Comparing postoperative pain control after modified radical mastectomy: a pilot study of ultra-sound guided erector spinae plane block vs intraoperative tramadol administration in oncology patients

Vol.:(0123456789)
Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140
h ps://doi.o g/10.1007/s00432-025-06197-8
RESEARCH
Compa ing pos ope a i e pain con ol a e modi ied adical
mas ec omy: apilo s udy o ul a‑sound guided e ec o spinae plane
block s in aope a i e amadol adminis a ion inoncology pa ien s
AnaC e ko ić1,3· Ma ko ićI an2,3· Žega acMilan2,3· Ma koJe ić2,3· Zo anBukumi ic3,4· Mi čićDijana1·
And ejJokić1· Badnja e ićDamjana1· Ma koBu a2,3
Recei ed: 7 Ma ch 2025 / Accep ed: 3 Ap il 2025 / Published online: 15 Ap il 2025
© The Au ho (s) 2025
Abs ac
Pu pose This s udy aimed o compa e he e ec i eness o ul asound-guided e ec o spinae plane block (ESPB) wi h in a-
ope a i e T amadol o pos ope a i e pain managemen a e modi ied adical mas ec omy (MRM). The p ima y ocus was
on pain in ensi y wi hin he i s 24h, while seconda y ou comes included he need o escue analgesia, nausea, omi ing,
and pa ien sa is ac ion.
Me hods In his e ospec i e coho s udy, 49 emale pa ien s (ASA I-II, aged 30–80) who unde wen MRM om 2021 o
2023 we e analyzed. Pa ien s we e di ided in o wo g oups: one ecei ing ESPB p eope a i ely (25 pa ien s) and he o he
ecei ing T amadol du ing su ge y (24 pa ien s). Pain le els we e measu ed using he Nume ic Ra ing Scale (NRS), and
da a on escue analgesia, i al signs, nausea, omi ing, and pa ien sa is ac ion we e collec ed.
Resul s The ESPB g oup epo ed signi ican ly lowe pain le els du ing he i s six pos ope a i e hou s (NRS sco es o 0
s. 3; p = 0.005), along wi h a educed need o escue analgesia (88% s. 54.2%; p = 0.010). Mo eo e , pa ien sa is ac ion
was highe in he ESPB g oup (64% s. 37.5%; p = 0.03). The in aope a i e hea a e was also lowe in he ESPB g oup
(65.3 s. 72.0bpm; p = 0.030). No signi ican di e ences we e ound in nausea, omi ing, o leng h o hospi al s ay.
Conclusion O e all, ESPB demons a es supe io ea ly pos ope a i e pain con ol and imp o ed pa ien sa is ac ion compa ed
o T amadol. Fu he s udies a e needed o con i m hese indings.
Keywo ds ESPB· T amadol· Plane block· MRM
In oduc ion
Modi ied adical mas ec omy (MRM) is one o he su gical
ea men op ions o b eas cance . MRM accoun s o 31%
o all b eas su ge ies (Poleshuck e al. 2006). This su ge y
emo es he en i e b eas including he b eas issue, skin,
a eola, nipple and mos o he unde a m (axilla y) lymph.
In con as o o he b eas su ge ies MRM equi es ex en-
si e issue dissec ion, wi h pos ope a i e se oma o ma ion
and pain being he p ima y conce ns o pa ien s. Pain is
one o he mos equen ly expe ienced symp oms, a ec -
ing up o 50% o women unde going mas ec omy (Wang
e al. 2020). Among hese, 40% o he emales expe ienced
acu e pos ope a i e pain, and be ween 25 o 60% de eloped
pe sis en ch onic pos su gical pain (Cheng and Il eld 2017;
Abu Elyazed e al. 2020). Se e e acu e pos ope a i e pain
esul s in an inc eased incidence o pe sis en pos ope a i e
pain (Kehle e al. 2006).
Un o una ely, he e has been minimal p og ess in
enhancing pos ope a i e pain managemen ollowing modi-
ied adical mas ec omy (MRM). P e en i e analgesia using
mul imodal s a egies helps egula e ongoing in lamma ion
and neu onal ac i i y, ul ima ely educing he occu ence
o ch onic pain, complica ions, and mo ali y (Huang e al.
* Ana C e ko ić
[email p o ec ed]
1 Depa men o Anes hesia andIn ensi e Ca e Uni , Clinic
o Su gical Oncology, Ins i u e o Oncology andRadiology
o Se bia, 14 Pas e o a S ee , Belg ade, Se bia
2 Clinic o Su gical Oncology, Ins i u e o Oncology
andRadiology o Se bia, Belg ade, Se bia
3 School o Medicine, Uni e si y o Beg ade, Belg ade, Se bia
4 Ins i u e o Medical S a is ics andIn o ma ics, Facul y
o Medicine, Uni e si y o Belg ade, Belg ade, Se bia
Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140140 Page 2 o 9
2018). This app oach includes p e en i e and pe iope a i e
o ms o analgesia and pha macological agen s, egional
analgesia along wi h pa en e al analgesics. While he e a e
a ious egional analgesic echniques used o MRM, includ-
ing neu axial and egional analgesia hey a e no always
ideal echniques and come wi h hei complica ions and di -
icul ies. The e ec o spinae plane block is no el p omising
block wi h many ad an ages and less disad an ages han
o he commonly used echniques.
