Erector spinae plane block combined with a novel technique for selective brachial plexus block in breast cancer surgery -a case report-

  • De Cassai, Alessandro (Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padua) ;
  • Bonvicini, Daniele (Department of Urgency and Emergency, Anesthesiology and Intensive Care Unit, University Hospital of Padova) ;
  • Ruol, Michele (Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padua) ;
  • Correale, Christelle (Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padua) ;
  • Furnari, Maurizio (Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padua)
  • Received : 2018.09.07
  • Accepted : 2018.11.21
  • Published : 2019.06.01


Background: The breast is innervated by the intercostal nerves and the brachial plexus. We propose a technique to perform breast surgery without general anesthesia using the erector spinae plane (ESP) block and selective block of four nerves that arise from the brachial plexus innervate the breast and the axilla (SBP block). Case: A 77-year-old man with breast cancer was scheduled for radical mastectomy and axillary clearance. He had a previous history of myocardial infarction with dilated cardiomyopathy and severely impaired ejection fraction. The surgery was performed under regional anesthesia with combined ESP and SBP block. The patient did not require opioids or other supplemental analgesics intra- or postoperatively and was discharged uneventfully. Conclusions: SBP is a novel block that selectively blocks branches of the brachial plexus that innervate the breast.


  1. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016; 41: 621-7.
  2. Bonvicini D, Giacomazzi A, Pizzirani E. Use of the ultrasound-guided erector spinae plane block in breast surgery. Minerva Anestesiol 2017; 83: 1111-2.
  3. Kimachi PP, Martins EG, Peng P, Forero M. The erector spinae plane block provides complete surgical anesthesia in breast surgery: a case report. A A Pract 2018; 11: 186-8.
  4. De Cassai A, Marchet A, Ori C. The combination of erector spinae plane block and pectoralis blocks could avoid general anesthesia for radical mastectomy in high risk patients. Minerva Anestesiol 2018; 84: 1420-1.
  5. Woodworth GE, Ivie RMJ, Nelson SM, Walker CM, Maniker RB. Perioperative breast analgesia: a qualitative review of anatomy and regional techniques. Reg Anesth Pain Med 2017; 42: 609-31.
  6. Ueshima H, Hiroshi O. Erector spinae plane block for carotid endarterectomy. J Clin Anesth 2018; 48: 11.
  7. Darling CE, Pun SY, Caruso TJ, Tsui BC. Successful directional thoracic erector spinae plane block after failed lumbar plexus block in hip joint and proximal femur surgery. J Clin Anesth 2018; 49: 1-2.
  8. Forero M, Rajarathinam M, Adhikary SD, Chin KJ. Erector spinae plane block for the management of chronic shoulder pain: a case report. Can J Anaesth 2018; 65: 288-93.
  9. Ueshima H, Otake H. Limitations of the Erector Spinae Plane (ESP) block for radical mastectomy. J Clin Anesth 2018; 51: 97.
  10. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012; 59: 470-5.
  11. Hanson NA, Auyong DB. Systematic ultrasound identification of the dorsal scapular and long thoracic nerves during interscalene block. Reg Anesth Pain Med 2013; 38: 54-7.
  12. Chang KV, Lin CP, Lin CS, Wu WT, Karmakar MK, Ozcakar L. Sonographic tracking of trunk nerves: essential for ultrasound-guided pain management and research. J Pain Res 2017; 10: 79-88.
  13. Zin T, Maw M, Oo S, Pai D, Paijan R, Kyi M. How I do it: simple and effortless approach to identify thoracodorsal nerve on axillary clearance procedure. Ecancermedicalscience 2012; 6: 255.