Ultrasound-Guided Erector Spinae Block Versus Serratus Anterior Block for Perioperative Analgesia In Patients Undergoing Modified Radical Mastectomy Surgery
Phase: NA
Conditions: Mastectomy, Postoperative Pain
Sponsor: Zagazig University

 
 
 
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Zagazig University                                                                                               
Faculty of Medicine                                                                                          
Department of Anesthesia and Surgical Intensive Care  
Ultrasound-Guided Erector Spinae Block Versus 
Serratus anterior Block for Perioperative Analgesia In 
Patients Undergoing Modified Radical Mastectomy 
Surgery 
A Protocol of Thesis Submitted in Partial Fulfillment for MD Degree 
In Anesthesia and Surgical Intensive care 
By  
Sara Heikal Mohamed Yousif 
Ass. Lecturer of Anesthesia and Surgical Intensive care 
Faculty of Medicine, Zagazig University 
Under supervision of 
Dr. Hassan Mohamed Ali Magid 
Professor of anesthesia and surgical Intensive care         
Faculty of Medicine, Zagazig University 
Dr. Hala Ibrahim Zanfaly  
Professor of anesthesia and surgical Intensive care         
Faculty of Medicine, Zagazig University 
Dr. Asmaa Mohamed Galal  
Lecturer of anesthesia and surgical Intensive care          
Faculty of Medicine, Zagazig University 
Faculty of Medicine 
zagazig university 
- 2019 - 

 
 
 
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Introduction  
Breast cancer is the most common malignancy of women all over the world. 
Unfortunately, two-thirds of women who undergo breast cancer surgery are 
reported to develop chronic pain in the postoperative period. Surgery type, 
radiation therapy, and clinically acute pain are the most important risk factors for 
the development of more intense chronic pain (Altıparmak et al., 2019). 
With improved diagnostic techniques and treatment regimens, prognosis in 
breast cancer is improving, with the 5-year survival of patients diagnosed with 
primary breast cancer having increased to approximately 85%. Persistent post-
surgical pain states in this group is reported in 30-50% of patients, up to half of 
whom may have pain well beyond 5 years. Over one-third of patients who 
underwent breast cancer surgery have inadequately controlled acute post-operative 
pain (FitzGerald et al., 2019).  
There are several ways to manage pain after mastectomy. Common systemic 
medications, particularly opioids, have different side effects, such as itching, 
nausea, vomiting and respiratory depression. Non-steroidal anti-inflammatory 
drugs are associated with impaired renal function and hemorrhagic disorders ( 
Rahimzadeh et al., 2018). 
Regional anesthesia has been believed as one of the formats for effective 
perioperative pain control. Regional blocks using ultrasound-guide has become a 
perfect supplement to general anesthesia for extending analgesia after modified 
radical mastectomy. The advantage includes post-operative pain relief 
prolongation, a decrease in analgesic requirement post-operatively, a reduction in 

 
 
 
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nausea and vomiting scores and probability for ambulatory discharge and hospital 
stay (Mohamady et al,. 2019). 
The complex innervation of breast tissues poses a great challenge for the 
anesthesiologists to provide adequate perioperative analgesia by ultrasound guided 
regional blocks. Thoracic epidural, interscalene brachial plexus block, 
paravertebral block, pectoral nerve I and pectoral nerve II blocks have been used in 
different studies with good results. There are also technically simple regional 
blocks as ultrasound-guided Serratus anterior Plane (US-guided SAP) block and 
erector spinae plane (US-guided ESP) block which can be used effectively for this 
purpose (Singh et al., 2019). 
Forero et al. described ultrasound-guided Erector Spinae Plane (US-ESP) 
block as a novel analgesic technique in which local anesthetic  injection is done 
beneath the erector spinae muscle (Forero et al., 2016). Previous studies reported 
effective postoperative pain reduction with ESP block after radical mastectomy 
surgery. Nevertheless, few studies have compared the efficacy of ESP block with 
another block technique. (Gad et al., 2019). 
The Serratus Anterior Plane block (SAP) provides anterolateral and partial 
posterior thoracic wall analgesia, affecting dermatomes from T2 to T9. SAP is 
affecting predominantly the lateral cutaneous branches of the thoracic intercostal 
nerves, along with intercostobrachial, thoracodorsal and long thoracic nerves. The 
block is performed further posteriorly and caudally than Pectoral Nerve Block-2, 
where the target nerves are located between the serratus anterior and the latissimus 
dorsi muscles. (Blanco et al., 2013) 

