Skip to main content
Download PDF

Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: a randomized controlled clinical trial

BMC Anesthesiology volume 25, Article number: 184 (2025) Cite this article

Abstract

Background

Nerve blocks are one of the most important methods of postoperative analgesia in breast cancer surgery. We used a randomized controlled clinical trial to compare the effects of rhomboid intercostal nerve block, serratus anterior plane block, and paravertebral block on the quality of recovery and postoperative analgesia in modified radical mastectomy.

Methods

We used a randomized controlled clinical trial to compare the effects of rhomboid intercostal nerve block, serratus anterior plane block, and paravertebral block on the postoperative quality of recovery and postoperative analgesia in modified radical mastectomy. A total of 132 breast cancer surgery patients were randomized 1:1:1 into three groups. 0.375% ropivacaine 20 ml for ultrasound-guided rhomboid intercostal nerve block group (n = 44), serratus anterior plane block group(n = 44), and paravertebral block group (n = 44). The primary outcome was the quality of the recovery-40 questionnaire (QoR-40 score).

Results

The postoperative 24-hour QoR-40 scores of the rhomboid intercostal nerve block group (median: 186; interquartile range: 177, 190.5) and the paravertebral block group (median: 186.5; interquartile range: 176.25, 190.5) were not statistically significant. The serratus anterior plane block group (median: 168; interquartile range: 163.25, 172) had significantly lower QoR-40 scores than the paravertebral block group (median difference: -17, 95%CI: -20, -13; P < 0.001). Furthermore, the rhomboid intercostal nerve block group had significantly higher global QoR-40 scores than the serratus anterior plane block group (median difference: 17, 95%CI: 14, 20; P < 0.001). In addition, the intraoperative sufentanil consumption (P < 0.001), number of intraoperative sufentanil users (P < 0.001), and postintubation NRS scores (P = 0.01) of the rhomboid intercostal nerve block and paravertebral block group were significantly lower than those of the serratus plane block group, but there was no statistically significant difference between the rhomboid intercostal nerve block and paravertebral block group. There was no statistically significant difference between the three groups in postoperative numerical rating scale scores, postoperative tramadol consumption, adverse events, and average length of stay.

Conclusion

Rhomboid intercostal nerve block and paravertebral block were able to provide similar analgesic effects and QoR-40 scores in breast cancer surgery. However, the blocking effect of the serratus anterior plane block was inferior to the rhomboid intercostal nerve block and paravertebral block. Rhomboid intercostal nerve block may be one of the best alternatives to paravertebral block as a fascial plane block.

Trial registry

Chinese Clinical Trial Registry ChiCTR2300079196. Registered on 27 December, 2023.

Peer Review reports

Introduction

Breast cancer is the most common malignant tumor in women worldwide [1]. Surgical resection remains the primary treatment modality [2]. Approximately half of all surgical patients experience moderate to severe acute pain after surgery [3].

Regional anesthetic techniques are an important part of multimodal analgesia as they have been demonstrated to reduce opioid consumption and numerical rating scale (NRS) in breast cancer surgery [4,5,6]. Furthermore, evidence from the 40-item Quality of Recovery Questionnaire (QoR-40), a validated patient-oriented multidimensional assessment tool, indicates that regional analgesia may promote recovery following surgery [7, 8]. Paravertebral block (PVB) is the most used regional analgesia in breast cancer surgery [9,10,11,12]. However, PVB can also cause adverse effects such as hypotension, pneumothorax, hemorrhage, and respiratory depression [13, 14]. Furthermore, PVB is demanding for the operator and difficult to master [15, 16]. With the increasing popularity and development of ultrasound, the safety and efficacy of fascial plane blocks have improved. In recent years, several planes of fascial plane blocks have been found in breast cancer surgery, including pectoral nerve block (PECS), erector spine plane block (ESPB), serratus anterior plane block (SAPB), and rhomboid intercostal nerve block (RIB) [4, 9, 17, 18]. However, it is unclear which technique can provide more effective analgesia in breast cancer surgery.

Our previous network meta-analysis revealed that RIB and SAPB may be the optimal nerve block modalities, but this conclusion was based on indirect comparisons and statistical probabilities and was not confirmed by direct clinical trials [4]. We hypothesized that RIB and SAPB would provide better analgesia than PVB in breast cancer surgery. Therefore, we conducted this prospective randomized study to assess the impact of the use of RIB, SAPB, and PVB in modified radical mastectomy on postoperative recovery and analgesic effects.

