Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial

Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial Jiali Yu, Yi Qi, Dan Wang, Qi Chen, Ran An, Hongliang Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4905136/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Nerve blocks are among the most important methods of postoperative analgesia in breast cancer surgery. We used a randomized controlled clinical trial to compare the effects of rhomboid intercostal nerve block (RIB), serratus anterior plane block (SAPB), and paravertebral block (PVB) on the postoperative quality of recovery and postoperative analgesia in modified radical mastectomy. A total of 132 breast cancer surgery patients were randomized 1:1:1 into three groups. 0.375% ropivacaine 20 ml for ultrasound-guided RIB (RIB group, n = 44), SAPB (SAPB group, n = 44), and PVB (PVB group, n = 44). The primary outcome was the QoR-40 score at 24 hours after surgery. The postoperative 24-hour QoR-40 scores of the RIB (median: 186; interquartile range: 177, 190.5) and PVB (median: 186.5; interquartile range: 176.25, 190.5) groups were higher than those of the SAPB group (median: 168; interquartile range: 163.25, 172) ( P < 0.001). In addition, the intraoperative sufentanil consumption ( P < 0.001), number of intraoperative sufentanil users ( P < 0.001), and postintubation NRS scores ( P = 0.01) of the RIB and PVB groups were significantly lower than those of the SAPB group, but there was no statistically significant difference between the RIB and PVB groups. Compared with SAPB, RIB and PVB improve the quality of postoperative recovery, reduce intraoperative opioid use, and improve early postoperative analgesia. RIB may be one of the best alternatives to PVB as a facial plane block. Health sciences/Diseases/Cancer/Breast cancer Health sciences/Signs and symptoms/Pain Rhomboid intercostal nerve Serratus anterior plane block Paravertebral block Quality of recovery Postoperative pain Breast cancer surgery Figures Figure 1 Figure 2 Figure 3 Introduction Breast cancer is the most common malignant tumor in women worldwide.[ 1 ] Surgical resection remains the primary treatment modality[ 2 ]. Approximately half of all surgical patients experience moderate to severe acute pain after surgery[ 3 ]. Regional anesthetic techniques are an important part of multimodal analgesia as they have been demonstrated to reduce opioid consumption and numerical rating scale (NRS) in breast cancer surgery[ 4 – 6 ]. Furthermore, evidence from the 40-item Quality of Recovery Questionnaire (QoR-40), a validated patient-oriented multidimensional assessment tool, indicates that regional analgesia may promote recovery following surgery.[ 7 , 8 ] Paravertebral block (PVB) is the most used regional analgesia in breast cancer surgery[ 9 – 12 ]. However, PVB can also cause adverse effects such as hypotension, pneumothorax, hemorrhage, and respiratory depression[ 13 , 14 ]. Furthermore, PVB is demanding for the operator and difficult to master[ 15 , 16 ]. With the increasing popularity and development of ultrasound, the safety and efficacy of fascial plane blocks have improved. In recent years, several planes of fascial plane blocks have been found in breast cancer surgery, including pectoral nerve block (PECS), erector spine plane block (ESPB), serratus anterior plane block (SAPB), and rhomboid intercostal nerve block (RIB) [ 4 , 9 , 17 , 18 ]. However, it is unclear which technique can provide more effective analgesia in breast cancer surgery. Our previous network meta-analysis revealed that RIB and SAPB may be the optimal nerve block modalities, but this conclusion was based on indirect comparisons and statistical probabilities and was not confirmed by direct clinical trials[ 4 ]. We hypothesized that RIB and SPAB would provide better analgesia than PVB in breast cancer surgery. Therefore, we conducted this prospective randomized study to assess the impact of the use of RIB, SAPB, and PVB in modified radical mastectomy on postoperative recovery and analgesic effects. Methods Study design and participants The prospective single-center, parallel-group, single-blind randomized, and controlled trials were approved on 22 November 2023 by the Ethics Committee of the Chongqing University Cancer Hospital (CZLS2023325-A). The trial was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before enrollment. The trial was registered with ClinicalTrials.gov (ChiCTR2300079196). The reporting complies with the most recent version of the Consolidated Standards of Reporting Trials (CONSORT). Following the acquisition of written informed consent from the patients, the women with physical statuses Ⅰ to Ⅲ as determined by the American Society of Anesthesiologists (ASA), aged 18 years or older, and scheduled for elective modified radical mastectomy were included in the study. The surgical procedures performed included radical mastectomy with sentinel lymph node biopsy, radical mastectomy, and modified radical mastectomy with axillary lymph node dissection. The following criteria were used to exclude patients from the study: unsuitability for regional anesthesia when the anesthetist assessed the patient in the pre-anesthetic; coagulation disorders, infections, or a history of allergy to local anesthetic medications; speech disorders; a body mass index greater than 35 kg m − 2 ; and an age of less than 18 years or more than 85 years. Subjects who met the eligibility criteria were randomly assigned to receive RIB, SAPB, or PVB at a ratio of 1:1:1 on the day of surgery. Randomization was performed via SPSS-generated random numbers. Concealment was achieved using sealed opaque envelopes. All patients, surgeons, and outcome assessors were unaware of the group assignment, whereas the anesthetist performing the nerve block was aware of the group assignment. Intervention RIB group: The patient was positioned in the lateral position, with the surgical side facing upward and the upper limb of the surgical side extending downward naturally. The high-frequency line array probe (8–14 MHz) is located on the lower edge of the scapula on the operative side of the medial T5–6 level. The probe marking point indicates the cephalic side. The ultrasound image revealed, in turn, the trapezius, rhomboid, intercostal muscles, ribs, pleura, and other structures. The puncture needle is inserted from the caudal end to the cephalic end. The cephalic end of the piercing is visible through the trapezius, rhomboid, and rhomboid muscles and the intercostal muscles between the gaps. After the injection of 20 ml of 0.375% ropivacaine, the local anesthetic diffused in a shuttle-shaped manner into the gap. