Background and aims The multiple-injection costotransverse block (MICB) combines the positive mechanism of action from the thoracic paravertebral block with a reduced risk profile and we have, with success, obtained postoperative pain management with MICB for both unilateral mastectomy with sentinel node biopsy and bilateral mastectomy with primary reconstructive surgery (BMPR). We present two pilot cases (patients’ oral and written informed consent obtained).

Methods Preoperative multimodal analgesic regime for both patients consisted of Acetaminophen 1 g, Celecoxib 400 mg, Gabapentin 600 mg, Dexamethasone 8 mg and Dextromethorphan 30 mg. The MICB was successfully applied preoperatively at levels T2, T4, T6 and 30 min. Prior to emergence 10μg Sufentanil was administered.

Case A: A 56-year-old woman, weight 68 kg (body mass index, 24.1 kg/m²) with a history of thrombocytopenic purpura, hypertension and poor morphine tolerance (syncope), scheduled for unilateral mastectomy and sentinel node biopsy due to breast cancer. MICB: Ropivacaine 0.5%, 3×10 ml respectively. A PECS1 block² using Ropivacaine 0.375% 10 ml block was added.

Case B: A 67-year-old woman, weight 55 kg (body mass index, 23.2 kg/m²) with a history of chronic obstructive pulmonary disease scheduled for BMPR due to breast cancer. Bilateral MICB: Ropivacaine 0.375% 6×10 ml supplemented with 60μg Dexmedetomidine.

Results Case A: Oral Tradolan 100 mg was administered within the first 24 hrs. Reported diplopia 12 hrs. postoperative; presumably from sympathetic block.

Case B: Sufentanil 10μg and Morphine 5 mg was administered within the first 24 hrs. (all in the post anaesthesia care unit). Left surgical field was completely pain free.

Conclusions The MICB is effective as postoperative pain management in regards to major breast cancer surgery.