Tho acic epidu al anes hesia comes wi h an inc eased
isk o complica ions such as hypo ension, in ec ion, ne e
inju y, and ca he e mig a ion. I is echnically mo e chal-
lenging o pe o m and may also esul in mo o blockade,
which can hinde he pa ien ’s mobili y du ing he immedia e
pos ope a i e pe iod (Se cakacila e al. 2022). The pec o al
ne e (Pecs) blocks may no o e comple e pain elie o
deepe s uc u es in ol ed in mas ec omy o axilla y dissec-
ion. Pecs II can help wi h deepe co e age bu migh s ill
lea e gaps (Kim e al. 2018). While e ec i e o supe icial
pain, he axilla y dissec ion may equi e addi ional pa a e -
eb al blocks o ESPB o comp ehensi e pain con ol. Pa a-
e eb al blocks (PVB) ca ies a highe isk o complica ions
such as pneumo ho ax, ascula punc u e, and ne e inju y,
especially i pe o med inco ec ly, equi e a highe le el
o skill and al hough less common, PVB can occasionally
cause mo o block i he anes he ic sp eads o mo o ne es,
a ec ing mobili y. (Slinchenko a e al. 2023).
By a ge ing he e ec o spinae muscle and deli e ing
local anes he ic a ound he ho acic ne es, ESPB can help
educe pain in a eas like he ches wall, axilla, and shoulde ,
which a e commonly a ec ed a e his su ge y (Li e al.
2021; Soni e al. 2024). Due o di usion in o he pa a e -
eb al space local anes he ic can induce senso y block a
he mul ide ma omal le els ac oss all ches walls. Beside i s
e ec on ami communicans ha supply sympa he ic chain
(Singh e al. 2019), ESPB a ge s do sal and en al ami o
he ho acic ne es (Ince e al. 2018).
The ESP block has ad an ages o e o he echniques
because i can p o ide bo h soma ic and isce al pain elie ,
imp o ing pos ope a i e com o and educing he need o
opioid medica ions. I ’s pa icula ly bene icial o pain p e-
en ion, as i can help manage pain igh om he s a o he
pos ope a i e pe iod and acili a es as e e u n o no mal
unc ion po en ially educing he incidence o ch onic pain
and complica ions like se oma o ma ion.
Howe e , as wi h any echnique, i s e ec i eness may
a y om pa ien o pa ien , and i should be conside ed as
pa o a mul imodal pain managemen plan.
Unde s anding o pain dis ibu ion be o e planning
a egional ne e block o MRM is c ucial. The an e io
and la e al di isions o he in e cos al ne es supply he
skin o e lying he ches and la e al ho ax. The axilla is
supplied by T1 and T2 de ma ome, which includes he
in e cos ob achial ne e. The pec o al muscles, which a e
no a ec ed wi h his p ocedu e, a e supplied by la e al and
medial pec o al ne es (b anches om he la e al and medial
co d o he b achial plexus) (Blanco and Ba ing on 2017).
Ou p ima y aim is o compa e he in ensi y o pain in a
g oup o pa ien s who ecei ed a p eope a i e e ec o spinae
block as pa o mul imodal analgesia e sus a con ol g oup
who ecei ed in a enous T odon in aope a i ely, wi hin he
i s 24 pos ope a i e hou s.
Ou seconda y aim is o compa e which g oup had a
g ea e need o escue analgesia, wha ype and how many
addi ional analgesics we e adminis e ed du ing b eak h ough
pain, and in which g oup he incidence o nausea and omi -
ing was highe du ing he i s 24 pos ope a i e hou s, as
well as pa ien sa is ac ion wi h he se ice p o ided in ou
ins i u ion.
Me hods
Pa ien s
This coho pilo s udy e ospec i ely analyzes 49 emale
pa ien s who unde wen elec i e modi ied adical mas ec-
omy, aged 30 o 80 yea s, wi h Ame ican Socie y o Anes-
hesiologis physical s a us I o II. This s udy was conduc ed
be ween 2021 and 2023 in he Depa men o Anes hesia
a he Ins i u e o Oncology and Radiology o Se bia in
Belg ade a e app o al o he local e hics commi ee. The
goal was o ind a be e app oach o pain managemen in ou
popula ion o pa ien s and po en ially upg ade ou s anda d
o ca e. The pa ien s we e in o med abou he p ocedu e, ou
s anda d ca e app oach, ESP block, and he s udy. A e his,
he pa ien s choose whe he o be included in he s udy and
con i m i wi h w i en consen .
