Paravertebral Blocks in Tissue Expander Breast Reconstruction: A Propensity-matched Analysis of Perioperative Opioid Consumption and Patient-reported Outcomes
Jacqueline J. Chu, BA1, Meghana G. Shamsunder, MPH1, Erin Taylor, MD1, Thais O. Polanco, MD1, Babak J. Mehrara, MD1, Joseph J. Disa, MD1, Robert J. Allen, Jr., MD1, Hanae K. Tokita, MD2, Jonas A. Nelson, MD, MPH1
1Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, 2Anesthesiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
Background: The paravertebral block (PVB) is an adjunctive perioperative pain control method for breast reconstruction patients that may improve perioperative pain control and reduce narcotic use. The purpose of this study is to determine the efficacy of preoperative paravertebral blocks in perioperative pain management in tissue expander breast reconstruction patients.
Methods: A retrospective review of patients undergoing tissue expander breast reconstruction at Memorial Sloan Kettering Cancer Center from December 2017 to September 2019 was performed. Propensity scoring based on age, BMI, laterality, TE placement was used to match patients who received paravertebral block to those who received no block. Patients were matched 2 PVB patients to 1 No Block patient using a nearest neighbor algorithm with no replacement. Perioperative analgesics, pain severity scores on days 1-10 after discharge, and BREAST-Q Physical Wellbeing of the Chest scores at 2 weeks, 6 weeks, and 3 months after surgery for the two groups were evaluated for differences using Pearson Chi-Square tests or Mann-Whitney U tests.
Results: Propensity-matching included 471 patients: 314 received PVB and 157 received no block. Intra-operatively, the PVB cohort used significantly fewer milligrams of morphine equivalents (MMEs) than the No Block cohort, with median of 20 MME vs. 40 MME (p<0.001). PACU opioid and antiemetic use did not differ between study groups, but ketorolac use was significantly greater in the No Block cohort (17.8% vs. 6.7%, p<0.001). Average daily postoperative pain severity scores were comparable, with a maximum difference of 0.3 points on a 0-4 scale overall. BREAST-Q Physical Wellbeing scores were significantly higher in the PVB group at 6 weeks after surgery (60.6 vs. 51, p=0.015).
Conclusions: Paravertebral block was effective at reducing intraoperative and immediate postoperative opioid requirements but did not impact pain scores after discharge. Plastic surgeons should consider incorporating PVB as an adjunct of perioperative pain management protocol to reduce intraoperative and immediate postoperative narcotic use.
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