Ultrasound-Guided Thoracic Paravertebral Block Enhances the Quality of Recovery After Modified Radical Mastectomy: A Randomized Controlled Trial

Abstract

Purpose: Ultrasound-guided thoracic paravertebral block (TPVB) has become increasingly popular for postoperative analgesia after breast surgery. We designed this prospective, randomized, double-blind, placebo-controlled trial to test the hypothesis that TPVB is superior to placebo in improving the patient quality of recovery following modified radical mastectomy.

Patients and methods: Sixty-eight female patients undergoing elective unilateral modified radical mastectomy were enrolled. Patients were randomized to receive preoperative ultrasound-guided TPVB with 0.5% ropivacaine (TPVB group, n=34) or 0.9% saline (Control group, n=34). The primary outcome was quality of recovery, measured 24 h after surgery using the 40-item Quality of recovery questionnaire (QoR-40). Secondary outcomes were the area under the curve of the visual analog scale pain scores over 24 h, postoperative 24-h morphine consumption, time to first rescue analgesia, length of post-anesthesia care unit stay, postoperative nausea and vomiting, and patient satisfaction.

Results: The global QoR-40 score 24 h postoperatively (median [interquartile range]) was 173 [170-177] in the TPVB group and 161 [160-164] in the control group (P<0.001), respectively, with a median difference (95% confidence interval) of 11 (9-14). Compared with the control group, preoperative TPVB decreased the area under the curve of the visual analog scale pain scores over 24 h, reduced postoperative 24-h morphine consumption, prolonged the time to first rescue analgesia, shortened the length of post-anesthesia care unit stay, lessened postoperative nausea and vomiting, and improved the patient satisfaction.

Conclusion: A single preoperative injection of TPVB with ropivacaine enhances the quality of recovery and postoperative analgesia in patients following modified radical mastectomy.

Keywords: breast cancer surgery; pain management; quality of recovery; regional anesthesia; thoracic paravertebral block; ultrasonography.

Figure 1

Consolidated standards of reporting trials (CONSORT) flowchart describing patient progress through the study.

Figure 2

Violin plots of the global QoR-40 scores before surgery and 24 h after surgery. The global QoR-40 scores in the TPVB group were higher than the control group (P<0.001 by the Mann–Whitney U-test), with a median difference of 11 (95% confidence interval, 9 to 14).

Figure 3

Box plots of postoperative visual analog scale pain scores at rest (A) and on movement (B) in patients receiving TPVB with 0.5% ropivacaine or 0.9% saline during the first 24 h postoperatively.

Figure 4

Kaplan-Meier survival plot of time to first rescue analgesia, defined as the time from emergence from general anesthesia until the VAS pain score exceeded 3 cm.