The c i e ia o pa ien selec ion comp ised indi iduals
who me he ollowing condi ions: age > 18, emale gen-
de , ASA I o II, pa ien s who unde wen unila e al MRM,
pa ien s who ecei ed an ESPB p eope a i ely and did no
unde go o he egional anes hesia echniques, pa ien s who
ecei ed T amadol hal an hou be o e he end o he su ge y
as pa o he s anda d p o ocol a he Ins i u e o Oncology
and Radiology o Se bia, and hose who we e no gi en o he
analgesics besides T amadol o any o he egional anes hesia
echniques.
We excluded pa ien s who ha e dep ession, ca dio as-
cula diseases, kidney ailu e, hema ological diso de s, a
his o y o medica ion abuse o ch onic opioid use, alle gic
eac ions o any o he medica ions, mo bidly obese (BMI
> 40), o i hey we e p egnan , hose pa ien s wi h incom-
ple e da a and e e y pa ien who we e no ea ed acco ding
o ou s anda d p ocedu es o p emedica ion, ESP block,
moni o ing du ing and a e he anes hesia.
Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140 Page 3 o 9 140
We collec ed pa ien s o bo h g oups om medical
eco d sys em. All pa ien s included in s udy had a clinical
assessmen on he p eope a i e isi .
All emale pa ien s in bo h g oups we e p emedica ed
wi h midazolam a a dose o 0.03 mg/kg IV, dexame hasone
4mg, and all ecei ed an ibio ics as pa o s anda d an i-
bio ic p ophylaxis, in he p eope a i e p epa a ion oom, as
pa o he ou ine p ocedu e.
US‑guided ESPB g oup
Ou s anda d p ocedu e o he E ec o Spinae Plane Block
(ESPB) is o pe o m he block one hou be o e he su gical
p ocedu e. Pa ien s a e posi ioned p one, and he ans e se
p ocesses o he 2nd and 4 h ho acic e eb ae a e loca ed
using a Siemens Acuson P500 ul asound. The co ec le els
a e iden i ied by coun ing he e eb ae om he spinous
p ocess o he 7 h ce ical e eb a.
A e an isep ic p epa a ion o he skin, he ESP block
is pe o med unde ul asound guidance using he in-plane
echnique. We in il a e 1% Lidocaine a he needle en y
si e on bo h le els and inse a 21G, 100 mm needle in align-
men wi h he ul asound p obe un il we make con ac wi h
he ans e se p ocess, i s a he 2nd le el, and hen a he
4 h le el. A e con i ming nega i e aspi a ion, 1 o 3mL o
saline solu ion is injec ed o con i m he ele a ion o he as-
cia o he e ec o spinae muscle o e he ans e se p ocess.
The ESP block is comple ed wi h a single-sho injec ion o
0.25% Bupi acaine, adminis e ed in a olume o 20 mL a
each le el.
A e 45 min o he ESP block, he pa ien is aken o
he ope a ing oom (OR), and anes hesia induc ion is pe -
o med. All pa ien s we e induced in o gene al anes hesia
using Fen anyl (1–2 mcg/kg induc ion dose) and P opo ol,
i-gel masks we e applied o mechanical en ila ion ( olume
con ol mode was used on he GE A ance CS2 P o de ice).
Anes hesia was main ained using Se o lu ane in combina-
ion wi h oxygen and ai . Hal an hou be o e he end o
su ge y, all pa ien s ecei ed 4mg o Ondanse on as an
an ieme ic.
The dis ibu ion o he local anes he ic is eco ded cau-
dally and c anially.
T amadol g oup
These pa ien s we e also collec ed om medical eco d
sys em. In he second con ol g oup, a e he p emedica-
ion desc ibed abo e, he pa ien s we e induced in o gene al
anes hesia in he same manne as in he p e ious g oup. Hal
an hou be o e he end o he su ge y, he pa ien s ecei ed
100 mg o T amadol in a slow in a enous in usion and
Ondanse on 4mg, as in he ESPB g oup.
In bo h g oups, we used da a om medical eco ds,
including age, BMI, su ge y du a ion, measu ed a e ial
ension, hea a e, and mean a e ial p essu e e e y i e
minu es, du ing anes hesia induc ion, and h oughou he
anes hesia. We also collec ed da a on he amoun o Fen-
anyl applied in aope a i ely. Fo bo h g oups o pa ien s,
a e anes hesia weaning, we collec ed da a on pain in en-
si y. Pain in ensi y was eco ded in he medical eco ds as
pa o he usual pos ope a i e documen a ion. The pain
assessmen was pe o med using Nume ic Ra ing Scale
(0-no pain and 10- maximum pain). F om hese iles, o
each pa ien , we collec ed da a on pain in ensi y immedi-
a ely a e weaning, up o he 1 s hou , om he 1 s o he
3 d hou , om he 3 d o he 6 h hou , om he 6 h o he
12 h hou , and om he 12 h o he 24 h hou , using a
nume ic a ing scale (NRS). A he same ime, we eco ded
nausea and omi ing. We de ine nausea as he unpleasan
sensa ion in he abdomen di e en om pain ha p ecedes
omi ing, and omi ing as he o ce ul e og ade expul-
sion o gas ic con en s om he body. Reco ds o nau-
sea and omi ing we e clinical mani es a ions ha we e
eco ded by s a .
