New kid on the block: Covering neck, shoulder, and chest wall postoperative pain!
Year: 2024
Type: article
Abstract: Dear Editor, We report our experience using serratus posterior superior intercostal plane block (SPSIPB) for analgesia in a 69-year-old male patient, American Society of Anesthesiologists (ASA) physical status II, scheduled for the excision of a large, lobulated fungating mass (measuring 116 mm × 74 mm × 53 mm) on the right shoulder, along with axillary lymph node dissection and reconstruction. The mass extended from the right shoulder to the ipsilateral supraclavicular region, abutting the sternocleidomastoid muscle superiorly, the pectoral muscles inferolaterally, and the trapezius muscle posteriorly [Figure 1a and b]. Due to the location of the tumour, an interscalene brachial plexus block was not feasible, and other blocks, such as the serratus anterior plane block, erector spinae plane block, and rhomboid intercostal and subserratus plane block, would not have provided sufficient analgesia from the shoulder to the neck.Figure 1: (a) Location of the large ulceroproliferative mass. (b) The scope of dissection includes the neck, shoulder, and chest wall. (c) Diagram showing the anatomy of the serratus posterior superior muscle and the position of the transducer. (d, e) Post-block ultrasound images displaying sono-anatomy, reverse sono-anatomy, and the distribution of local anaesthetic (the blue star indicates the spread of local anaesthetic, a red triangle denotes the needle path)In the operating room, after standard monitoring, the patient was positioned sitting, with the affected side arm touching the opposite shoulder to displace the overlying scapula for SPSIPB laterally. After ensuring a sterile field, a high-frequency (7–12 MHz) linear transducer (Fujifilm Sonosite M Turbo Edition, USA) was placed over the base of the neck in a parasagittal orientation and traced downwards to identify the 1st–3rd ribs, the overlying serratus posterior superior muscle (SPSM), the rhomboid major, and the trapezius muscles along the upper medial border of the scapula. A 22-gauge Stimuplex A (B Braun, Melsungen, Germany) was advanced in-plane (caudal to cephalad) towards the interfascial plane between the SPSM and the intercostal muscles. Following negative aspiration, 1–2 mL of saline was injected to confirm correct placement, and 30 mL of 0.375% ropivacaine with 6 mg dexamethasone was administered into the space between the SPSM and the intercostal muscles [Figure 1c–e]. The craniocaudal spread of the anaesthetic was monitored in real time using ultrasound. The sensory assessment confirmed successful analgesia in the neck, lateral chest wall, axilla, and shoulder 20 minutes post-block, using spirit-soaked gauze. General anaesthesia was induced with intravenous fentanyl (2 µg/kg), propofol (2 mg/kg), and rocuronium (0.9 mg/kg), followed by tracheal intubation with an 8-mm cuffed tracheal tube. Mechanical ventilation was maintained using an oxygen-air mix at 1.5 L/min and isoflurane (1%–1.5%). The surgery included wide local excision with axillary lymph node dissection and regional pedicle flap reconstruction. No additional analgesic was required intraoperatively. At extubation, the patient was comfortable and breathing well. Postoperative pain management included intravenous paracetamol 1 g every 8 hours, and intravenous tramadol 50 mg reserved for rescue analgesia if the Numeric Rating Scale for either dynamic or resting pain exceeded 3 out of 10. Pain was assessed by the acute pain service team in the post-anaesthesia care unit immediately after shifting (0 hours) of the patient and at various intervals: 1, 4, 8, 16, and 24 hours postoperatively. Pain scores remained below 3/10 during the first 24 hours. The patient received a total of 3 g intravenous paracetamol postoperatively as a part of a multimodal analgesia regimen. After 24 hours, the patient was transitioned to oral analgesics. The SPSM, located in the posterior thorax, originates from the nuchal ligament and spinous processes of C7–T3, inserting obliquely onto the upper borders of the 2nd–5th ribs. This muscle lies deep into the scapula, creating a plane through which local anaesthetic can spread from the neck to the shoulder. Administering a local anaesthetic in this plane allows the drug to bathe both the dorsal rami and lateral cutaneous branches of the intercostal nerves at the C3–T7 levels, providing analgesia to the ipsilateral neck, shoulder, and hemithorax. Initially, SPSIPB was studied through cadaveric examination and a retrospective evaluation of patients with thoracic pain.[1] Subsequently, the analgesic efficacy of this block has been evaluated in video-assisted thoracoscopic surgery, minimally invasive cardiac surgery, and breast surgery.[2,3] Declaration of patient consent We certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Indian Journal of Anaesthesia
Authors: Sachin Bansal, Anita Bansal, Anjum K. Joad, Soumi H Choudhari, Pushplata Gupta
Institution: Bhagwan Mahaveer Cancer Hospital and Research Centre
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4404960180