 
 
 
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Rationale  
  
Modified radical mastectomy is one of the commonly performed breast 
surgery. Postoperative pain following mastectomy should be minimised, as in a 
number of women it may chronically persist for months in the form of 
postmastectomy pain syndrome. 
Morphine administration for acute pain after mastectomy surgery has many 
side effects. Regional block techniques as paravertebral block and thoracic epidural 
anathesia has possible complications and technical difficulties. 
The new alternative regional techniques such as erector spinae plane block 
and serratus anterior plane block are clinical trials for providing a safe, easy and 
painless anesthetic procedure with good hemodynamic and recovery profile with 
adequate perioperative analgesia for a large section of patients undergoing 
mastectomy operation in order to reduce opiods consumption and subsequently 
avoid opiod-related adverse effects. 
  
 
  

 
 
 
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Research question  
 
Is there difference between the Ultrasound-Guided Erector Spinae Plane 
Block and the Serratus anterior plane Block in providing peri operative analgesia 
for patients undergoing Modified Radical Mastectomy?   
  
  
  
  
Hypothesis  
 
Null hypothesis (H0):  
There is no difference between Ultrasound-Guided Erector Spinae Plane 
Block and Serratus anterior plane Block in providing peri operative analgesia for 
patients undergoing Modified Radical Mastectomy under general anesthesia. 
 
Alternative hypothesis (H1):  
There is difference between Ultrasound-Guided Erector Spinae Plane Block 
and Serratus anterior plane Block in providing peri operative analgesia for 
patients undergoing Modified Radical Mastectomy under genera anesthesia. 

 
 
 
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Aim of the work  
To compare between Ultrasound-Guided Erector Spinae Plane Block and 
Serratus anterior plane Block for peri operative analgesia in patients undergoing 
Modified Radical Mastectomy operations under general anesthesia. 
  
  
Objectives  
To:  
• Assess sensory block (onset, quality and duration) of both erector spinae 
plane block and serratus anterior plane block and detect which of them 
gives better analgesia. 
• Assess post operative static and dynamic pain. 
• Assess the time of first analgesic requirement post Modified Radical 
Mastectomy surgery.  
• Detect the presence of side effects with general anesthesia.  
• Assess patient satisfactions.  
 
  

 
 
 
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Patients And Methods  
  
1- Technical design:  
  
• Site of the study:  
         The study will be conducted in operating room in Zagazig University 
Hospitals.  
• Duration of the study: 
The study will be conducted over two years. 
 
• Sample size:  
   
Assuming that the mean ± standard deviation of time of first 
analgesia requirement in erector spinae block group is 416+_108.2 
minute and that in serratus anterior block is 343+_99.7 minute ( 
Eldemrdash et al., 2019), so sample size is calculated by open EPI 
programme to be 75 cases (25 cases in each group) with confidence 
level of 95% and power of test 80%. 
Inclusion criteria: 
• Written informed consent from the patient. 
• Age: 21 – 60 years old. 
• Gender: female patients. 

 
 
 
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• Body mass index: < 35 kg/m2. 
• Physical status: ASA grade I-II (American society of anesthiologists). 
• Type of operation: unilateral modified radical mastectomy operation. 
 
Exclusion criteria: 
 
• Patient with known history of allergy to study drugs. 
• Chronic use of analgesics or drug dependence. 
• Patients not able to understand pain assessment test. 
• Anatomical abnormalities. 
• Neuropathic disease. 
• Pregnancy or breast feeding. 
•  Other contraindication of regional anesthesia e.g. septic focus at site of 
injection. 
•  patient with coagulopathy or on anticoagulant therapy. 
  
• Tools of data collection : 
• Anesthetic sheet to all patients. 
• Intra operative assessment of vital signs by the anesthesiologist. 
• Post-operative assessment of pain, use of systemic analgesics and 
patient satisfaction in ward. 
2- Operational design:  
• Type of the study: prospective comparative randomized controlled 
clinical study. 
• Randomization:  
A computer-generated table will be used to divide patients equally into 3 
study groups.   

 
 
 
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• Group C (Control group) (n=25 ) patients will receive only 
general anesthesia for Modified Radical Mastectomy.   
• Group E (n=25) patients will receive Ultrasound‑Guided Erector 
Spinae Plane Block before induction of general anesthesia for 
Modified Radical Mastectomy. 
• Group S (n=25) patients will receive Ultrasound‑Guided 
Serratus anterior Block before induction of general anesthesia for 
Modified Radical Mastectomy. 
 
