The Washington Post
My surgery was pain-free. Why? Nerve blocks.
As I faced a prophylactic double mastectomy in hopes of averting cancer, I had many questions for my surgeons — one of which was about pain.
I was stunned when both my breast surgeon and plastic surgeon said that a nerve block would leave me pain-free for about three days, after which the worst of the pain would be over. Pectoralis nerve (PECS) blocks were developed to provide analgesia or pain relief for chest surgeries, including breast surgery. That is what happened.
I went through the mastectomy Dec. 1 after learning I had the PALB2 gene mutation that carried a sharply elevated risk of breast cancer as well as a higher risk of ovarian and pancreatic cancers. I also had my fallopian tubes and ovaries removed in July. I had learned about the gene mutation in April 2021, when one of my daughters found out she was a carrier.
As a 24-year breast cancer survivor and longtime health reporter, I was astonished that I had heard nothing about this mutation. I researched it and wrote “This Breast Cancer Gene Is Less Well Known, but Nearly as Dangerous” in August. After the double mastectomy, I also wrote about it for The Washington Post.
Just as my surgeons at NorthShore University Healthsystem predicted, I was released from the hospital the same day as my surgery and remarkably painfree. I took one Tramadol (a step down from stronger medications containing codeine) when I got home — only because it was suggested I take one pill. As I recovered, I only took Advil and Tylenol.
Reduced use of opioids
The opioid epidemic is a major public health issue in the United States and nerve blocks could be a solution. According to a study published in the Journal of Clinical Medicine in 2021, 1 in 20 surgical patients will continue to use opioids beyond 90 days. “There is no association with magnitude of surgery, major versus minor, and the strongest predictor of continued use is surgical exposure,” the study states.
The study describes regional anesthesia (nerve blocks) as having “excellent opioid-sparing properties” and accounting for same-day surgical discharge for a large number of painful orthopedic procedures that were previously performed on an inpatient basis.
According to a Clinical Journal of Pain article published in 2020, “Perioperative use of opioid-free anesthesia and analgesia regimens implemented as a significant component of ERAS (enhanced recovery after surgery) protocols have proved to reduce or replace opioid use.”
PECS blocks were created by Rafael Blanco at the King’s College Hospital in Dubai in 2011.
PECS blocks, used as part of the ERAS program, work to minimize pain, opioid use and nausea, and get mastectomy patients home sooner, and feeling much better than in years past, said Akhil Seth, director of Reconstructive Microsurgery at NorthShore University Healthsystem.
ERAS is a widely used program that focuses on the time before, during and after surgery and results in better outcomes in terms of length of stay in the hospital, pain control and opioid use, according to studies. ERAS was first introduced in the 1990s in Denmark by Henrik Kehlet who was frustrated that even surgeries performed laparoscopically kept patients in hospitals sometimes for six days.
Northshore implemented ERAS for implant-based, post-mastectomy procedures using PECS blocks in 2018, said Rebecca Blumenthal, anesthesiologist and vice chair of Innovation, Department of Anesthesiology, Critical Care and Pain Medicine at Northshore. She developed and leads the ERAS program at Northshore, which has hospitals in the suburbs of Chicago.
“The goal is patient comfort, with the fewest narcotics used,” Blumenthal said.
Nerve blocks are also used for colorectal, orthopedic, gynecologic, pancreatic and other procedures.
Blumenthal reported in 2019 in the Anesthesia Patient Safety Foundation’s newsletter a reduction of between 78 percent and 85 percent in the use of opioids for four ERAS protocols with nerve blocks — colorectal, ventral hernia, mastectomy with implant reconstruction and abdominal hysterectomy. In the last three years, Northshore has added the ERAS protocol with nerve blocks to prostate, C-section, spinal fusion, liver and pancreatic surgeries as well, Blumenthal said. In a * small study published in American Journal of Perinatology in December 2020, Blumenthal and others found a decrease in the use of opioids, length of stay and pain scores among women undergoing scheduled Caesarean deliveries.
She also said that many other studies have shown a decrease in opioid use because of nerve blocks and ERAS.
At Northshore, patients are given a number of medications in the preoperative area. “They are analgesic, pain medications, but they are nonnarcotic,” Blumenthal said.
The medications I received are called multimodals. They included Tylenol, Celebrex and Gabapentin. I was also given Ketamine following a sedative Versed.
Before surgery, the ERAS protocol includes a carbohydrate drink, which encourages nutrition and hydration, and uses multimodal medications to capture and control pain pathways, says an information sheet that doctors at Northshore provide to patients before mastectomies. Patients also receive prophylactic anti-nausea medication. The reduction in pain meds also decrease nausea, itching and constipation and increase nutrition and ambulation.
Seth said patients are surprised to learn two surgeons will work on both sides at the same time — taking about four hours. Patients typically go home the same day.
“For the longest time, mastectomy was thought to be a daunting operation, requiring one to two nights’ stay,” Seth said. “The recovery is more streamlined than it used to be.”
My treatment included PECS I and PECS II blocks with a shortacting local anesthetic and a long-acting local anesthetic called Exparel. The nerve blocks are done with ultrasound guidance and provide pain relief for about three days. They are administered by an anesthesiologist in the operating room before surgery.
“The combination of the PECS I and PECS II blocks provide pain relief for chest surgeries,” Blumenthal says. “The nerve supply to the breast and chest wall is extremely complex, and several nerves and nerve branches contribute to postoperative pain and need to be blocked to provide adequate pain relief.”
Julie Gillette, 50, of Vernon Hills, Ill., underwent a prophylactic mastectomy in February. She decided to have the surgery upon learning she had the PALB2 mutation from her father’s side, and she had a mother with unknown origin metastatic lung cancer, diagnosed at 57. Gillette had the nerve blocks and said it made her first three days at home tolerable. “I couldn’t imagine going through this without” the nerve blocks, she said.
Megan Schwartz, 40, also a carrier of the PALB2 mutation, lives in southeast Central Texas and had a prophylactic double mastectomy in January at MD Anderson Cancer Center in Houston. She did not have a nerve block and managed pain for a few days with Tramadol every six hours alternating with acetaminophen. She did have mild discomfort but the Tramadol, she said, “really affected my ability to function well for the few days I took it. It made my brain feel foggy.”
Seth said that the technical aspects of a mastectomy has not changed much in the past 10 years, but the combination of ERAS and nerve blocks has made a difference.
“It is the enhanced recovery and nerve blocks that is the game changer,” he said. “It’s our ability to not only encourage patients to go through with it and feel comfortable — but our ability to offer reconstruction in an efficient and relatively easier way as opposed to 10-20 years ago.”