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation. Ultrasound images of the RIB are shown in the Appendix. In the SAPB group, the patient was placed in the supine position. A high-frequency line array probe (8–14 MHz) was placed in the sagittal direction at the level of the midclavicular line on the operative side. The 2nd rib at the axillary artery and vein was identified, and the probe was moved downward and outward to count the ribs until they reached the level of the 5th rib in the midaxillary line. The superficial posterior latissimus dorsi muscle and the caudal deep side of the anterior serratus should be identified ultrasonographically, after which the nerve block needle should be advanced from the anterosuperior to posterior-inferior direction until it is between the latissimus dorsi muscle and the anterior serratus muscle. Following the withdrawal of no blood or gas, 20 ml of 0.375% ropivacaine was injected between the latissimus dorsi and the serratus anterior muscle. The local anesthetic was observed to diffuse in the interstices in the shape of a shuttle. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation. In the PVB group: All patients were positioned in the lateral decubitus position with the operative side up and the upper extremity of the operative side naturally extending downward. The seventh rib is located at the angle of the scapula, and a high-frequency line array probe (8–14 MHz) is selected to locate and mark the third rib and T3 spinous process at the level of the seventh rib. The probe was placed on the marked spinous processes with the long axis of the probe parallel to the spine, and the probe was moved along the alignment of the ribs to the affected side to view the image of the stacked transverse processes. The nerve block needle was inserted in the lateral to the medial intermediate plane, advancing the needle medially to the transverse processes. After the bloodless and airless injection of 20 ml of 0.375% ropivacaine is withdrawn, the puncture needle should be placed deep in the transverse process of the highly echogenic bulge, and the local anesthetic should diffuse into the interstitial space in the form of a shuttle. Following the completion of the block, the skin was observed for 20 minutes to ascertain whether any loss of sensation had occurred. Ultrasound images of the PVB are shown in the Appendix. The procedure involved the administration of nerve blocks by two anesthetists with extensive experience in this field (Jiali Yu and Yi Qi). All patients received a dose of midazolam (2 mg) and sufentanil (5 µg) via standard monitoring and oxygenation via a facemask before the nerve block. Standard monitoring methods include electrocardiography, peripheral pulse oximetry, noninvasive blood pressure (BP) measurement, temperature measurement, and the bispectral index (BIS). Anesthesia was induced following successful nerve block puncture. Following the successful administration of a nerve block, all patients were preoxygenated with 100% oxygen for three minutes before induction. General anesthesia was induced using 2 mg kg − 1 propofol and 0.5 µkg − 1 sufentanil, with 0.6 mg kg − 1 rocuronium administered to promote muscle relaxation. The anesthesia was maintained with an oxygen/air mixture (FiO2 = 0.5, fresh gas flow rate 3/L min − 1 ) and sevoflurane [1.0 to 1.5 minimum alveolar concentration (MAC)] to a BIS of 40 to 60. An endotracheal tube with a 7.0-mm internal diameter and a cuffed endotracheal tube were used for tracheal intubation. The initial respiratory rate was 12 breaths per minute, the positive end-expiratory pressure was 5 cmH₂O, and the tidal volume was 6 ml per ideal body weight. The respiratory rate was adjusted to maintain end-tracheal carbon dioxide (ETCO2) levels between 35 and 45 mmHg. Vasoactive drugs were administered intraoperatively based on alterations in blood pressure and heart rate. All patients received a preoperative dose of dexamethasone (4 mg) and ondansetron (0.1 mg/kg) to prevent postoperative nausea and vomiting (PONV). When the patient's depth of anesthesia was adequate and the heart rate and blood pressure were 20% above normal, 5 µg of sufentanil was given. Tramadol 50 mg or 100 mg was given to the patient after extubation when the postoperative NRS score was greater than 4. If tramadol was not controlled, morphine (0.1mg kg − 1 ) was given. Outcomes The primary outcomes included postoperative 24-hour NRS scores (resting and movement), postoperative 24 morphine consumption, and postoperative quality of recovery. The primary outcome measure was the quality of recovery, which was evaluated at 24 hours postoperatively via the Chinese version of the QoR-40. The QoR-40 is composed of two parts: the QoR-40A and the QoR-40B. The questionnaire comprises 40 items that assess five dimensions of recovery: emotional state (9 items), physical comfort (12 items), psychological support (7 items), physical independence (5 items), and pain (7 items). The secondary outcomes included post-extubation, postoperative 2-hour, and postoperative 48-hour NRS scores (resting and movement) and intraoperative sufentanil