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 Table of Contents  
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 68-70

Our experience with the mid-point transverse process to pleura block in two patients undergoing modified radical mastectomy

Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission13-Apr-2020
Date of Decision29-Jun-2020
Date of Acceptance30-Jul-2020
Date of Web Publication27-Apr-2021

Correspondence Address:
Dr. Rakesh Kumar
Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_47_20

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Thoracic paravertebral block is frequently used in the breast surgeries. Procedure-related complications lead to the development of safer approaches to make patient pain free with fewer side effects. One such approach is the “mid-point transverse process to pleura” (MTP) block. Here, we present our experience with two patients scheduled for modified radical mastectomy where ultrasound-guided MTP block was performed for analgesia.

Keywords: Breast surgery, mid-transverse process to pleura block, novel technique, postoperative analgesia, thoracic paravertebral block

How to cite this article:
Syal R, Chhabra S, Kumar R, Kamal M. Our experience with the mid-point transverse process to pleura block in two patients undergoing modified radical mastectomy. Indian J Pain 2021;35:68-70

How to cite this URL:
Syal R, Chhabra S, Kumar R, Kamal M. Our experience with the mid-point transverse process to pleura block in two patients undergoing modified radical mastectomy. Indian J Pain [serial online] 2021 [cited 2021 Sep 24];35:68-70. Available from: https://www.indianjpain.org/text.asp?2021/35/1/68/314699

  Introduction Top

Regional blocks are an integral component of perioperative pain management in the breast surgeries since they provide excellent postoperative analgesia and prevent cancer progression and recurrence.[1],[2] Thoracic paravertebral block (TPVB) is a frequently used technique in the breast surgeries for perioperative analgesia, but side effects such as pleural puncture, pneumothorax, and vascular injury are associated with it.[3] Safer approaches of TPVB blocks have been developed for satisfactory analgesia, with fewer side effects. One such approach of paravertebral block has recently been described as “mid-point transverse process to pleura” (MTP) block.[4] We share our experience of successful perioperative management of two patients scheduled for modified radical mastectomy (MRM) using ultrasound-guided MTP block. Informed consent from the patients was obtained for block and for possible publication.

  Case Reports Top
Case 1

A 46-year-old female patient weighing 60 kg (BMI – 22 kg/m[2]) and the American Society of Anesthesiologists (ASA) physical status II was scheduled for the right MRM. She was a known case of hypertension. In the preanesthesia room, standard ASA monitors were attached and intravenous (IV) lines were secured. The patient was positioned sitting and after taking sterile precautions, the T4 spine was identified. A high-frequency linear ultrasound probe (LOGIQe, GE Healthcare, China) was placed longitudinally 2.5 cm lateral to the T4 spine. After skin infiltration with a local anesthetic, 18G nerve block needle (Contiplex D, B Braun) inserted in plane, in cranial to caudal direction. The needle was targeted at the mid-point between the posterior border of the transverse process and pleura [Figure 1]. A bolus of 22 ml of 0.5% ropivacaine was injected at the target site after confirming the spread with normal saline. Thereafter, a 20G catheter was threaded through the needle with a catheter tip about 2.5 cm beyond the needle tip [Figure 2]. The patient reported decreased sensation to cold and pinprick from T1 to T7 dermatome level 30 min after giving block. The patient received general anesthesia as per the institutional protocol. Continuous infusion of 0.5% ropivacaine was maintained at 7.5 ml/h for intraoperative analgesia. The hemodynamic parameters were stable throughout the surgical procedure with no surgical stress response to skin incision. The surgery lasted 150 min without the requirement of additional opioids. The postoperative analgesia was maintained with IV paracetamol 1 g every 8 h and continuous infusion of 0.2% ropivacaine at 6–8 ml/h through the block catheter maintained in situ for 72 h. Her postoperative visual analogue scale (VAS) at rest and on movement remained between 0–1/10 and 1–3/10, respectively. The patient was satisfied with the pain relief, was able to ambulate independently, and there were no complaints of nausea and vomiting in the postoperative period. She was discharged home pain free on the 4th postoperative day.