• Equipment  needed for technique: 
• High frequency linear transducer ultrasound. 
• 22 gauge spinal needle 10 cm length. 
• Local anesthetic: bupivacaine 0.25% (for the erector spinae plane 
block and serratus plane block) and lidocaine 1% (for local 
infiltration at the site of injection). 
• Sterile preparation for the site of needle insertion, equipments and 
anesthesiologist. 
 All Cases Will Undergo:  
The process  
• Patient Examination:  
• All participating patients will be interviewed preoperatively during 
their preoperative preparation. The goal and endpoints of the study 

 
 
 
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will be discussed. Understanding of the block will be reviewed and 
emphasized, informed cosent will be taken.   
• On physical examination, special attention will be given to 
document vital signs, cardiac, chest condition and exclude 
contraindications.  
• All patients will be investigated by complete blood count, Liver 
functions test, kidney functions test and coagulation profile.  
Steps of Performance: 
• Preparation:  
• All patients will be kept fasting for minimum 6 hours before the 
operation.  
• All patients will be clinically examined in the preoperative period 
and routine investigations will be checked and at the same time, 
whole procedure will be explained. Ten centimeters visual analog 
scale (VAS) (Metwally et al., 2016), (0 – no pain and 10 – worst 
pain imaginable) will be also explained during preoperative visit. 
•  The monitors attached included non-invasive blood pressure 
(NIBP), electrocardiography (ECG), and pulse oximetry.  
• An 18 G I.V cannula will be secured in the opposite hand and fluid 
will be started. supplemental oxygen will be administered at 6 to 8 
L/min via face mask. Procedural sedation will be provided 
intravenously by midazolam 0.03 to 0.04 mg/kg, as needed 
  
 

 
 
 
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• Technique:  
• Erector Spinae Plane Block: 
 
Position  
      sitting position   
Type of needle 
Using 22 gauge spinal needle 10 cm length. 
Scanning  
Linear ultrasound probe is placed in a longitudinal parasagittal 
orientation 3 cm lateral to the T5 spinous process. 
The erector spinae muscle is identified superficial to the tip of The T5 
transverse process. 
Needle insertion  
The needle is inserted in- plane superior to inferior approach. The tip of 
the needle is placed into the fascial plane on the deep aspect of erector spinae 
muscle. 
The location of the needle tip is confirmed by visible normal saline 
fluid spread separating erector spinae muscle off the bony shadow of the 
transverse process on ultrasonographic imaging . 
Local anesthetic and volume 
Injection of 20 ml of bupivacaine 0.25 %. (Singh et al., 2019) 
  

 
 
 
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II.Serratus Anterior Plane Block: 
Position  
The patient lies supine with placing the ipsi-lateral upper limb in abduction at 
90° position.  
 
Type of needle 
Using 22 gauge spinal needle 10 cm length. 
 
Scanning 
After skin sterilization, Ultrasound device with high frequency [9-12] and 
superficial linear probe that is first placed inferior to the middle of the clavicle and 
moved laterally and downward to locate the 1st rib where pectoralis major and 
pectoralis minor muscles are identified at this US window.  
The US probe is moved toward axilla till serratus anterior muscle is identified 
above 2nd, 3rd and 4th ribs. The transducer is held at a slightly oblique angle at the 
level of the 4th and 5th rib, with the upper edge supero-anterior and the lower edge 
infero-anterior. 
Needle insertion 
After infiltration of the skin at puncture site with 3 ml of lidocaine 1%, the 
needle is inserted inplane between the anterior serratus and the latissimus dorsi 
muscle on the mid-axillary line.  
Local anesthetic and volume 
Injection of 20 mL of 0.25% bupivacaine. (Khemka et al., 2019) 
 
  

 
 
 
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Assessment of block: 
 
Onset time of sensory block  
Time between injection of the drugs and loss of pin prick sensation in operating 
field, pin prick test done with sterile 25G needle.  
 
Quality of sensory block will be graded as :  
• Grade 0 : normal sensation 
• Grade 1: loss of sensation to pinprick.  
• Grade 2: loss of sensation to light touch (Swami et al., 2012). 
Duration of sensory block   
Time between onset of sensory block to the first report of postoperative pain at 
the surgical site that is VAS score >3, with first analgesic requirement by the 
patient.  
  
The patients will be delivered to the operating room to receive 
general anesthsia with good monitoring. 
 