consumption (excluding sufentanil given before intubation), number of intraoperative users of sufentanil and postoperative 24-hour tramadol, incidence of intraoperative adverse events such as hypotension, arrhythmia, and pneumothorax, PONV, and average length of stay. Statistical analysis Our sample size was calculated for two-tailed testing. A pre-experimental analysis revealed that the postoperative 24-hour QoR-40 scores for RIB, PVB, and SAPB were 178.9 ± 5.01, 175.11 ± 4.17, and 174.8 ± 6.61, respectively. One-way analysis of variance allowing unequal variances (a = 0.05 and β = 0.1) in the PASS (21.03, USA) was used for the analysis. A sample size of 37 participants per group was deemed necessary. In consideration of a 20% dropout rate, 44 participants were required per group[ 19 ]. Statistical analyses were conducted via SPSS 25.0 software (SPSS, Chicago, IL, USA). The distribution of continuous data was initially evaluated via the Shapiro‒Wilk test and Q‒Q plots. Data with a normal distribution were analyzed via one-way ANOVA or repeated-measures ANOVA, and the results are expressed as the means ± standard deviations (SDs). Data with a nonnormal distribution were analyzed via the Kruskal‒Wallis test, and the results are expressed as medians and interquartile ranges(IQR). Comparisons between groups were made via Kruskal‒Wallis one-way ANOVA. Categorical variables were analyzed via the χ 2 test or Fisher's exact test, with the results described as numbers (%). Post hoc analyses were performed via the Bonferroni correction. The P value for significant differences was adjusted to 0.05. Results Patient characteristics The clinical trial was conducted between March 2016 and June 2017 at Chongqing University Cancer Hospital. Figure 1 presents a summary of the study flow according to the Consolidated Standards of Reporting Trials (CONSORT) statement. A total of 143 participants were first evaluated for eligibility to participate in the study. Seven did not meet the inclusion criteria, and three declined to participate, leaving 132 individuals available for enrollment (Fig. 1 ). Baseline personal and clinical characteristics and perioperative global QoR-40 scores were comparable between the groups (Table 1 ). Table 1 Characteristics of the patients at baseline Characteristic RIB group SPAB group PVB group F/χ2values P values Age, yr 55.61 ± 7.22 55.62 ± 8.85 55.63 ± 7.16 0.87 0.42 Weight, kg 60.44 ± 7.61 57.99 + 9.67 59.26 ± 6.91 1.44 0.24 Height, cm 154.59 ± 5.05 154.60 ± 6.3 154.61 ± 5.69 0.995 0.37 BMI, Kg/m2 25.27 + 3.06 24.77 + 3.06 24.86 + 2.82 0.35 0.7 ASA physical status 1.53 0.57 Ⅱ 34(77.3%) 29(65.9%) 30(68.2%) N N Ⅲ 10(22.7%) 15(34.1%) 14(31.8) N N Chemotherapy 14(31.8%) 17(38.6%) 11(25%) 1.89 0.41 Type of surgery 1.35 0.87 Mastectomy 7(38.9%) 5(27.8%) 6(33.3%) N N Mastectomy with sentinel lymph node biopsy 13(27.7%) 18(38.3%) 16(34%) N N Mastectomy with axillary lymph node dissection 24(35.8%) 21(31.3%) 22(32.8%) N N Operation time, min 129.1 ± 23.7 134.8 ± 31.1 135.8 ± 28.8 0.73 0.49 Intraoperative intravenous fluid, ml 1300(1200,1700) 1300(1200,1600) 1300(1200,1600) 0.87 0.65 Intraoperative urine Output, ml 200(150,250) 200(150,300) 300(200,337.5) 7.36 0.03 Intraoperative blood loss, ml 80(50,80) 80(80,80) 80(80,80) 2.53 0.28 Intraoperative sevoflurane, ml 29.68 ± 7 28.40 ± 8.34 28.32 ± 5.39 0.52 0.59 Intraoperative propofol, mg 44.68 ± 8.71 45.86 ± 11.39 43.14 ± 12.63 0.677 0.51 Note: Data are presented as mean ± SD, median (interquartile range), or number (percentage); N: none QoR-40 scores The RIB, SAPB and RIB groups had statistically significant global QoR-40 scores at 24 hours postoperatively. A comparison of each group revealed that the global QoR-40 scores for the RIB group (median: 186; IQR: 177, 190.5) and the PVB group (median: 186.5; IQR: 176.25, 190.5) were significantly higher than those for the SAPB group (median: 168; IQR: 163.25, 172) ( P < 0.001). There was no statistically significant difference in global QoR-40 scores between the RIB and SAPB groups ( P = 0.54). Among the QoR-40 scores, the comfort and pain scores were significantly different across the groups. A comparison of the comfort and pain scores within each group revealed that the RIB and PVB groups had significantly higher comfort scores than did the SAPB group (P < 0.001). There was no statistically significant difference in the comfort or pain scores between the RIB and SAPB groups. There were no statistically significant differences in the other scores between the groups in terms of the postoperative 24-hour QoR-40 scores. Figure 2 shows the global QoR-40 scores at 24 hours postoperatively. The detailed scores of the QoR-40 are shown in Table 2 . Table 2 The QoR-40 and dimensions scores at postoperative 24 hours Variables RIB(n = 44) SPAB (n = 44) PVB(n = 44) F values P values Part A Comfort 17(16,18) a 16(15.16) b 17(15.25,18) a 13.735 0.001 Emotions 14(13,15) 13(12,14) 14(13,15) 5.836 0.054 Physical independence 24(23,24) 24(23,24) 24(23,24) 5.136 0.076 Patient support 30(28,30) 28(27.25,30) 30(28,30) 4.911 0.086 Part A total score 85(81,87) 81(79.25,83) 84.5(81.25,86) 16.349 < 0.001 Part B Comfort 39(38,39) a 27(26,25) b 39(38,39) a 86.621 < 0.001 Emotions 26(25,28) 26(25,28) 26(25,28) 0.141 0.932 Patient Support 5(4,5) 5(4,5) 5(4,5) 0.186 0.911 Pain 33(29.5,34.75) a 28(25,32) b 32.5(28,34) a 16.422 < 0.001 Part B total score 102(95.5,104) a 86.5(83,89.75) b 100(94.5,105.75) a 69.464 < 0.001 Global total scores 186(177,190.5) a 168(163.25,172) b 186.5(176.25,190.5) a 60.989 < 0.001 Note: Data are presented median (interquartile range); For within-group comparisons, comparison between a and a: no statistical significance between the two groups( P < 0.05); comparison between a and b: statistical significance between the two groups( P < 0.05); Postoperative NRS score The RIB, SAPB, and RIB groups had statistically significant NRS scores after