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Erector spinae plane versus paravertebral nerve blocks for postoperative analgesia after breast surgery: a randomized clinical trial
  1. Matthew W Swisher1,
  2. Anne M Wallace2,
  3. Jacklynn F Sztain1,
  4. Engy T Said1,
  5. Bahareh Khatibi1,
  6. Maryann Abanobi1,
  7. John J Finneran IV1,
  8. Rodney A Gabriel1,3,
  9. Wendy Abramson1,
  10. Sarah L Blair2,
  11. Ava Hosseini2,
  12. Marek K Dobke2,
  13. Michael C Donohue4 and
  14. Brian M Ilfeld1
  1. 1Anesthesiology, University of California San Diego, San Diego, California, USA
  2. 2Surgery, University of California San Diego, San Diego, California, USA
  3. 3Biomedical Informatics, University of California San Diego, San Diego, California, United States
  4. 4Neurology, University of Southern California, Los Angeles, California, USA
  1. Correspondence to Dr Matthew W Swisher, Anesthesiology, University of California San Diego, San Diego, CA 92103, USA; mwswisher{at}


Background Paravertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique.

Methods Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB.

Results Both pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI −3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI −1.2 to −0.1; p=0.0043). No block-related adverse events occurred in either group.

Conclusions PVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1–2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery.

Trial registration number NCT03549234.

  • truncal blocks
  • acute pain
  • pain outcome measurement

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  • Contributors MWS, MCD, and BMI: helped with literature search, data collection, study design, analysis of data, manuscript preparation, and review of manuscript. AMW, SLB, AH, and MKD: helped with literature search, study design, manuscript preparation, and review of manuscript. JS, ES, BK, MA, JF, RAG, and WA: helped with literature search, data collection, study design, manuscript preparation, and review of manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MWS, JS, ES, BK, JF, RAG, WA, and BMI: The University of California has received funding and product for other research projects from Myoscience (Fremont, CA) and Epimed (Farmers Branch, TX); infusion pump manufacturer Infutronics (Natick, MA); and a manufacturer of a peripheral nerve stimulation device, SPR Therapeutics (Cleveland, OH). MBI: in addition to the above, MBI’s institution has received funding from a manufacturer of a long-acting bupivacaine formulation, Heron Pharmaceuticals.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Please contact the corresponding author for data.