Fo escue analgesia (RA), we use a non-s e oidal an i-
in lamma o y d ug (NSAID) o T amadol. Fo pa ien s
wi h an NRS lowe han 3 and 3, we do no adminis e
RA. Fo pa ien s wi h an NRS highe han 3 o 6, we apply
Diclo enac 75 mg, and o hose wi h an NRS highe han
6, we adminis e ed T amadol 100 mg. All analgesics and
hei applica ion imes we e eco ded in de ail in he pa ien
iles. We eco ded pa ien sa is ac ion based on he pos op-
e a i e pain and nausea and omi ing p esence.Pa ien sa -
is ac ion was measu ed using a ques ionnai e consis ing o
ques ions abou pe iope a i e anspa ency, com o in he
p e-ope a i e holding a ea, and pos ope a i e complica ion
managemen , which included managing b eak h ough pain,
nausea and omi ing, and s a a ailabili y. Pa ien s could
check he box nex o he co esponding ques ion indica -
ing dissa is ac ion. Based on he answe s, sa is ac ion was
e alua ed as 0 ma ks—sa is ied; 1–2 ma ks pa ly sa is ied;
3 + ma ks unsa is ied. We also eco ded he leng h o he
hospi al s ay, exp essed in days, om he day o su ge y un il
hospi al discha ge.
S a is ical analysis
Depending on he ype o a iables and he no mali y o he
dis ibu ion, da a will be p esen ed as n (%), mean ± s and-
a d de ia ion, o median ( ange). S a is ical hypo heses we e
es ed using - es , Mann–Whi ney es , Fishe ’s exac es .
All p- alues less han 0.05 we e conside ed signi ican . The
‘‘IBM SPSS S a is ics 24’’ p og am (IBM Co po a ion,
A monk, NY, USA) was used o p ocess all o he da a.
Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140140 Page 4 o 9
Resul s
The demog aphic da a (age, BMI), ASA s a us, su -
ge y du a ion and Fen anyl consump ion a e compa a-
ble be ween he s udied g oups, as shown in Table1 (p
> 0.05). The mean age o pa icipan s in he ESPB g oup
is 56.8 ± 12.0, while he mean age o pa icipan s in he
T amadol g oup was 62.5 ± 12.5, which is no a s a is-
ically signi ican di e ence ( = 1.616; p = 0.113). The
mean BMI o pa icipan s in he ESPB g oup was 24.1
± 2.3, while he mean BMI o pa icipan s in he T amadol
g oup was 24.1 ± 2.0, which is no a s a is ically signi i-
can di e ence ( = 0.013; p = 0.990). Su ge y du a ion is
106.8 s 106.0 min in ESPB s T amadol g oup, he e is
no s a is ical signi icance ( = 0.195, p = 0.800). The e is
no s a is ical di e ence in en anyl consump ion be ween
g oups (Z = 0.575, p = 0.909).