extubation (resting: P = 0.01; movement: P < 0.01). A comparison of each group revealed that the RIB [median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 1 (movement)] and PVB groups [median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 0.75 (movement)] had significantly lower post-extubation NRS scores than did the SAPB group [median: 1; IQR: 0, 1 (resting), median: 1; IQR: 1, 2 (movement)] ( P < 0.01). There was no statistically significant difference in NRS scores after extubation between the RIB and SAPB groups. There was no statistically significant difference in NRS scores between the RIB, SAPB, and PVB groups at 2, 24, and 48 hours postoperatively, respectively. Figure 3 shows the postoperative NRS scores. Intraoperative sufentanil consumption There was a statistically significant difference in intraoperative sufentanil consumption among the RIB, SAPB, and PVB groups. A comparison of each group revealed that the intraoperative consumption of sufentanil was significantly lower in the RIB (median: 0; IQR: 0, 0) and PVB groups (median: 0; IQR: 0, 5) than in the SAPB group (median: 0; IQR: 0, 5) ( P < 0.01), and there was no statistically significant difference in intraoperative sufentanil consumption between the RIB and PVB groups. Furthermore, the number of patients requiring sufentanil intraoperatively was significantly greater in the SAPB group (40.9%) than in the RIB (11.4%) and PVB groups (13.6%) ( P < 0.001). There was no statistically significant difference in the number of patients requiring sufentanil intraoperatively between the RIB and PVB groups. Table 3 shows the intraoperative sufentanil consumption. Table 3 Secondary outcomes during the study period Outcomes RIB group SPAB group PVB group F/χ2values P values Intraoperative sufentanil consumption, µg 0(0,0) a 0(0,5) b 0(0,0) a 15.1 < 0.001 Number of intraoperative sufentanil users 5(11.4%) a 18(40.9%) b 6(13.6%) a 13.88 < 0.001 PACU tramadol, mg 0(0,0) 0(0,0) 0(0,0) 0.512 0.77 Postoperative 24-hour tramadol, mg 0(0,100) 1 0(0,100) 2 0(0,0) 3 6.25 0.046 Intraoperative hypotension 20(40.6%) 21(48.8%) 24(54.5%) 0.79 0.67 Intraoperative bradycardia 14(33.3) 13(31%) 15(35.7%) 0.21 0.972 Intraoperative arrhythmia 0 1(2.3%) 2(4.5%) 2 0.368 terms of the time to extubation 5(3,5) 5(3,6) 3(2,5.75) 1.49 0.661 PONV 5(11.3%) 12(27.3%) 6(13.6%) 4.53 0.126 Hospital length of stay 14.3 ± 4.3 12.75 ± 4.97 13.14 ± 3.68 1.49 0.23 Notes: Data are presented as mean ± SD, median (interquartile range), or number (percentage). For within-group comparisons, comparison between a and a, 1 and 2 or 1 and 3: no statistical significance between the two groups( P < 0.05); comparison between a and b or 2 and 3: statistical significance between the two groups( P < 0.05); comparison between a and c: statistical significance between the two groups( P < 0.05). Multiple comparisons within groups have been adjusted for significance values by Bonferroni correction for multiple tests; PONV: postoperative nausea and vomiting. Postoperative tramadol and morphine consumption There was no statistically significant difference in PACU tramadol consumption among the RIB (median: 0; IQR: 0, 0), SAPB (median: 0; IQR: 0, 0), and PVB (median: 0; IQR: 0, 0) groups ( P = 0.77). There was a statistically significant difference in tramadol consumption among the RIB (median: 0; IQR: 0, 100), SAPB (median: 0; IQR: 0, 100), and PVB (median: 0; IQR: 0,0) groups at 24 hours postsurgery( P = 0.046). A comparison of each group revealed that the postoperative 24 hours consumption of tramadol was significantly lower in the PVB group than in the SAPB group ( P < 0.041), and there was no statistically significant difference in postoperative 24 hours tramadol consumption between the SPAB and PVB groups than in the RIB group ( P = 0.334 and 1). The only one patient used morphine(5mg) at postoperative 24 hours, we did not perform statistical analyses. Table 3 shows the tramadol consumption. Adverse events There were no significant differences between RIB, SAPB, or PVB in the incidence of intraoperative hypotension, arrhythmia, or bradycardia. There were no significant differences among the three groups in terms of the time to extubation, PONV, or average length of stay. Table 3 shows the incidence of adverse events. Discussion In our study, we found that postoperative 24-hour QoR-40 scores were significantly higher in the RIB and PVB groups than in the SAPB group. In addition, post-extubation NRS scores for the number of patients requiring sufentanil intraoperatively and, intraoperative sufentanil consumption were significantly lower in the RIB and PVB groups than in the SAPB group. Furthermore, there were no significant differences in the QoR-40 scores, analgesic medication consumption, or postoperative NRS scores between the RIB and PVB groups. There was no significant difference in the NRS score among the three groups at 2 h, 24 h, or 48 h after surgery. We did not find any adverse events associated with RIB, PVB, or SAPB. The breast is innervated by the lateral and anterior cutaneous branches of the second to sixth thoracic intercostal nerve branches and several branches of the supraclavicular nerve[ 20 , 21 ]. The SAPB is one of the most common interfacial blocks and is superficial and easy to perform. SAPB relieves postoperative pain and benefits patient recovery after breast surgery[ 7 , 22 , 23 ]. A meta-analysis by Chong et al. revealed that SAPB provides significant analgesia and reduces opioid consumption in patients undergoing breast cancer surgery. Nevertheless, the analgesic effect of SAPB is inferior to that of PVB[ 24 ]. Our study reached similar conclusions. Compared with PVB, SAPB was associated with significantly lower QoR-40 scores at 24 hours postoperatively, higher NRS scores, and increased intraoperative sufentanil consumption. SAPB is performed by blocking the lateral cutaneous branches of