Dear Editor,
I read with interest the excellent case report by Selvi et al. (1) regarding the use of erector spinae plane block (ESP) for bilateral segmental mastectomy, and I congratulate the authors for their clinical results and case presentation.
I would like to contribute to the discussion by mentioning a possible alternative block for breast surgery for cases in which dissection of the axillary lymph nodes is not performed, as was the situation for the right breast in the case described (2).
Rhomboid intercostal block (RIB) consists of the injection of anaesthetic between the intercostal and rhomboid muscles and has been used for breast surgery (2, 3). The injection site is more peripheral than that used with ESP, and the spread of local anaesthetic runs mostly towards the lateral branches of the intercostal nerves rather than to the paravertebral and epidural space, as it can occur with ESP (4, 5). Because the sympathetic chain blockade is not as deep with RIB as compared with ESP, reduced hypotension can result. This has particular importance for cases in which a bilateral ESP block is needed, as in the case described by Selvi et al. (1), which have a higher potential risk for hypotension.
RIB can be performed by placing the linear transducer in the sagittal plane at the T5–6 level, just 2 cm medial to the scapula, to identify the trapezius muscles, rhomboid major muscles, and intercostal muscles. Using an in-plane approach, the needle can be inserted into the fascia between the rhomboid major and the intercostal muscles in a caudal-to-cephalad or cephalad-to-caudal direction (4).
Block of the anterior cutaneous branches of the intercostal nerves is difficult to obtain with RIB, so it cannot provide adequate anaesthesia near the sternum or the inner quadrants. Moreover, slight pain in the axillary area has been reported with RIB for breast surgery (2).
Nevertheless, I believe that in particular circumstances, RIB can be considered instead of ESP for breast surgery when a bilateral block is planned.
References
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