A he induc ion o anes hesia among he hemodynamic
pa ame e s (Table2.), sys olic p essu e ( - es = − 1.525,
p = 0,134) and dias olic p essu e ( - es = − 0.949, p =
0.347) he e is no s a is ically signi ican di e ence be ween
he obse ed g oups. Howe e , a s a is ically signi ican
Table 1 Pa ien s cha ac e is ics % Mean sd Med Min Max p
Age
ESPB 56.8 12.0 55.0 36.0 12.0 0.113
TRAMADOL 62.5 12.5 65.0 42.0 78.0
ASA 2
ESPB 100 –
TRAMADOL 100
BMI
ESPB 24.1 2.3 24.7 19.6 27.1 0.990
TRAMADOL 24.1 2.0 24.2 20.9 27.9
Fen anyl Consump ion
ESPB 250 150 350 0.990
TRAMADOL 200 150 350
Su ge y du a ion (min)
ESPB 106.8 14.9 110.0 80.0 130.0 0.800
TRAMADOL 106.0 12.2 110.0 80.0 130.0
Table 2 Hemodynamics
Bold ex indica es s a is ically signi ican esul s (p<0.05)
Anes hesia induc ion G oups Mean sd Med Min Max p
Sys olic p essu e ESPB 123.6 19.4 120.0 89.0 60.0 0.134
TRAMADOL 133.4 25.5 140.0 80.0 200.0
Dyas olic p essu e ESPB 72.2 15.4 71.0 41.0 100.0 0.347
TRAMADOL 76.0 12.0 79.0 50.0 92.0
Mean a e ial P ESPB 84.3 17.9 84.0 55.0 115.0 0.029
TRAMADOL 95.2 15.5 95.6 67.0 127.0
Hea a e ESPB 72.1 13.3 70.0 60.0 120.0 0.205
TRAMADOL 77.3 14.9 78.5 52.0 111.0
In aope a i ely
Sys olic p essu e ESPB 106.5 14.0 110.0 80.0 130.0 0.144
TRAMADOL 113.1 17.0 111.0 80.0 143.0
Dyas olic p essu e ESPB 64.2 11.5 63.5 43.0 80.0 0.703
TRAMADOL 62.9 12.0 63.5 43.0 80.0
Mean a e ial P ESPB 76.7 12.7 77.0 59.0 103.0 0.212
TRAMADOL 81.3 12.5 82.0 55.0 100.0
Hea a e ESPB 65.3 7.8 60.0 55.0 85.0 0.030
TRAMADOL 72.0 12.3 73.0 49.0 95.0
Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140 Page 5 o 9 140
di e ence is egis e ed in he mean a e ial p essu e o
ESPB s T amadol g oup (T- es = − 2.256, p = 0.029).
Hemodynamic pa ame e s in aope a i ely (Table2).,sys-
olic p essu e ( es = − 1.488, p = 0,144) and dias olic p es-
su e ( - es = − 0.383, p = 0.703), mean a e ial p essu e (T
es = − 1.266, p = 0.212) he e was no s a is ically signi i-
can di e ence be ween he obse ed g oups,
While he e is no any s a is ical di e ence in hea a e a
he induc ion o anes hesia (T- es = 1.286, p = 0.205), in a-
ope a i e hea a e is lowe in he ESPB g oup s T amadol
g oup, 65.3bea s/min s 77.3 bea s/min, wi h a s a is ically
signi ican dec ease (T- es = − 2.270, p = 0.030), as shown
in Tables2.
The equency o pain is less in he ESPB g oup com-
pa ed o he T amadol g oup 1h a e waking up om anes-
hesia un il he hi d hou , 48 s 79.2%, and also a e he
hi d ill he six h hou , 56 s 83.3%, which was s a is ically
signi ican in bo h cases (p = 0.024, p = 0.038). In he i s
hou and a e he 6 h hou a e su ge y ill he 24 h hou ,
he e was no signi ican di e ence in he equency o pain
be ween hese wo g oups o subjec s.
In hese same in e als om 1 s o 3 d hou and a e
3 d o he 6 h hou , a dec ease in pain in ensi y is ound in
he ESPB g oup compa ed o he T amadol g oup acco d-
ing o he NRS sco e, 0 s 3 and 2 s 3, which was highly
s a is ically signi ican in bo h cases (p = 0.005, p = 0.016),
and in he 1 s hou as well as om he 6 h hou ill 24 h
hou he e is no a s a is ically signi ican di e ence in NRS
sco es be ween g oups as shown in Table3.
Subjec s om he ESPB and T amadol g oups we e mos
o en wi hou escue analgesia in he in e al om he 1 s o
3 d hou (88.0% s. 54.2%, espec i ely). The e is a s a is i-
cally signi ican di e ence in he equency o ca ego ies
be ween he examined g oups (Fishe ’s exac p obabil-
i y es = 0.356; p = 0.010) as shown in Table4. A e 12
h o su ge y ill he 24 h hou , 96% in ESPB g oup did
no ecei e escue analgesia and only 4% ecei ed NSAID
which is s a is ically signi ican (Fishe ’s exac p obabili y
es = 2.145, p = 0.007). The e is no s a is ical signi icance
be ween g oups in o he ime in e als.
The e is no s a is ically signi ican di e ence in he e-
quency o nausea and omi ing be ween g oups, as shown
in Table5.
Rega ding pa ien sa is ac ion, he da a sugges s ha he
ESPB g oup is associa ed wi h highe pa ien sa is ac ion
compa ed o he T amadol g oup, he e is 64% sa is ac ion
in he ESPB g oup and 37.5% in he T amadol g oup wi h
s a is ical signi icance, (Z = −2.104, p = 0,03), as shown in
Table6. The leng h o s ay in hospi al a e su ge y is wi h-
ou s a is ical signi icance be ween he g oups.