the intercostal nerve, which provides analgesia to the anteromedial and partial posterior thoracic wall (T2-T9) [ 25 ]. However, the anterior branch of the intercostal nerve provides innervation to the anteromedial chest wall, and it is unlikely that the SAPB adequately covers this area[ 26 , 27 ]. This may result in incomplete relief of pain from the medial breast wound and cause significant pain and discomfort. The RIB, as first described by Elsharkawy et al. in 2016[ 28 ], has been demonstrated to facilitate the spread of dye from caudad to cephalad, encompassing the T2 to T8 tissue plane and extending to the lateral branches of the intercostal nerves T3 to T8, the posterior primary rami close to the midline, and the clavipectoral fascia within the axilla[ 29 ]. Therefore, RIB can provide superior analgesia for axillary surgery. Some studies have shown that RIB improves the QoR-40 score and reduces the postoperative pain score and the consumption of opioids[ 30 – 32 ]. Our study revealed that RIB produced similar QoR-40 scores, postoperative pain scores, and analgesic consumption as PVB did. Jiang et al. compared the effects of RIB, SAPB, and ESPB on analgesia in breast cancer surgery and reported that the analgesic effects of RIB and ESPB were superior to those of SAPB[ 33 ]. Our study revealed that the analgesic effect of RIB was superior to that of SAPB. The RIB is in the posterior chest wall and is superficial, easily localized via ultrasound, and distant from the surgical site. Therefore, it may be an optimal alternative to PVB for an interfacial block. Our study is the first to perform ultrasound-guided nerve blocks for preoperative comparison of the efficacy of RIB, PVB, and SAPB in providing intraoperative analgesia. A single nerve block was performed, with additional sufentanil administered based on the patient's requirements. Approximately 13% of patients who underwent RIB and PVB required additional intraoperative sufentanil, whereas 40.9% of those who underwent SAPB required additional sufentanil. Therefore, RIB and PVB have the potential to reduce the total amount of intraoperative opioids required and provide an effective analgesic strategy for opioid-free anesthesia. We found fewer patients with postoperative pain greater than 4 in all three groups, indicating that nerve blocks are effective in reducing postoperative pain. Only 1 patient required morphine 24 hours postoperatively. Therefore, PVB was associated with significantly lower tramadol consumption than SAPB was, but RIB was not significantly different from PVB or SAPB at 24 hours postoperatively. We did not use PCA for postoperative analgesia, and postoperative tramadol consumption may be subject to patient and doctor intervention. A single nerve block does not provide continuous analgesia and may result in a burst of pain. Consequently, there was no significant difference in pain scores among the three groups after 2 hours. There were differences in the QoR-40 scores among the three groups, which were due mainly to differences in patient comfort and pain scores 24 hours after surgery. We did not find any nerve block-related complications, indicating that ultrasound-mediated RIB, SAPB, and PVB are safe and effective nerve blocks. Our study had several limitations: First, our study revealed statistically significant differences in only the QoR-40 scores and analgesic effects among the three groups but did not reveal clinical differences. Second, our study used nerve blocks selected based on a previous network analysis and did not compare the analgesic effects of the other nerve blocks with those of the RIB. Third, postoperative tramadol consumption may be subject to human error. Fourth, we observed only QoR-40 scores at 24 hours postoperatively and did not observe long-term QoR-40 scores or the incidence of chronic pain. Fifth, we used the Chinese version of the QoR-40, which may have impacted the results. Conclusion In the current study, RIB and PVB were superior to SAPB in terms of the quality of recovery and perioperative analgesia in patients undergoing breast surgery. In addition, RIB and PVB significantly reduced NRS scores after extubation. There was no significant difference between RIB and PVB in terms of the quality of recovery and analgesia indicating that RIB may be an optimal alternative nerve block to PVB. Declarations Disclosure No potential conflict of interest relevant to this article was reported. Funding This work was supported by Technology innovation and application development project in Chongqing Shapingba District (No. 2023114), the Key R & D project of Chongqing Science and Technology Bureau (No. cstc2020jscx‑dxwtBX0010) and the Key R & D project of the Ministry of Science and Technology of China (No: 2018YFC0116704). Author Contribution JL Yu: Data curation, Visualization, Investigation, Writing – original draft. Y Qi: Data curation, Methodology, Formal analysis, Software, Writing – original draft. D Wang: Validation, Methodology, Formal analysis. Q Chen: Software, Validation, writing-original draft. R An: Conceptualization, Funding acquisition, Methodology, Writing-review& editing. HL Liu: Conceptualization, Methodology, Supervision, Writing-review& editing. All authors reviewed the manuscript. Data Availability To original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author. References Siegel RL, Miller KD, Wagle NS, Jemal A: Cancer statistics, 2023. CA: a cancer journal for clinicians 2023, 73(1):17–48. Lei S, Zheng R, Zhang S, Wang S, Chen R, Sun K, Zeng H, Zhou J, Wei W: Global patterns of breast cancer incidence and mortality: A population-based cancer registry data analysis from 2000 to 2020. Cancer communications (London, England) 2021, 41(11):1183–1194. Fecho K, Miller NR, Merritt SA, Klauber-Demore N, Hultman CS, Blau WS: Acute and persistent postoperative pain after breast surgery. Pain medicine (Malden, Mass) 2009, 10(4):708–715. 