General  anesthesia: 
 
• It will be standardized for all patients.  

 
 
 
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• Fentanyl 2 mcg/kg, propofol 2 mg/kg will be intravenously 
administered, followed by cisatracurium 0.15 mg/kg to facilitate 
endotracheal intubation with a suitable size of endotracheal tube.  
• Lungs will be ventilated by pressure controlled mode to maintain 
normocapnia (PaCo2 = 35-45 mmHg) and isoflurane/O2 mixture will 
be administered. 
• Concentration of the inhalational agent will be 1.2 MAC of isoflurane, 
Heart rate and mean arterial blood pressure will be recorded every 10 
minutes. 
• Incremental doses of fentanyl can be given in inadequate analgesia 
{presented by tachycardia and hypertension (mean arterial blood 
pressure) >20% from baseline} after exclusion of other causes}, total 
amount of fentanyl consumption intraoperative will be calculated. 
• Paracetamol 15ml/kg will be administered by iv infusion to all patients.  
• After completion of the surgery, inhalational anesthesia will be stopped 
and the patient will receive neostigmine (0.05 mg/kg) and atropine 
sulphate (0.01 mg/kg). 
Postoperative: 
 
• After recovery from anesthesia, the patient will be transferred to the 
post-anesthesia care unit. 
• All patients will receive paracetamol as standard intravenous infusion 
analgesia at dose of 15mg/Kg every 8 hours (maximum dose: 4 g / 
day).  
• Pain will be observed and recorded using the pain assessment on a 0-10 
cm line [visual analogue scale (VAS) (Metwally et al., 2016); 0=no 
pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, 7 to 10 = severe pain].  

 
 
 
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• The pain is measured both at rest and movement (arm movement of 90° 
and sitting from lying down position) after explanation of the procedure 
to the patient at 2,4,8,12,18& 24 hours after surgery by an observer 
blinded to treatment groups.  
• All patients will be assessed for the time to first rescue analgesic and 
when the patient suffer from pain at score equal or above 3 on VAS, the 
patient will receive morphine (dose: 0.1 mg/kg intravenous as initial 
dose then 0.025 to 0.05 mg/kg every 5 minutes till the pain is relieved 
not exceeding 4 mg/h). Total morphine consumption will be calculated. 
• Post-operative nausea and vomiting will be noticed, recorded using a 
categorical scoring system (0 = none, 1 = mild, 2 = moderate, 3 = 
severe) and treated, Ondansetron 4 mg IV will be administered in case 
of reported nausea and/or vomiting.  
• Patient satisfaction will be assessed post operatively using satisfaction 
score (4= excellent, 3 = good, 2 = fair and 1 = poor) (Ross et al., 2009). 
Complications and side effects: 
It may include failure of the block, intra-muscular hematoma, pleural 
perforation, Post-operative nausea and vomiting (PONV), sedation and respiratory 
depression. These complications will be observed and recorded. 
Data collection: 
From each patient the following data will be collected upon admission: 
1-Demografic data: 
• Name 
• Age 
• Body Mass Index 
• Hospital diagnosis 
• Date of admission in hospital 
• Medical and past history 

 
 
 
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• ASA grade I-II 
• Type of operation : unilateral mastectomy surgery 
• Duration of operation 
 
2-Sensory block assessment: onset, quality of sensory block, duration of the 
block. 
3-Hemodynamics (HR, Mean Arterial Bl.Pr), total intra-operative fentanyl 
consumption. 
 4-Static and dynamic pain scores (VAS) at 2, 4, 8, 12, 18 and 24 hours    
post-operatively. 
5- The time to first rescue analgesic request.  
6- Total morphine consumption during 24 hours post-operative. 
7- Complications. 
8-Satisfaction score of patient. 
Administrative design: 
 
• Approval of anaesthesia department committee. 
• Approval of ethical committee in faculty of medicine. 
• Ethical approval:Approval will be obtained from Institutional Review 
Board (IRB) at Zagazig University Hospitals. 
• A written informed consent will be signed from all patients after 
discussing the study design including procedure , drugs and possible adverse 
effects .  
 
  
 
 

 
 
 
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Results 
 
Collected data will be presented in tables and suitable graphs and analyzed 
according to standard statistical methods. 
 
 
Discussion 
 
Discussion will be done on results compared to related relevant literature and 
scientific researches. 
 
 
Conclusion and Recommendations 
 
It will be derived from the findings of the study. 
 
 
 
 
 
 
 
  
 

 
 
 
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