Table 3 P esence o pain a e su ge y, in ime in e als
Bold ex indica es s a is ically signi ican esul s (p<0.05)
Time ESPB, n = 25 (%) TRAMADOL, n = 24 (%) p
0 h–1 h 64 66.7 0.845
> 1h–3 h 48 79.2 0.024
> 3h–6 h 56 83.3 0.038
> 6h–12 h 64 83.3 0.125
> 12 h–24 h 60 50 0.482
NRS a e su ge y in ime in e als
Time in e als ESPB, n = 25
Med (Min–Max)
TRAMADOL, n = 24
Med (Min–Max)
p
0 h–1 h 2 (0–9) 2,5 (0–9) 0.524
> 1h–3 h 0 (0–8) 3 (0–8) 0.005
> 3h–6 h 2 (0–8) 3 (0–8) 0.016
> 6h–12 h 2 (0–8) 3 (0.8) 0.119
> 12 h–24 h 1 (0–4) 1.5 (0–7) 0.211
Table 4 RA om 0 o 1h
Bold ex indica es s a is ically signi ican esul s (p<0.05)
Time G oups No RA NSAID Opioid p
0–1 h ESPBG % 68 28 4 0.356
TG % 62.5 20.8 16.7
> 1–3 h ESPBG % 88 8 4 0.010
TG % 54.2 41.7 4.2
> 3–6 h ESPBG % 84 12 4 0.117
TG % 58.3 33.3 8.3
> 6–12 h ESPBG % 76 16 8 0.426
TG % 62.5 33.3 4.2
> 12–24 h ESPBG % 96 4 0 0.007
TG % 62.5 29.2 8.3

Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140140 Page 6 o 9
Discussion
Sa is ac o y pain con ol is o g ea impo ance in pos op-
e a i e pain managemen . Fe e o e al. i s showed he
alue o ESPB as an analgesic echnique in a case epo
p esen ing i s e ec a e ho aco omy. Nowadays, i is
known ha ESPB is a aluable componen o mul imodal
pain ea men .
This s udy compa ed he e icacy o he E ec o Spinae
Plan and T amadol in p e en ing and managing pos ope a-
i e pain a e unila e al mas ec omy wi h axilla y dissec-
ion. Ou esul s showed ha ESPB p o ided signi ican ly
be e pain elie in he ea ly pos ope a i e pe iod (1–6 h),
wi h lowe pain in ensi y, less need o escue analgesia,
and g ea e sa is ac ion in he ESPB g oup compa ed o
he T amadol g oup.
T amadol is a cen ally ac ing analgesic widely used
o pos ope a i e pain managemen , including in b eas
su ge y. I is ypically adminis e ed a doses anging om
50 o 100 mg e e y 4 o 6h, wi h a maximum daily dose
o 400 mg in adul s. The d ug has an elimina ion hal -li e
o app oxima ely 5–6 h, al hough his can a y based on
indi idual me abolism and enal unc ion.The mechanism
o ac ion o amadol is dual in na u e. I ac s as a weak
μ-opioid ecep o agonis , p o iding mode a e analge-
sia, while also inhibi ing he eup ake o se o onin and
no epineph ine, enhancing descending pain modula ion.
This dual ac ion makes amadol pa icula ly use ul in
managing bo h nocicep i e and neu opa hic pain, which
a e commonly expe ienced a e b eas su ge y.Despi e i s
e icacy, amadol is associa ed wi h se e al side e ec s.
The mos common include nausea, omi ing, dizziness,
seda ion, and cons ipa ion. In some pa ien s, amadol
may lowe he seizu e h eshold, inc easing he isk o
seizu es, especially in hose wi h a p edisposi ion o when
combined wi h o he se o one gic medica ions. Addi ion-
ally, amadol ca ies a isk o se o onin synd ome when
used wi h o he se o one gic agen s, which is an impo -
an conside a ion in pos ope a i e pain managemen .In
he con ex o b eas su ge y, amadol is o en p e e ed
o e s onge opioids due o i s lowe isk o espi a o y
dep ession and educed po en ial o addic ion. Addi ion-
ally, because i modula es bo h opioid and non-opioid pain
pa hways, i may p o ide mo e balanced pain con ol,
pa icula ly o p ocedu es in ol ing bo h issue auma
and ne e in ol emen , such as mas ec omy o b eas
econs uc ion. Howe e , despi e hese ad an ages, newe
egional anes hesia echniques—such as he e ec o spi-
nae plane block (ESPB)—o e supe io pain elie while
educing he need o sys emic opioids like amadol.