Methods

Study design and participants

The prospective single-center, parallel-group, single-blind randomized, and controlled trials were approved on 22 November 2023 by the Ethics Committee of the Chongqing University Cancer Hospital (CZLS2023325-A). The trial was conducted by the Declaration of Helsinki. Written informed consent was obtained from all participants before enrollment. The trial was registered with ClinicalTrials.gov (ChiCTR2300079196). The reporting complies with the most recent version of the Consolidated Standards of Reporting Trials (CONSORT).

Patients

Following the acquisition of written informed consent from the patients, the women with physical statuses I to III as determined by the American Society of Anesthesiologists (ASA), aged 18 years or older, and scheduled for elective modified radical mastectomy were included in the study. The surgical procedures performed included radical mastectomy with sentinel lymph node biopsy, radical mastectomy, and modified radical mastectomy with axillary lymph node dissection. The following criteria were used to exclude patients from the study: unsuitability for regional anesthesia when the anesthetist assessed the patient in the pre-anesthetic; coagulation disorders, infections, or a history of allergy to local anesthetic medications; speech disorders; a body mass index greater than 35 kg/m2 and an age of less than 18 years or more than 85 years.

Randomization and blinding

Subjects who met the eligibility criteria were randomly assigned to receive RIB, SAPB, or PVB at a ratio of 1:1:1 on the day of surgery. Randomization was performed via SPSS-generated random numbers. Concealment was achieved using sealed opaque envelopes. All patients, surgeons, and outcome assessors were unaware of the group assignment, whereas the anesthetist performing the nerve block was aware of the group assignment.

RIB procedure

The patient was positioned in the lateral position, with the surgical side facing upward and the upper limb of the surgical side extending downward naturally. The high-frequency line array probe (8–14 MHz) is located on the lower edge of the scapula on the operative side of the medial T5–6 level. The probe marking point indicates the cephalic side. The ultrasound image revealed, in turn, the trapezius, rhomboid, intercostal muscles, rhomboid intercostal nerve blocks, pleura, and other structures. The puncture needle is inserted from the caudal end to the cephalic end. The cephalic end of the piercing is visible through the trapezius, rhomboid, and rhomboid muscles and the intercostal muscles between the gaps. After the injection of 20 ml of 0.375% ropivacaine, the local anesthetic diffused in a shuttle-shaped manner into the gap. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation. The ice water test was employed to evaluate the extent of sensory deficit.

SAPB procedure

The patient was placed in the supine position. A high-frequency line array probe (8–14 MHz) was placed in the sagittal direction at the level of the midclavicular line on the operative side. The 2nd rhomboid intercostal nerve block at the axillary artery and vein was identified, and the probe was moved downward and outward to count the rhomboid intercostal nerve blocks until they reached the level of the 5th rhomboid intercostal nerve block in the midaxillary line. The superficial posterior latissimus dorsi muscle and the caudal deep side of the anterior serratus should be identified ultrasonographically, after which the nerve block needle should be advanced from the anterosuperior to posterior-inferior direction until it is between the latissimus dorsi muscle and the anterior serratus muscle. Following the withdrawal of no blood or gas, 20 ml of 0.375% ropivacaine was injected between the latissimus dorsi and the serratus anterior muscle. The local anesthetic was observed to diffuse in the interstices in the shape of a shuttle. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation. The ice water test was employed to evaluate the extent of sensory deficit.

PVB procedure

All patients were positioned in the lateral decubitus position with the operative side up and the upper extremity of the operative side naturally extending downward. The seventh rhomboid intercostal nerve block is located at the angle of the scapula, and a high-frequency line array probe (8–14 MHz) is selected to locate and mark the third rhomboid intercostal nerve block and T3 spinous process at the level of the seventh rhomboid intercostal nerve block. The probe was placed on the marked spinous processes with the long axis of the probe parallel to the spine, and the probe was moved along the alignment of the rhomboid intercostal nerve blocks to the affected side to view the image of the stacked transverse processes. The nerve block needle was inserted in the lateral to the medial intermediate plane, advancing the needle medially to the transverse processes. After the bloodless and airless injection of 20 ml of 0.375% ropivacaine is withdrawn, the puncture needle should be placed deep in the transverse process of the highly echogenic bulge, and the local anesthetic should diffuse into the interstitial space in the form of a shuttle. Following the completion of the block, the skin was observed for 20 min to ascertain whether any loss of sensation had occurred. The ice water test was employed to evaluate the extent of sensory deficit.

The procedure involved the administration of nerve blocks by two anesthetists with extensive experience in this field(Jiali Yu and Yi Qi). Ultrasound images of the nerve block are presented in Fig. 1.

