An Evidence-Based Review of the Efficacy of Perioperative Analgesic Techniques for Breast Cancer-Related Surgery

Objective. To review the published evidence regarding perioperative analgesic techniques for breast cancer-related surgery. Design. Topical review. Methods. Randomized, controlled trials (RCTs) were selected for inclusion in the review. Also included were large prospective series providing estimates of potential risks and technical reports and small case series demonstrating a new technique or approaches of interest to clinicians. Results. A total of 514 abstracts were reviewed, with 284 studies meeting criteria for full review. The evidence regarding preemptive ketamine, scheduled opioids, perioperative non-steroidal anti-inflammatory drugs (NSAIDs), and intravenous lidocaine is mixed and deserves further investigation. There is strong evidence that both pregabalin and gabapentin provide analgesic benefits following breast surgery. There is minimal and conflicting data from high-quality randomized, controlled studies suggesting that directly infiltrating and/or infusing local anesthetic (liposome encapsulated or unencapsulated) into the surgical wound is a reliably effective analgesic. In contrast, there is a plethora of data demonstrating the potent analgesia, opioid sparing, and decreased opioid-related side effects from thoracic epidural infusion and both single-injection and continuous paravertebral nerve blocks (the latter two demonstrating decreased persistent post-surgical pain between 2.5 and 12 months). Techniques with limited-yet promising-data deserving additional investigation include brachial plexus blocks, cervical epidural infusion, interfascial plane blocks, and inter-pleural blocks. Conclusions. While there are currently multiple promising analgesic techniques for surgical procedures of the breast that deserve further study, the only modalities demonstrated to provide potent, consistent perioperative pain control are thoracic epidural infusion and paravertebral nerve blocks.