In a sys ema ic e iew and me a-analysis which was
unde aken o de e mine i he ESPB is e ec i e a educ-
ing pain sco es and opioid consump ion a e b eas su -
ge y, i has been shown ha he ESPB is mo e e ec i e
a educing pos ope a i e opioid consump ion and pain
sco es up o 24 h compa ed wi h gene al anes hesia alone
(Leong e al. 2021 Ma ). In his analysis, which included
13 s udies, o 861 pa ien s, his block ecei ed 418
pa ien s, 215 ecei ed no block, and 228 ecei ed o he
blocks. The ESPB signi ican ly educed pain in he i s 2h
in 6,12, and 24 h a e su ge y. Despi e he he e ogenei y
o he esul s, I2 alues ange om 58 o 99%; analysis
ound ha he ESPB e ec i ely educed pos ope a i e
pain. Ou indings a e consis en wi h p e ious s udies,
demons a ing ha he E ec o Spinae Plane Block (ESPB)
g oup expe iences signi ican ly lowe pain equency
and in ensi y 1 o 6h a e su ge y, as indica ed by he
Nume ic Ra ing Scale (NRS) sco es. This sugges s ha
ESPB o e s supe io pos ope a i e pain elie , pa icula ly
in he immedia e hou s ollowing su ge y, compa ed o
he g oup o pa ien s who only ecei ed T amadol du ing
he p ocedu e.
These esul s suppo o he esea ch highligh ing he
e ec i eness o ESPB in p o iding ea ly pain elie (Sha ma
e al. 2020; Gü kan e al. 2020 Feb). Howe e , i should be
no ed ha pain in ensi y immedia ely a e su ge y is gen-
e ally bellow NRS 3 in bo h g oups, which ypically does
no equi e any analgesic in e en ion. Ne e heless, he
ad an ages o ESPB become mo e e iden 6h pos -su ge y,
indica ing a po en ial need o ongoing pain managemen
s a egies a e he e ec s o he ESPB wea o .
Table 5 Nausea/ omi ing in ime in e als
Time ESPBG (%) TG (%) p
0 h–1 h 16 12.5 1.000
> 1h–3 h 8 25 0.138
> 3h–6 h 16 28 0.725
> 6h–12 h 0 16.7 0.50
> 12 h–24 h 0 8.3 0.235
Table 6 Pa ien sa is ac ion and Leng h o s ay in hospi al
Bold ex indica es s a is ically signi ican esul s (p<0.05)
ESPB (%) TRAMADOL
(%)
p
Pa ien sa is ac ion
Dissa is ied 8 29.2 0.03
Pa ially sa is ied 28 33.3
Sa is ied 64 37.5
LOS
3 days 100 95.8 0.490
4 days 0 4.2
Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140 Page 7 o 9 140
In a ecen sys ema ic e iew ocused on ca diac su ge y,
G eene e al. e alua ed he bene i s o single-sho E ec o
Spinae Plane Block (ESPB) in educing pain a pos ope a-
i e hou s 4 and 12. They concluded ha he single-sho
ESPB a m exhibi ed s a is ically signi ican educ ions in
pain sco e a pos ope a i e hou 4 bu did no exhibi a s a-
is ically signi ican educ ion in pain sco e a pos ope a i e
hou 12 (G eene e al. 2024 Ap ).
Aks e al. compa ed ESPB o “no block con ol” a e
b eas su ge y; hey en olled i y pa ien s. In he ESPB
g oup, he e was a signi ican educ ion in opioid use; he
pos ope a i e mo phine equi emen was signi ican ly lowe
in he ESPB g oup compa ed o he con ol g oup du ing 24
h (Aksu e al. 2019). Ou s udy has demons a ed ha ESPB
can educe he need in he pos ope a i e pe iod o NSAID
and sys emic opioids, po en ially upg ading eco e y and
pa ien sa is ac ion. Use o escue analgesia is signi ican ly
lowe in he i s 3h, and ill he six h hou , pa ien s in he
ESPB g oup ecei ed mos ly NSAID. In e es ingly, 12 h
a e he p ocedu e, he ESPB g oup mos ly (96%) did no
need escue analgesia compa ed o he T amadol g oup.
This inding can be unde s ood as he inal dis ibu ion and
pene a ion o local anes he ic in pa a e eb al space o as
po en ial syne gism o his block and ecei ed escue analge-
sics ill he 12 h pos -su ge y pe iod. These s a emen s need
u he examina ion. Acco ding o ou esul s, he supe io
e icacy o ESPB in he ea ly eco e y phase may be a
p e e able op ion o pa ien s unde going su ge ies wi h
expec ed mode a e o se e e pos ope a i e pain. Also,
he educed need o escue analgesia sugges s ha ESPB
may help minimize he use o opioids, which can help educe
opioid consump ion and i s associa ed side e ec s, includ-
ing nausea, omi ing, and dependence. In ou s udy, T ama-
dol use is gene ally less e ec i e in con olling mode a e
o se e e pos ope a i e pain compa ed o egional blocks,
especially in he i s ew hou s pos -su ge y.
Acco ding o hemodynamic changes, ou esul s show
some di e ences in blood p essu e be ween he wo g oups,
wi h he T amadol g oup showing highe MAP, bu hea
a e and dias olic p essu e a e qui e simila du ing he
induc ion pe iod. This may poin o he di e en ways
hese in e en ions a ec he ca dio ascula sys em. Also,
he in aope a i e hea a e esul shows a s a is ically
signi ican educ ion in he ESPB g oup du ing su ge y
(65.3 bpm s. 72.0 bpm in he T amadol g oup, p = 0.030).
