Regional anaesthesia for breast surgery: a narrative review

Regional anaesthesia for breast surgery has evolved rapidly in recent decades. Breast cancer surgery is associated with significant postoperative pain. This narrative review explores the relevant anatomy, regional anaesthetic strategies and their efficacy for breast surgery based on the most recent evidence available.

We performed a focused literature review to identify articles published within the last 3 years evaluating the efficacy of regional anaesthetic techniques in breast surgery. Identified abstracts underwent screening and full-text review before inclusion.

The initial search identified 558 papers, 182 of which were published in the last 3 years. After screening, 63 were included in the narrative synthesis. Breast and axillary innervation arises from several neural territories. Newer paraspinal blocks, including the erector spinae plane block, have shown analgesic efficacy, but the thoracic paravertebral remains the most reliable technique. Anterolateral chest wall blocks, including the serratus anterior plane and pectoserratus, cover the lateral cutaneous branches of the intercostal nerves but may also provide axillary coverage. The interpectoral block is the sole chest wall approach that covers the medial and lateral pectoral nerves supplying the pectoral muscles. Techniques such as the superficial parasternal intercostal plane block cover the medial breast and can be combined with anterolateral chest wall blocks for mastectomy. All blocks are superior to local anaesthetic infiltration.

Regional anaesthesia provides superior analgesic outcomes for patients undergoing breast surgery compared with local infiltration. Despite the multitude of recent studies, heterogeneity in surgical procedures and outcome measures limits direct comparison between blocks. Regional anaesthesia should be tailored to the surgical procedure based on an understanding of breast innervation, with an individualised approach formulated in partnership with patients and surgeons. Future research should prioritise comparing nerve blocks with similar anatomical or neural targets for specific surgical procedures, using patient-centred outcomes.