Fig. 1
figure 1

Ultrasound images of nerve block (A: rhomboid intercostal nerve block; B: serratus plane block; C: paravertebral block; The red arrow indicates the local anesthetic injection site)

Full size image

Anesthesia procedure

All patients received a dose of midazolam (2 mg) and sufentanil (5 µg) via standard monitoring and oxygenation via a facemask before the nerve block. Standard monitoring methods include electrocardiography, peripheral pulse oximetry, noninvasive blood pressure (BP) measurement, temperature measurement, and the bispectral index (BIS). Anesthesia was induced following a successful nerve block puncture. Following the successful administration of a nerve block, all patients were preoxygenated with 100% oxygen for three minutes before induction. General anesthesia was induced using 2 mg/kg propofol and 0.5µ/kg sufentanil, with 0.6 mg/kg rocuronium administered to promote muscle relaxation. The anesthesia was maintained with an oxygen/air mixture (FiO2 = 0.5, fresh gas flow rate 3/L/min) and sevoflurane [1.0 to 1.5 minimum alveolar concentration (MAC)] to a BIS of 40 to 60. An endotracheal tube with a 7.0-mm internal diameter and a cuffed endotracheal tube were used for tracheal intubation. The initial respiratory rate was 12 breaths per minute, the positive end-expiratory pressure was 5 cmH₂O, and the tidal volume was 6 ml per ideal body weight. The respiratory rate was adjusted to maintain end-tracheal carbon dioxide (ETCO2) levels between 35 and 45 mmHg. Vasoactive drugs were administered intraoperatively based on alterations in blood pressure and heart rate. All patients received a preoperative dose of dexamethasone (4 mg) and ondansetron (0.1 mg/kg) to prevent postoperative nausea and vomiting (PONV). When the patient’s depth of anesthesia was adequate and the heart rate and blood pressure were 20% above normal, 5 µg of sufentanil was given. Tramadol 50 mg or 100 mg was given to the patient after extubation when the postoperative NRS score was greater than 4. If tramadol was not controlled, morphine (0.1 mg/kg) was given.

Outcomes

The primary outcome was QoR-40 scores. The primary outcome measure was the quality of recovery, which was evaluated at 24 h postoperatively via the Chinese version of the QoR-40. The QoR-40 scores are composed of two parts: the QoR-40 A and the QoR-40B. The questionnaire comprises 40 items that assess five dimensions of recovery: emotional state (9 items), physical comfort (12 items), psychological support (7 items), physical independence (5 items), and pain (7 items).

The secondary outcomes included postoperative NRS scores (resting and movement), postoperative 24 morphine consumption, and postoperative quality of recovery. Intraoperative sufentanil consumption (excluding sufentanil given before intubation), number of intraoperative users of sufentanil and postoperative 24-hour tramadol, incidence of intraoperative adverse events such as hypotension, arrhythmia, and pneumothorax, PONV, and average length of stay.

Statistical analysis

Our sample size was calculated for two-tailed testing. A pre-experimental analysis revealed that the postoperative 24-hour QoR-40 scores for RIB, PVB, and SAPB were 178.9 ± 5.01, 175.11 ± 4.17, and 174.8 ± 6.61, respectively. One-way analysis of variance allowing unequal variances (a = 0.05 and β = 0.1) in the PASS (21.03, USA) was used for the analysis. A sample size of 37 participants per group was deemed necessary. In consideration of a 20% dropout rate, 44 participants were required per group [19].

Statistical analyses were conducted via SPSS 27.0 software (SPSS, Chicago, IL, USA). The distribution of continuous data was initially evaluated via the Shapiro‒Wilk test and Q‒Q plots. Data with a normal distribution were analyzed via one-way ANOVA or repeated-measures ANOVA, and the results are expressed as the means ± standard deviations (SDs). Data with a nonnormal distribution were analyzed via the Kruskal‒Wallis test and the results are expressed as medians and interquartile ranges (IQR). Comparisons between groups were made via Kruskal‒Wallis one-way ANOVA. Categorical variables were analyzed via the χ2 test or Fisher’s exact test, with the results described as numbers (%). Post hoc analyses were performed via the Bonferroni correction. The P value for significant differences was adjusted to 0.05. The comparison between the two groups was expressed by the median difference (MD) and 95% confidence interval (CI). The P value for significant differences was adjusted to 0.05.

Results

Patient characteristics

The clinical trial was conducted between January 2024 and June 2024 at Chongqing University Cancer Hospital. Figure 2 presents a summary of the study flow according to the Consolidated Standards of Reporting Trials (CONSORT) statement. A total of 143 participants were first evaluated for eligibility to participate in the study. Seven did not meet the inclusion criteria, and three declined to participate, leaving 132 individuals available for enrollment (Fig. 2). Baseline personal and clinical characteristics and perioperative global QoR-40 scores were comparable between the groups (Table 1).