These indings sugges ha ESPB may ha e some e ec
on he sympa he ic ne ous sys em. Liao e al., in hei
s udy, showed ha he ESPB g oup demons a ed a lowe
in aope a i e HR han he con ol g oup h oughou he
ini ial 90 min o su ge y (Liao e al. 2024 No 20). These
esul s could be explained by he slow pene a ion o
local anes he ic in o he pe idu al space, which somewha
blocks he sympa he ic ne ous sys em. Sø ens ua M e al.
explained ha local anes he ic injec ed deep in o he e ec o
spinae muscle could hus each he do sal oo ganglion by
combining bulk low and simple di usion. The physical
ex en o his sp ead o he neu al o amina, pa a e eb al,
and in e cos al spaces, has been con i med by MRI in human
subjec s (Sø ens ua e al. 2023 Feb).
The equency o nausea and omi ing be ween he
g oups is almos he same and wi hou signi icance, sugges -
ing ha nei he ESPB no T amadol led o a majo inc ease
in hese common side e ec s. This is a posi i e ou come, as
i indica es ha ESPB did no exace ba e unpleasan symp-
oms mo e han T amadol.
Pa ien s who pe cei e less pain and equi e less escue
analgesics a e mo e likely o ha e a be e eco e y expe-
ience, con ibu ing o inc eased sa is ac ion. Rega ding
pa ien sa is ac ion, he ESPB g oup had signi ican ly highe
sa is ac ion sco es (64%) han he T amadol g oup (37.5%),
which may be a ibu ed o be e pain elie and educed
need o addi ional medica ions. This is also a signi ican
inding, as pa ien sa is ac ion is an impo an goal o pos -
ope a i e eco e y and can in luence bo h sho - and long-
e m ou comes.
While ou indings o e aluable insigh s, we ecognize
se e al limi a ions. The small sample size may a ec he
s a is ical powe and inc ease he isk o s a is ical a iabil-
i y and limi b oade applicabili y. Second, he e ospec-
i e design inhe en ly in oduces po en ial biases, including
selec ion bias and con ounde s we could no ully con ol.
Fu u e p ospec i e s udies wi h la ge coho s would help
cla i y hese ela ionships u he . Addi ionally, he s udy
is limi ed only o he sho - e m pos ope a i e pe iod, so
he long- e m e ec i eness o ESPB compa ed o T ama-
dol emains unknown. Fu u e s udies could also in es iga e
whe he he ESPB could be combined wi h o he ea men
modali ies o imp o e pain managemen and spa e opioid
consump ion.
Conclusion
The ESPB appea s o be a mo e e ec i e pain managemen
modali y han T amadol, pa icula ly in he ea ly
pos ope a i e pe iod. I p o ides supe io pain elie ,
educes he need o escue analgesia, and enhances
pa ien sa is ac ion. Howe e , o u he alida e hese
indings, la ge p ospec i e s udies wi h di e se su gical
popula ions a e needed. Fu u e esea ch should aim o no
only con i m hese indings in la ge p ospec i e s udies bu
also explo e how ESPB a ec s long- e m eco e y, pa ien
well-being, and o e all quali y o li e beyond he immedia e
pos ope a i e phase. Addi ionally, longi udinal ollow-up
Jou nal o Cance Resea ch and Clinical Oncology (2025) 151:140140 Page 8 o 9
s udies could p o ide aluable insigh s in o how ESPB
impac s pain con ol, ehabili a ion, and o e all well-being
in he mon hs ollowing su ge y.
Au ho con ibu ions All au ho s con ibu ed o he s udy concep ion
and design. Ma e ial p epa a ion and da a collec ion we e pe o med
by Ana C e ko ić, And ej Jokić and analysis was pe o med by Zo an
Bukumi ićić. The i s d a o he manusc ip was w i en by Ana
C e ko ić and all au ho s commen ed on p e ious e sions o he
manusc ip . All au ho s ead and app o ed he inal manusc ip .
Funding The au ho s decla e ha no unds, g an s, o o he suppo
we e ecei ed du ing he p epa a ion o his manusc ip .
Da a a ailabili y No da ase s we e gene a ed o analysed du ing he
cu en s udy.
Decla a ions
Con lic o in e es The au ho s ha e no ele an inancial o non- i-
nancial in e es s o disclose. The au ho s ha e decla ed ha no compe -
ing in e es s exis .
E hical app o al This s udy was pe o med in line wi h he p inciples
o he Decla a ion o Helsinki. App o al was g an ed by he E hics
Commi ee o ins i u e o Oncology and Radiology o Se bia on he
09.08.2023. app o al no. 010/2023/1979.
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