Figure 1: Ultrasound scan at the level of T4 level while transducer placed parasagittal orientation, needle coming in-plane cranial to caudal direction showing site for mid-point transverse process to pleura block superior costotransverse ligament, transverse process

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Figure 2: Image of the patient's back with a catheter in situ attached

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Case 2

A 60-year-old female patient weighing 64 kg (BMI – 24.5 kg/m[2]) and ASA physical status II was posted for the left MRM. The MTP block and general anesthesia were given as per the standard protocol as described in the first case. Hemodynamically, the patient remained stable throughout the surgical procedure. The surgery lasted for 170 min. Postoperative pain was managed by paracetamol and continuous infusion of 0.2% ropivacaine at 7–10 ml/h. Overall, her VAS at rest and on movement remained in the ranges 2–3/10 and 3–4/10, respectively. The postoperative course was uneventful and without any complaints.

  Discussion Top

Breast cancer surgery is associated with moderate-to-severe perioperative pain. Inadequate pain management leads to the development of postsurgical chronic pain. The incidence of chronic pain after mastectomy ranges from 10% to 50%.[5] Various regional techniques (thoracic epidural and TPVB) are the routinely described techniques for multimodal analgesia after MRM. Procedure-related complications of such techniques include inadvertent vascular/dural puncture, pneumothorax due to more invasive nature of these techniques. Variants of paravertebral blocks (also called as “paravertebral by proxy”) include erector spinae plane block, retrolaminar block, intercostal paraspinal block, and MTP block have gained popularity for analgesia.[6] MTP block is the recent addition among these. Costache et al. first described this block in which drug was deposited midway between the transverse process to pleura.[4] A possible mechanism by which drug reaches the paravertebral space is by diffusion of drug through septations and fenestrations in the superior costotransverse ligament (SCTL) and free gap between SCTL and surrounding structure. The authors earlier described the role of this newer approach in a patient with multiple rib fractures with excellent result.[7] Watton et al. utilized MTP block for postoperative analgesia following video-assisted thoracoscopic surgery.[8]

The MTP block in all the patients was successful and intraoperative infusion of 0.5% ropivacaine helped in maintaining stable intraoperative hemodynamics, with no repeat boluses of fentanyl. Postoperatively, continuous infusion of 0.2% ropivacaine through the catheter reduced the IV analgesic requirements, which leads to enhanced recovery and early ambulation without any complication. The advantage of MTP block over other approaches of paravertebral block is that the block needle need not pierce the SCTL, thus, minimizing the chances of pleural puncture and pneumothorax.

We conclude that MTP block may be equally effective as thoracic epidural or paravertebral block with better safety profile in patients undergoing breast surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sekandarzad MW, van Zundert AA, Lirk PB, Doornebal CW, Hollmann MW. Perioperative anesthesia care and tumor progression. Anesth Analg 2017;124:1697-708.  Back to cited text no. 1
Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology 2006;105:660-4.  Back to cited text no. 2
Coveney E, Weltz CR, Greengrass R, Iglehart JD, Leight GS, Steele SM, et al. Use of paravertebral block anesthesia in the surgical management of breast cancer: Experience in 156 cases. Ann Surg 1998;227:496-501.  Back to cited text no. 3
Costache I, de Neumann L, Ramnanan CJ, Goodwin SL, Pawa A, Abdallah FW, et al. The mid-point transverse process to pleura (MTP) block: A new end-point for thoracic paravertebral block. Anaesthesia 2017;72:1230-6.  Back to cited text no. 4
Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth 2008;101:77-86.  Back to cited text no. 5
Costache I, Pawa A, Abdallah FW. Paravertebral by proxy-Time to redefine the paravertebral block. Anaesthesia 2018;73:1185-8.  Back to cited text no. 6
Syal R, Kumar R, Kamal M, Bhatia P. Novel block and new indication: Ultrasound-guided continuous “mid-point transverse process to pleura” block in a patient with multiple rib fractures. Saudi J Anaesth 2019;13:365-7.  Back to cited text no. 7
[PUBMED]  [Full text]  
Watton DE, Rose PG, Abdallah FW, Thompson CP, Maziak DE, Costache I. Midpoint transverse process to pleura catheter placement for postoperative analgesia following video-assisted thoracoscopic surgery. Anaesth Rep 2019;7:65-8.   Back to cited text no. 8


  [Figure 1], [Figure 2]


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