Table 1 Characteristics of the patients at baseline
Full size table
Fig. 2
figure 2

The flow of participants through the study

Full size image

QoR-40 scores

The RIB (median: 186; IQR: 177, 190.5), SAPB (median: 168; IQR: 163.25, 172), and PVB (median: 186.5; IQR: 176.25, 190.5) group had statistically significant global QoR-40 scores at 24 h postoperatively (P < 0.001). A comparison of each group revealed that the global QoR-40 scores for the RIB group and the PVB group were not statistically significant (MD: 0, 95%CI: -3, 4; P = 0.6) and the SAPB group had significantly lower global QoR-40 scores than PVB group (MD: -17, 95%CI: -20, -13; P < 0.001). Furthermore, RIB group had significant higher in global QoR-40 scores than SAPB group (MD: 17, 95%CI: 14, 20; P < 0.001). Among the QoR-40 scores, the comfort and pain scores were significantly different across the group. A comparison of the comfort and pain scores within each group revealed that the RIB and PVB groups had significantly higher comfort scores than the SAPB group (P < 0.001). However, there was no statistically significant difference in the comfort or pain scores between the RIB and SAPB groups. There were no statistically significant differences in the other scores between the groups in terms of the postoperative 24-hour QoR-40 scores. Figure 3 shows the global QoR-40 scores at preoperative 1 day and 24 h postoperatively. The detailed scores of the QoR-40 are shown in Tables 2 and 3 shows the MD and 95% CI with statistical differences.

Table 2 The QoR-40 and dimensions scores at postoperative 24-hours
Full size table
Table 3 Comparison of QoR-40 and post-extubation NRS scores between groups with statistically significant differences
Full size table
Fig. 3
figure 3

Global QoR-40 scores(*: Statistical significance between the three groups, P < 0.05; #: No statistical significance between the three groups, P > 0.05. Violin plots are characterized by kernel density estimates of the underlying distribution. Kernel density estimates of the distribution. The red solid line represents the median and the blue dotted line represents the interquartile range.)

Full size image

Postoperative NRS score

The RIB[median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 1 (movement)], SAPB[median: 0; IQR: 0, 1 (resting), median: 1; IQR: 1,2 (movement)], and PVB[median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 0.75 (movement)] group had statistically significant NRS scores after extubation (resting: P = 0.01; movement: P < 0.01). A comparison of each group revealed that the RIB and PVB groups had no statistically significant difference in post-extubation NRS scores (resting: P = 0.64; movement: P = 0.9) and SAPB had significantly higher post-extubation NRS scores than PVB group (resting, MD: 0, 95%CI: 0,1; P = 0.002; movement, MD: 1, 95%CI: 0,1; P < 0.001). The RIB group had significantly lower post-extubation NRS than the SAPB group (resting, MD: -1, 95%CI: -1,0; P < 0.001; movement, MD: -1, 95%CI: -1,0; P < 0.001). There was no statistically significant difference in NRS scores between the RIB, SAPB, and PVB groups at 2, 24, and 48 h postoperatively, respectively. Figure 4 shows the postoperative NRS scores and Table 3 shows the MD and 95% CI with statistical differences.

Fig. 4
figure 4

Postoperative NRS scores(*: Statistical significance between the three groups, P < 0.05; #: No statistical significance between the three groups, P > 0.05; PACU: postoperative care unit; The boxes represent the median and the whiskers represent the interquartile range)

Full size image

Intraoperative sufentanil consumption

There was a statistically significant difference in intraoperative sufentanil consumption among the RIB (median: 0; IQR: 0, 0), SAPB (median: 0; IQR: 0, 5), and PVB (median: 0; IQR: 0, 5) group (P < 0.001). A comparison of each group revealed that intraoperative consumption of sufentanil was no statistically significant difference RIB and PVB groups (P = 0.64) and the SAPB group had significantly higher intraoperative consumption of sufentanil than the PVB group (P = 0.006). The rhomboid intercostal nerve block group had a significantly lower intraoperative consumption of sufentanil than the SAPB group (P = 0.001). Furthermore, the number of patients requiring sufentanil intraoperatively was significantly greater in the SAPB group (40.9%) than in the RIB (11.4%) and PVB group (13.6%) (P < 0.001). There was no statistically significant difference in the number of patients requiring sufentanil intraoperatively between the RIB and PVB groups. Table 4 shows the intraoperative sufentanil consumption.