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European journal of anaesthesiology 2019, 36(6):436–441. Abdallah FW, Morgan PJ, Cil T, McNaught A, Escallon JM, Semple JL, Wu W, Chan VW: Ultrasound-guided multilevel paravertebral blocks and total intravenous anesthesia improve the quality of recovery after ambulatory breast tumor resection. Anesthesiology 2014, 120(3):703–713. Heesen M, Klimek M, Rossaint R, Imberger G, Straube S: Paravertebral block and persistent postoperative pain after breast surgery: meta-analysis and trial sequential analysis. Anaesthesia 2016, 71(12):1471–1481. Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK: Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. British journal of anaesthesia 2010, 105(6):842–852. Terkawi AS, Tsang S, Sessler DI, Terkawi RS, Nunemaker MS, Durieux ME, Shilling A: Improving Analgesic Efficacy and Safety of Thoracic Paravertebral Block for Breast Surgery: A Mixed-Effects Meta-Analysis. Pain physician 2015, 18(5):E757-780. Jacobs A, Lemoine A, Joshi GP, Van de Velde M, Bonnet F: PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020, 75(5):664–673. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID: Paravertebral blockade. Failure rate and complications. Anaesthesia 1995, 50(9):813–815. Naja Z, Lönnqvist PA: Somatic paravertebral nerve blockade. Incidence of failed block and complications. Anaesthesia 2001, 56(12):1184–1188. Moustafa MA, Alabd AS, Ahmed AMM, Deghidy EA: Erector spinae versus paravertebral plane blocks in modified radical mastectomy: Randomised comparative study of the technique success rate among novice anaesthesiologists. Indian journal of anaesthesia 2020, 64(1):49–54. Abdallah FW, Brull R: Off side! A simple modification to the parasagittal in-plane approach for paravertebral block. Regional anesthesia and pain medicine 2014, 39(3):240–242. Huang W, Wang W, Xie W, Chen Z, Liu Y: Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis. Journal of clinical anesthesia 2020, 66:109900. Lovett-Carter D, Kendall MC, McCormick ZL, Suh EI, Cohen AD, De Oliveira GS: Pectoral nerve blocks and postoperative pain outcomes after mastectomy: a meta-analysis of randomized controlled trials. Regional anesthesia and pain medicine 2019. Jan SL, Shieh G: Sample size determinations for Welch's test in one-way heteroscedastic ANOVA. The British journal of mathematical and statistical psychology 2014, 67(1):72–93. Jaspars JJ, Posma AN, van Immerseel AA, Gittenberger-de Groot AC: The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. British journal of plastic surgery 1997, 50(4):249–259. Riccio CA, Zeiderman MR, Chowdhry S, Brooks RM, Kelishadi SS, Tutela JP, Choo J, Yonick DV, Wilhelmi BJ: Plastic Surgery of the Breast: Keeping the Nipple Sensitive. Eplasty 2015, 15:e28. Hu NQ, He QQ, Qian L, Zhu JH: Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Postoperative Analgesia in Patients Undergoing Breast Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Pain research & management 2021, 2021:7849623. Meng J, Zhao HY, Zhuo XJ, Shen QH: Postoperative Analgesic Effects of Serratus Anterior Plane Block for Thoracic and Breast Surgery: A Meta-analysis of Randomized Controlled Trials. Pain physician 2023, 26(2):E51-e62. Chong M, Berbenetz N, Kumar K, Lin C: The serratus plane block for postoperative analgesia in breast and thoracic surgery: a systematic review and meta-analysis. Regional anesthesia and pain medicine 2019. Mayes J, Davison E, Panahi P, Patten D, Eljelani F, Womack J, Varma M: An anatomical evaluation of the serratus anterior plane block. Anaesthesia 2016, 71(9):1064–1069. Fusco P, Scimia P, Petrucci E, S DIC, Marinangeli F: The ultrasound-guided parasternal block: a novel approach for anesthesia and analgesia in breast cancer surgery. Minerva anestesiologica 2017, 83(2):221–222. Brosnan KD, Coppens S, Ni Eochagain A: Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review. Anaesthesia 2023, 78(2):260–261. Elsharkawy H, Saifullah T, Kolli S, Drake R: Rhomboid intercostal block. Anaesthesia 2016, 71(7):856–857. Elsharkawy H, Maniker R, Bolash R, Kalasbail P, Drake RL, Elkassabany N: Rhomboid Intercostal and Subserratus Plane Block: A Cadaveric and Clinical Evaluation. Regional anesthesia and pain medicine 2018, 43(7):745–751. Altıparmak B, Korkmaz Toker M, Uysal AI, Dere Ö, Uğur B: Evaluation of ultrasound-guided rhomboid intercostal nerve block for postoperative analgesia in breast cancer surgery: a prospective, randomized controlled trial. Regional anesthesia and pain medicine 2020, 45(4):277–282. Wang X, Jia X, Li Z, Zhou Q: Rhomboid intercostal block or thoracic paravertebral block for postoperative recovery quality after video-assisted thoracic surgery: A prospective, non-inferiority, randomised controlled trial. European journal of anaesthesiology 2023, 40(9):652–659. Ciftci B, Ekinci M, Basim P, Celik EC, Tukac IC, Zenciroglu M, Atalay YO: Comparison of Ultrasound-Guided Type-II Pectoral Nerve Block and Rhomboid Intercostal Block for Pain Management Following Breast Cancer Surgery: A Randomized, Controlled Trial. Pain practice: the official journal of World Institute of Pain 2021, 21(6):638–645. Jiang CW, Liu F, Zhou Q, Deng W: Comparison of rhomboid intercostal nerve block, erector spinae plane block and serratus plane block on analgesia for modified radical mastectomy: A prospective randomised controlled trial. International journal of clinical practice 2021, 75(10):e14539. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4905136","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":355553057,"identity":"41a5a1f2-a78b-47b7-a269-8c3e62f0c302","order_by":0,"name":"Jiali Yu","email":"","orcid":"","institution":"Department of Anesthesiology, Chongqing University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiali","middleName":"","lastName":"Yu","suffix":""},{"id":355553065,"identity":"8f44fe7b-b0b1-4657-b7bd-4687b5000756","order_by":1,"name":"Yi Qi","email":"","orcid":"","institution":"Department of Anesthesiology, Chongqing University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Qi","suffix":""},{"id":355553067,"identity":"d4d48784-4e44-4591-8985-0621bf715882","order_by":2,"name":"Dan Wang","email":"","orcid":"","institution":"Chongqing University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Wang","suffix":""},{"id":355553068,"identity":"9a293b13-a808-45b0-884e-7c7d2c007d17","order_by":3,"name":"Qi Chen","email":"","orcid":"","institution":"Department of Anesthesiology, Chongqing University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Chen","suffix":""},{"id":355553069,"identity":"bec85893-8068-4a07-a463-e6d0045994ce","order_by":4,"name":"Ran An","email":"","orcid":"","institution":"Department of Anesthesiology, Chongqing University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ran","middleName":"","lastName":"An","suffix":""},{"id":355553070,"identity":"22a4612b-0677-4267-bcd7-98d7c95d5c4d","order_by":5,"name":"Hongliang Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACPmYGNoaH//7JQbhsRGhhA2lJYDtgTIIWBoiWxAbitbDzmD1I4LmT3t+eY8DwoewwA//sBkIO4zE3SJB4ljvjzBsDxhnnDjNI3DlAUIuZRIIBc+4GiRwDZt62wwwGEgnEaElgTjcAaflLvJYDhxPAWhiJ08JWJpHYkGY448yzgoM959J5JG4Q0MLPf3ibxMcGG3n+9uSND36UWcvxzyCgBQkkMBwAkjxEqwdrGQWjYBSMglGAFQAAVA853Zl4dFMAAAAASUVORK5CYII=","orcid":"","institution":"Department of Anesthesiology, Chongqing University Cancer Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hongliang","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-08-13 07:57:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4905136/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4905136/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66635913,"identity":"0080f907-86ff-4e17-80c5-49231b3cc027","added_by":"auto","created_at":"2024-10-15 05:24:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":474086,"visible":true,"origin":"","legend":"\u003cp\u003eFlow of participants through the study\u003c/p\u003e","description":"","filename":"Figure1.Flowofparticipantsthroughthestudy.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4905136/v1/6c7818cf931d5b82846906e2.jpg"},{"id":66636209,"identity":"a2291825-f56f-4144-8eec-0ac484b83d92","added_by":"auto","created_at":"2024-10-15 05:32:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":255927,"visible":true,"origin":"","legend":"\u003cp\u003eGobal QoR-40 scores(*: Statistical significance between the three groups, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05; #: No statistically significant between the three groups, \u003cem\u003eP\u003c/em\u003e\u0026gt;0.05. Violin plots are characterised by kernel density estimates of the underlying distribution. Kernel density estimates of the distribution. The red solid line represent the median and the blue dotted line represent the interquartile range.)\u003c/p\u003e","description":"","filename":"Figure2.GobalQoR40scores.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4905136/v1/14e595e81da87fe2d001dca1.jpg"},{"id":66635914,"identity":"fae7aee2-554e-4f8a-9c1f-59f4429e7f2f","added_by":"auto","created_at":"2024-10-15 05:24:47","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":133965,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative NRS scores(*: Statistical significance between the three groups, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05; #: No statistically significant between the three groups, \u003cem\u003eP\u003c/em\u003e\u0026gt;0.05. The boxes represent median and the whiskers represent the interquartile range)\u003c/p\u003e","description":"","filename":"Figure3.PostoperativeNRSscores.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4905136/v1/0269e28a0d8a31e415d46fa2.jpg"},{"id":73630083,"identity":"432d5352-8794-4e98-af1f-e63699fef384","added_by":"auto","created_at":"2025-01-13 06:09:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1676288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4905136/v1/abe91fbf-72b5-4873-a5d8-264672c41a21.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most common malignant tumor in women worldwide.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Surgical resection remains the primary treatment modality[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Approximately half of all surgical patients experience moderate to severe acute pain after surgery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegional anesthetic techniques are an important part of multimodal analgesia as they have been demonstrated to reduce opioid consumption and numerical rating scale (NRS) in breast cancer surgery[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Furthermore, evidence from the 40-item Quality of Recovery Questionnaire (QoR-40), a validated patient-oriented multidimensional assessment tool, indicates that regional analgesia may promote recovery following surgery.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Paravertebral block (PVB) is the most used regional analgesia in breast cancer surgery[\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, PVB can also cause adverse effects such as hypotension, pneumothorax, hemorrhage, and respiratory depression[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, PVB is demanding for the operator and difficult to master[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. With the increasing popularity and development of ultrasound, the safety and efficacy of fascial plane blocks have improved. In recent years, several planes of fascial plane blocks have been found in breast cancer surgery, including pectoral nerve block (PECS), erector spine plane block (ESPB), serratus anterior plane block (SAPB), and rhomboid intercostal nerve block (RIB) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, it is unclear which technique can provide more effective analgesia in breast cancer surgery.