Association of high thoracic erector spinae plane block and serratus posterior superior intercostal plane block for postoperative analgesia in rib removal surgery

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Dear Editor, Following our recent publication “Synergy from two different fascial blocks for multimodal analgesia in breast cancer surgery” in the Saudi Journal of Anesthesia,[1] we have further explored the potential of this dual-block strategy in the different surgical context. Costectomy is a surgical procedure consisting of the removal of a portion or entire rib to eliminate a tumor or other lesion. Technically, it involves manipulation of the scapula and dissection of periscapular muscles, potentially affecting cervical and upper thoracic nerves, which may predispose pain chronicization if acute postoperative pain is not adequately managed. Chronic postoperative shoulder and scapular pain is a well-recognized complication after thoracic and periscapular surgery, and procedures requiring scapular mobilization, may increase the risk of persistent pain syndromes that impair shoulder function and quality of life.[2] This risk is partly explained by scapular innervation, which arises from branches of the cervical and brachial plexus as well as intercostal nerves. Among them, the dorsal scapular nerve (C4–C5), supplying rhomboids and levator scapulae, is often implicated in chronic scapular pain.[3] Regional anesthesia is therefore essential not only for opioid-sparing analgesia but also to reduce long-term pain. Forero et al.[4] suggested that a high thoracic erector spinae plane (ESP) block at T2–T3 may relieve shoulder pain by spread toward cervical neural foramina and roots C4–C7. More recently, Tulgar et al.[5] described the serratus posterior superior intercostal plane (SPSIP) block, providing hemithoracic analgesia from C3 to T10. Their combined use may extend dermatomal coverage and optimize perioperative pain management.[1] We report the case of a 68-year-old woman undergoing left third-rib costectomy for surgical removal of a painful rib lesion. History included nephrectomy for renal carcinoma, hypertension, dyslipidemia, hysterectomy, and excision of breast papilloma. After informed consent, general anesthesia was induced with fentanyl 100 μg, propofol 150 mg and rocuronium 40 mg, followed by selective orotracheal intubation and left-lung exclusion confirmed by fiberoptic bronchoscopy, with one-lung ventilation. Anesthesia was maintained with sevoflurane and remifentanil infusion (0.05–0.1 μg/kg/min). Following induction and before incision, two ultrasound-guided blocks were performed in the lateral position using an out-of-plane technique. First, a high thoracic ESP block at T2–T3 with 20 mL of ropivacaine 0.5% plus dexmedetomidine 0.5 μg/kg, followed by SPSIP block with the same mixture, achieved by minimal probe shift laterally. Surgery proceeded uneventfully through a curvilinear incision along the superior scapular border. The trapezius, rhomboids, and part of the serratus anterior were divided, preserving the long thoracic nerve. The scapula was mobilized cranio-laterally, exposing the third rib, which was resected en bloc with the lesion [Figure 1]. Postoperative analgesia included scheduled paracetamol, with NSAIDs as rescue. At emergence the patient reported NRS 0, maintaining excellent pain control during mobilization, deep inspiration, and cough, without opioid requirement. At 6–12 months, she reported no recurrence of pain or functional limitation. This case shows that the association of high thoracic ESP and SPSIP blocks provides synergistic coverage of cervical, thoracic, and intercostal afferences, including the dorsal scapular nerve. Their sequential performance is feasible with minimal probe movement and without patient repositioning, making them safe and practical even in fragile subjects. In conclusion, this multimodal strategy ensured excellent opioid-free analgesia after costectomy with scapular mobilization and may help prevent pain chronicization.Figure 1: Costectomy. Surgical exposure and removal of a third-rib lesionAuthor contribution LG and PS were responsible for the concept, date collection, search, reviewing results, manuscript editing and review oversight. MD and AD were responsible for review oversight. All authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All authors approved submission. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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