Table 4 Secondary outcomes during the study period
Full size table

Postoperative tramadol and morphine consumption

There was no statistically significant difference in PACU tramadol consumption among the RIB (median: 0; IQR: 0, 0), SAPB (median: 0; IQR: 0, 0), and PVB (median: 0; IQR: 0, 0) group (P = 0.77). There was a statistically significant difference in tramadol consumption among the RIB (median: 0; IQR: 0, 100), SAPB (median: 0; IQR: 0, 100), and PVB (median: 0; IQR: 0,0) group at 24 h post-surgery (P = 0.046). A comparison of each group revealed that the postoperative 24-hour consumption of tramadol was not statistically significantly different in the RIB group than in the PVB group (P = 0.39), and the SAPB group had significantly higher postoperative 24-hour consumption of tramadol than PVB group (P = 0.042). The RIB group showed no statistically significant difference in tramadol consumption than the SAPB group (P = 1). Only one patient used morphine(5 mg) at postoperative 24 h, we did not perform statistical analyses. Table 4 shows the tramadol consumption.

Adverse events

There were no significant differences between RIB, SAPB, or PVB in the incidence of intraoperative hypotension, arrhythmia, or bradycardia. There were no significant differences among the three groups in terms of the time to extubation, PONV, or average length of stay. Table 4 shows the incidence of adverse events.

Discussion

In our study, there were no significant differences in the QoR-40 scores, analgesic medication consumption, or postoperative NRS scores between the RIB and PVB groups. We demonstrated that RIB and PVB exhibited comparable analgesic effects during breast cancer surgery. However, patients who received SAPB exhibited significantly lower QoR-40 scores at 24 h post-surgery and lower NRS scores after extubation compared to those who received PVB. Furthermore, the postoperative QoR-40 scores and analgesic efficacy associated with RIB were significantly greater than those observed with SAPB. There was no significant difference in the NRS score among the three groups at 2 h, 24 h, or 48 h after surgery. We did not find any adverse events associated with RIB, PVB, or SAPB.

The breast is innervated by the lateral and anterior cutaneous branches of the second to sixth thoracic intercostal nerve branches and several branches of the supraclavicular nerve [20, 21]. The SAPB is one of the most common interfacial blocks and is superficial and easy to perform. SAPB relieves postoperative pain and benefits patient recovery after breast surgery [7, 22, 23]. A meta-analysis by Chong et al. revealed that SAPB provides significant analgesia and reduces opioid consumption in patients undergoing breast cancer surgery. Nevertheless, the analgesic effect of SAPB is inferior to that of PVB [24]. Our study reached similar conclusions. Compared with PVB, SAPB was associated with significantly lower QoR-40 scores at 24 h postoperatively, higher NRS scores, and increased intraoperative sufentanil consumption. SAPB is performed by blocking the lateral cutaneous branches of the intercostal nerve, which provides analgesia to the anteromedial and partial posterior thoracic wall (T2-T9) [25]. However, the anterior branch of the intercostal nerve provides innervation to the anteromedial chest wall, and it is unlikely that the SAPB adequately covers this area [26, 27]. This may result in incomplete relief of pain from the medial breast wound and cause significant pain and discomfort.

The RIB, as first described by Elsharkawy et al. in 2016 [28], has been demonstrated to facilitate the spread of dye from caudad to cephalad, encompassing the T2 to T8 tissue plane and extending to the lateral branches of the intercostal nerves T3 to T8, the posterior primary rami close to the midline, and the clavipectoral fascia within the axilla [29]. Therefore, RIB can provide superior analgesia for axillary surgery. Some studies have shown that RIB improves the QoR-40 score and reduces the postoperative pain score and the consumption of opioids [30,31,32]. Our study revealed that RIB produced similar QoR-40 scores, postoperative pain scores, and analgesic consumption as PVB did. Jiang et al. compared the effects of RIB, SAPB, and ESPB on analgesia in breast cancer surgery and reported that the analgesic effects of RIB and ESPB were superior to those of SAPB [33]. Our study revealed that the analgesic effect of RIB was superior to that of SAPB. The RIB is in the posterior chest wall and is superficial, easily localized via ultrasound, and distant from the surgical site. Therefore, it may be an optimal alternative to PVB for an interfacial block.

