks group, but higher in the control group (250
mcg vs. 230 mcg vs. 410 mcg, p < 0.001). 23% of patients who received either ESP
or PECS II blocks had chronic pain at 3 months compared to 70% of patients who
endorsed this in the control group (p < 0.001) [24].
Another single-blinded RCT compared the ESP versus SAP versus thoracic
epidural in patients undergoing posterolateral thoracotomy for lung cancer. There
were no patients in the thoracic epidural group who required postoperative morphine,
while 88.2% of patients in the SAP and 47% in the ESP group required post-
thoracotomy morphine (p < 0.001). There was higher total postoperative morphine
consumption in the SAP group compared to the ESP and thoracic epidural groups
(p < 0.001), while the consumption between the ESP and thoracic epidural groups
was similar (p = 1). Likewise, the SAP group had significantly higher VAS scores
in the post-anesthesia care unit (PACU) and 24 hours postoperatively compared to
the thoracic epidural group (p = 0.002; p = 0.017), while the thoracic epidural and
ESP groups were comparable [25].
Turhan et al. also conducted a single-blinded randomized study comparing a 0.5%
bupivacaine ESP block versus a 0.5% bupivacaine thoracic PVB versus a 0.5% bupi-
vacaine intercostal nerve block in patients undergoing VATS. Patients who received
an ESP block had higher static and dynamic VAS scores at 0, 1, 4, 12, and 24 hours
postoperatively (p < 0.017) and a higher total amount of morphine compared to
the other two groups (p < 0.017). There were similar postoperative mobilization
times between the ESP, thoracic PVB, and intercostal nerve block groups (4.94 ±
0.82 hours vs. 5.04 ± 0.64 vs. 4.98 ± 0.67 hours, p > 0.05). There were also no
significant differences in LOS between the groups (4.00 ± 1.08 days vs. 3.80 ± 1.15
± days vs. 4.05 ± 1.06 days, p > 0.05) [26].
ESP Summary
The ESP block targets the dorsal rami of spinal nerves with variable and inconsistent
spread to the ventral rami via the paravertebral space. The block has been shown
to reduce pain scores, intraoperative fentanyl requirements, and rescue analgesia
requirements in surgeries involving the chest wall and improve inspiratory capacity
for rib fractures. An ESP block has not been shown to reduce intensive care LOS or
time to extubation in patients undergoing cardiac surgery. When compared to a PECS
II block, patients who receive an ESP block may require greater postoperative opioids
after breast surgery. An ESP and PVB have displayed similar postoperative opioid
requirements in breast surgery. An ESP in thoracic surgery may reduce postoperative
morphine requirements and pain scores when compared to an SAP block. An ESP
block for VATS may not be as effective at reducing postoperative pain scores and
opioid requirements as PVB or intercostal nerve blocks.
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