Reducing Pain and Disability After Breast Cancer Surgery (RELIeF)

The purpose of this study is to determine if the combination of thoracic paravertebral block and multimodal analgesia will decrease chronic pain and arm morbidity in patients undergoing breast cancer surgery with lymph node dissection as compared to patients receiving local anesthesia with multimodal analgesia.

Sixty percent of breast cancer patients undergo some form of breast surgery in the treatment of the early stages of the disease. The recovery from surgery can be associated with severe disabling pain persisting beyond 12 months after surgery. Research in pain has shown that early intervention of acute pain can prevent long term chronic pain.

At The Ottawa Hospital, patients receive either paravertebral blocks or wound infiltration with local anesthetic for postoperative pain management. We would like to compare these two methods of pain control to determine an analgesic technique that will reduce acute and chronic pain, and maximally improve long-term functional recovery and patient's quality of life.

• Breast Cancer
• Chronic Pain

• Procedure: Thoracic Paravertebral Block (TPVB)
  The middle of the spinous process above the nerve to be blocked is located and the overlying skin marked 2.5 centimeters lateral to this. Subcutaneous lidocaine is injected and a 22 G Tuohy tipped 8 cm needle is inserted at this level and advanced to identify the transverse process. The needle is then moved caudad off the transverse process and inserted a centimeter into the paravertebral space. Five mls of 0.5% ropivacaine with 1:200,000 epinephrine is injected at each paravertebral space. Blocks adjacent to the C7-T5 spinous processes are performed. For patients randomized to the LA group: The patients are identically positioned, sedated and identical landmarks are used to perform sham paravertebral blocks via a subcutaneous saline injection of 0.5mL with a 25G needle at each level.
  Other Name: Regional analgesia; neural blockade
• Procedure: Local Anesthetic
  At the conclusion of surgery, the surgeon will infiltrate the incision with 10 ml of saline 0.9% (TPVB group) or 0.5% ropivacaine (LA group). An axillary drain will be placed. After closure of the wound, 20 ml of saline 0.9% (TPVB group) or 0.5% ropivacaine (LA group) will be injected through the drain and the drain clamped for 30 minutes after injection.
  Other Name: local anesthesia

• Experimental: Thoracic PVB + multimodal anesthesia
  Intervention: Procedure: Thoracic Paravertebral Block (TPVB)
• Active Comparator: Local anesthetic + multi-modal analgesia
  Intervention: Procedure: Local Anesthetic

Inclusion Criteria:

• Patients with diagnosis of breast cancer
• Scheduled for elective modified radical mastectomy, simple mastectomy with SLNB, breast conserving surgery (ie lumpectomy, segmental mastectomy) with ALND or ALND alone (after positive SLNB)

Exclusion Criteria:

• American Society of Anesthesiologist (ASA) class 4 or 5
• Patients with contraindications to TPVB
• Allergy to study medications
• Chronic opioid use defined as daily consumption of greater than 20 mg of oral morphine or equivalent for >7days
• Renal insufficiency defined as a creatinine clearance <40ml/min as calculated using the Cockroft-Gault formula
• Preoperative radiation therapy
• Inability to achieve normal shoulder range of motion as defined as <100o of shoulder abduction or flexion