Our study is the first to perform ultrasound-guided nerve blocks for preoperative comparison of the efficacy of RIB, SAPB, and PVB in providing intraoperative analgesia. A single nerve block was performed, with additional sufentanil administered based on the patient’s requirements. Approximately 13% of patients who underwent RIB and PVB required additional intraoperative sufentanil, whereas 40.9% of those who underwent SAPB required additional sufentanil. Therefore, Rhomboid intercostal nerve block and PVB have the potential to reduce the total amount of intraoperative opioids required and provide an effective analgesic strategy for opioid-free anesthesia. We found fewer patients with postoperative pain greater than 4 in all three groups, indicating that nerve blocks are effective in reducing postoperative pain. Only 1 patient required morphine 24 h postoperatively. Therefore, PVB was associated with significantly lower tramadol consumption than SAPB was, but RIB was not significantly different from PVB or SAPB at 24 h postoperatively. We did not use PCA for postoperative analgesia, and postoperative tramadol consumption may be subject to patient and doctor intervention. A single nerve block does not provide continuous analgesia and may result in a burst of pain. Consequently, there was no significant difference in pain scores among the three groups after 2 h. There were differences in the QoR-40 scores among the three groups, which were due mainly to differences in patient comfort and pain scores 24 h after surgery. Research demonstrates that the Minimal Clinically Important Difference (MCID) for QoR-40 is 6.3. The findings of this study reveal that the difference between RIB and PVB compared to SAPB is 17, which substantially exceeds the MCID threshold [34]. Although our study demonstrated that RIB and PVB reduced NRS scores after extubation, the difference in NRS scores was minimal and did not reach the MCID of the NRS [35]. We did not find any nerve block-related complications, indicating that ultrasound-mediated RIB, SAPB, and PVB are safe and effective nerve blocks.

Our study had several limitations: First, our study revealed statistically significant differences in only the QoR-40 scores and analgesic effects among the three groups but did not reveal clinical differences. Second, our study used nerve blocks selected based on a previous network analysis and did not compare the analgesic effects of the other nerve blocks with those of the RIB. Third, postoperative tramadol consumption may be subject to human error. Fourth, we observed only QoR-40 scores at 24 h postoperatively and did not observe long-term QoR-40 scores or the incidence of chronic pain. Fifth, we used the Chinese version of the QoR-40, which may have impacted the results.

Conclusion

In the present study, RIB was found to yield postoperative QoR-40 scores and analgesic effects that were comparable to those achieved with PVB in the breast cancer surgery. However, SAPB was associated with a significant decrease in postoperative QoR-40 scores and an increase in intraoperative opioid consumption. While both RIB and PVB were associated with a significant reduction in the NRS score after extubation compared with SAPB, but no clinically relevant difference was observed between the two nerve blocks. RIB is a nerve block technique distinguished by its ease of implementation and precise analgesic efficacy, suggesting that it may represent a highly viable alternative to PVB for breast cancer surgery.

Data availability

All relevant data are within the manuscript.Further inquiries can be directed to the corresponding author(Ran An, Email: anran1011@163.com).

References

  1. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. Cancer J Clin. 2023;73(1):17–48.

    Article  Google Scholar 

  2. Lei S, Zheng R, Zhang S, Wang S, Chen R, Sun K, Zeng H, Zhou J, Wei W. Global patterns of breast cancer incidence and mortality: A population-based cancer registry data analysis from 2000 to 2020. Cancer Commun (London England). 2021;41(11):1183–94.

    Article  Google Scholar 

  3. Fecho K, Miller NR, Merritt SA, Klauber-Demore N, Hultman CS, Blau WS. Acute and persistent postoperative pain after breast surgery. Pain Med (Malden Mass). 2009;10(4):708–15.

    Article  Google Scholar 

  4. An R, Wang D, Liang XL, Chen Q, Pang QY, Liu HL. The postoperative analgesic efficacy of different regional anesthesia techniques in breast cancer surgery: A network meta-analysis. Front Oncol. 2023;13:1083000.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Wong HY, Pilling R, Young BWM, Owolabi AA, Onwochei DN, Desai N. Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis. J Clin Anesth. 2021;72:110274.

    Article  PubMed  Google Scholar 

  6. Wu J, Buggy D, Fleischmann E, Parra-Sanchez I, Treschan T, Kurz A, Mascha EJ, Sessler DI. Thoracic paravertebral regional anesthesia improves analgesia after breast cancer surgery: a randomized controlled multicentre clinical trial. Can J Anesthesia/Journal Canadien D’anesthésie. 2014;62(3):241–51.

    Article  Google Scholar 

  7. Yao Y, Li J, Hu H, Xu T, Chen Y. Ultrasound-guided serratus plane block enhances pain relief and quality of recovery after breast cancer surgery: A randomised controlled trial. Eur J Anaesthesiol. 2019;36(6):436–41.

    Article  PubMed  Google Scholar 

  8. Abdallah FW, Morgan PJ, Cil T, McNaught A, Escallon JM, Semple JL, Wu W, Chan VW. Ultrasound-guided multilevel paravertebral blocks and total intravenous anesthesia improve the quality of recovery after ambulatory breast tumor resection. Anesthesiology. 2014;120(3):703–13.

    Article  CAS  PubMed  Google Scholar 

  9. Heesen M, Klimek M, Rossaint R, Imberger G, Straube S. Paravertebral block and persistent postoperative pain after breast surgery: meta-analysis and trial sequential analysis. Anaesthesia. 2016;71(12):1471–81.

    Article  CAS  PubMed  Google Scholar 

  10. Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2010;105(6):842–52.

    Article  CAS  PubMed  Google Scholar 

  11. Terkawi AS, Tsang S, Sessler DI, Terkawi RS, Nunemaker MS, Durieux ME, Shilling A. Improving analgesic efficacy and safety of thoracic paravertebral block for breast surgery: A Mixed-Effects Meta-Analysis. Pain Physician. 2015;18(5):E757–780.

    Article  PubMed  Google Scholar 

  12. Jacobs A, Lemoine A, Joshi GP, Van de Velde M, Bonnet F. PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2020;75(5):664–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral Blockade. Failure rate and complications. Anaesthesia. 1995;50(9):813–5.

    Article  PubMed  Google Scholar 

  14. Naja Z, Lönnqvist PA. Somatic paravertebral nerve Blockade. Incidence of failed block and complications. Anaesthesia. 2001;56(12):1184–8.

    Article  CAS  PubMed  Google Scholar 

  15. Moustafa MA, Alabd AS, Ahmed AMM, Deghidy EA. Erector spinae versus paravertebral plane blocks in modified radical mastectomy: randomised comparative study of the technique success rate among novice anaesthesiologists. Indian J Anaesth. 2020;64(1):49–54.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Abdallah FW, Brull R. Off side! A simple modification to the parasagittal in-plane approach for paravertebral block. Reg Anesth Pain Med. 2014;39(3):240–2.

    Article  CAS  PubMed  Google Scholar 

  17. Huang W, Wang W, Xie W, Chen Z, Liu Y. Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis. J Clin Anesth. 2020;66:109900.

    Article  CAS  PubMed  Google Scholar 

  18. Lovett-Carter D, Kendall MC, McCormick ZL, Suh EI, Cohen AD, De Oliveira GS. Pectoral nerve blocks and postoperative pain outcomes after mastectomy: a meta-analysis of randomized controlled trials. Regional anesthesia and pain medicine 2019.

  19. Jan SL, Shieh G. Sample size determinations for Welch’s test in one-way heteroscedastic ANOVA. Br J Math Stat Psychol. 2014;67(1):72–93.

    Article  PubMed  Google Scholar 

  20. Jaspars JJ, Posma AN, van Immerseel AA, Gittenberger-de Groot AC. The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. Br J Plast Surg. 1997;50(4):249–59.

    Article  CAS  PubMed  Google Scholar 

  21. Riccio CA, Zeiderman MR, Chowdhry S, Brooks RM, Kelishadi SS, Tutela JP, Choo J, Yonick DV, Wilhelmi BJ. Plastic surgery of the breast: keeping the nipple sensitive. Eplasty. 2015;15:e28.

    PubMed  PubMed Central  Google Scholar 

  22. Hu NQ, He QQ, Qian L, Zhu JH. Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Postoperative Analgesia in Patients Undergoing Breast Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Pain research & management 2021, 2021:7849623.

  23. Meng J, Zhao HY, Zhuo XJ, Shen QH. Postoperative analgesic effects of serratus anterior plane block for thoracic and breast surgery: A Meta-analysis of randomized controlled trials. Pain Physician. 2023;26(2):E51–62.

    Article  PubMed  Google Scholar 

  24. Chong M, Berbenetz N, Kumar K, Lin C. The serratus plane block for postoperative analgesia in breast and thoracic surgery: a systematic review and meta-analysis. Regional anesthesia and pain medicine 2019.

  25. Mayes J, Davison E, Panahi P, Patten D, Eljelani F, Womack J, Varma M. An anatomical evaluation of the serratus anterior plane block. Anaesthesia. 2016;71(9):1064–9.

    Article  CAS  PubMed  Google Scholar 

  26. Fusco P, Scimia P, Petrucci E, Marinangeli SDIC. The ultrasound-guided parasternal block: a novel approach for anesthesia and analgesia in breast cancer surgery. Minerva Anestesiol. 2017;83(2):221–2.

    Article  PubMed  Google Scholar 

  27. Brosnan KD, Coppens S, Ni Eochagain A. Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review. Anaesthesia. 2023;78(2):260–1.

    Article  CAS  PubMed  Google Scholar 

  28. Elsharkawy H, Saifullah T, Kolli S, Drake R. Rhomboid intercostal block. Anaesthesia. 2016;71(7):856–7.

    Article  CAS  PubMed  Google Scholar 

  29. Elsharkawy H, Maniker R, Bolash R, Kalasbail P, Drake RL, Elkassabany N. Rhomboid intercostal and subserratus plane block: A cadaveric and clinical evaluation. Reg Anesth Pain Med. 2018;43(7):745–51.

    PubMed  Google Scholar 

  30. Altıparmak B, Korkmaz Toker M, Uysal AI, Dere Ö, Uğur B. Evaluation of ultrasound-guided rhomboid intercostal nerve block for postoperative analgesia in breast cancer surgery: a prospective, randomized controlled trial. Reg Anesth Pain Med. 2020;45(4):277–82.

    Article  PubMed  Google Scholar 

  31. Wang X, Jia X, Li Z, Zhou Q. Rhomboid intercostal block or thoracic paravertebral block for postoperative recovery quality after video-assisted thoracic surgery: A prospective, non-inferiority, randomised controlled trial. Eur J Anaesthesiol. 2023;40(9):652–9.

    Article  CAS  PubMed  Google Scholar 

  32. Ciftci B, Ekinci M, Basim P, Celik EC, Tukac IC, Zenciroglu M, Atalay YO. Comparison of Ultrasound-Guided Type-II pectoral nerve block and rhomboid intercostal block for pain management following breast cancer surgery: A randomized, controlled trial. Pain Practice: Official J World Inst Pain. 2021;21(6):638–45.

    Article  Google Scholar 

  33. Jiang CW, Liu F, Zhou Q, Deng W. Comparison of rhomboid intercostal nerve block, erector spinae plane block and serratus plane block on analgesia for modified radical mastectomy: A prospective randomised controlled trial. Int J Clin Pract. 2021;75(10):e14539.

    Article  CAS  PubMed  Google Scholar 

  34. Myles PS, Myles DB, Galagher W, Chew C, MacDonald N, Dennis A. Minimal clinically important difference for three quality of recovery scales. Anesthesiology. 2016;125(1):39–45.

    Article  PubMed  Google Scholar 

  35. Bahreini M, Safaie A, Mirfazaelian H, Jalili M. How much change in pain score does really matter to patients? Am J Emerg Med. 2020;38(8):1641–6.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

None.

Funding

This work was supported by the Chongqing Shapingba District Joint Medical Research Project of Science and Health, No. 2024SQKWLHMS006 and Chongqing Medical Scientific Research Project (Joint project of Chongqing Health Commission and Science and Technology Bureau), No: 2024MSXM128 and 2024MSXM025.

Author information

Author notes

  1. JialiYu, Yi Qi and Yiwei Shen contributed equally as the first authors of this work.

Authors and Affiliations

  1. Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, 400030, China

    Jiali Yu, Yi Qi, Jingyu Xiao, Qi Chen & Ran An

  2. Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China

    Yiwei Shen

  3. Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, 40030, China

    Dan Wang

Authors
  1. Jiali Yu
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Yi Qi
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Yiwei Shen
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Dan Wang
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Jingyu Xiao
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Qi Chen
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Ran An
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

JL Y: Writing– original draft, Data curation, Formal analysis, Investigation, Software. Y. Q: Writing-original draft, Conceptulizaon, Investigation, Software. YW. S: Writing– review & editing, Investigation, Methodology, Visualizaion. D W: Investigation, Data curation. JY. Xiao: Writing– original draft, Formal analysis, Funding acquisition, investigation. Q. C: Formal anslysis, Investigation, Project administraion, Validation. R. A: Writing– original draft and review & editing, Formal Analysis, Funding acquisition, Methodology, Resources. All authors reviewed the manuscript.

Corresponding author

Correspondence to Ran An.

Ethics declarations

Ethical approval and informed consent

for this study was granted by the Ethics Committee of the Chongqing University Cancer Hospital (CZLS2023325-A). All participants and their parents provided written informed consent, and this study was conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yu, J., Qi, Y., Shen, Y. et al. Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: a randomized controlled clinical trial. BMC Anesthesiol 25, 184 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12871-025-03049-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12871-025-03049-3

Keywords

BMC Anesthesiology

ISSN: 1471-2253

Contact us