\u003c/p\u003e \u003cp\u003eOur previous network meta-analysis revealed that RIB and SAPB may be the optimal nerve block modalities, but this conclusion was based on indirect comparisons and statistical probabilities and was not confirmed by direct clinical trials[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. We hypothesized that RIB and SPAB would provide better analgesia than PVB in breast cancer surgery. Therefore, we conducted this prospective randomized study to assess the impact of the use of RIB, SAPB, and PVB in modified radical mastectomy on postoperative recovery and analgesic effects.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003e The prospective single-center, parallel-group, single-blind randomized, and controlled trials were approved on 22 November 2023 by the Ethics Committee of the Chongqing University Cancer Hospital (CZLS2023325-A). The trial was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before enrollment. The trial was registered with ClinicalTrials.gov (ChiCTR2300079196). The reporting complies with the most recent version of the Consolidated Standards of Reporting Trials (CONSORT).\u003c/p\u003e \u003cp\u003eFollowing the acquisition of written informed consent from the patients, the women with physical statuses Ⅰ to Ⅲ as determined by the American Society of Anesthesiologists (ASA), aged 18 years or older, and scheduled for elective modified radical mastectomy were included in the study. The surgical procedures performed included radical mastectomy with sentinel lymph node biopsy, radical mastectomy, and modified radical mastectomy with axillary lymph node dissection. The following criteria were used to exclude patients from the study: unsuitability for regional anesthesia when the anesthetist assessed the patient in the pre-anesthetic; coagulation disorders, infections, or a history of allergy to local anesthetic medications; speech disorders; a body mass index greater than 35 kg m\u003csup\u003e\u0026minus;\u0026thinsp;2\u003c/sup\u003e; and an age of less than 18 years or more than 85 years. Subjects who met the eligibility criteria were randomly assigned to receive RIB, SAPB, or PVB at a ratio of 1:1:1 on the day of surgery. Randomization was performed via SPSS-generated random numbers. Concealment was achieved using sealed opaque envelopes. All patients, surgeons, and outcome assessors were unaware of the group assignment, whereas the anesthetist performing the nerve block was aware of the group assignment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eRIB group: The patient was positioned in the lateral position, with the surgical side facing upward and the upper limb of the surgical side extending downward naturally. The high-frequency line array probe (8\u0026ndash;14 MHz) is located on the lower edge of the scapula on the operative side of the medial T5\u0026ndash;6 level. The probe marking point indicates the cephalic side. The ultrasound image revealed, in turn, the trapezius, rhomboid, intercostal muscles, ribs, pleura, and other structures. The puncture needle is inserted from the caudal end to the cephalic end. The cephalic end of the piercing is visible through the trapezius, rhomboid, and rhomboid muscles and the intercostal muscles between the gaps. After the injection of 20 ml of 0.375% ropivacaine, the local anesthetic diffused in a shuttle-shaped manner into the gap. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation. Ultrasound images of the RIB are shown in the Appendix.\u003c/p\u003e \u003cp\u003eIn the SAPB group, the patient was placed in the supine position. A high-frequency line array probe (8\u0026ndash;14 MHz) was placed in the sagittal direction at the level of the midclavicular line on the operative side. The 2nd rib at the axillary artery and vein was identified, and the probe was moved downward and outward to count the ribs until they reached the level of the 5th rib in the midaxillary line. The superficial posterior latissimus dorsi muscle and the caudal deep side of the anterior serratus should be identified ultrasonographically, after which the nerve block needle should be advanced from the anterosuperior to posterior-inferior direction until it is between the latissimus dorsi muscle and the anterior serratus muscle. Following the withdrawal of no blood or gas, 20 ml of 0.375% ropivacaine was injected between the latissimus dorsi and the serratus anterior muscle. The local anesthetic was observed to diffuse in the interstices in the shape of a shuttle. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation.\u003c/p\u003e \u003cp\u003eIn the PVB group: All patients were positioned in the lateral decubitus position with the operative side up and the upper extremity of the operative side naturally extending downward. The seventh rib is located at the angle of the scapula, and a high-frequency line array probe (8\u0026ndash;14 MHz) is selected to locate and mark the third rib and T3 spinous process at the level of the seventh rib. The probe was placed on the marked spinous processes with the long axis of the probe parallel to the spine, and the probe was moved along the alignment of the ribs to the affected side to view the image of the stacked transverse processes. The nerve block needle was inserted in the lateral to the medial intermediate plane, advancing the needle medially to the transverse processes. After the bloodless and airless injection of 20 ml of 0.375% ropivacaine is withdrawn, the puncture needle should be placed deep in the transverse process of the highly echogenic bulge, and the local anesthetic should diffuse into the interstitial space in the form of a shuttle. Following the completion of the block, the skin was observed for 20 minutes to ascertain whether any loss of sensation had occurred. Ultrasound images of the PVB are shown in the Appendix. The procedure involved the administration of nerve blocks by two anesthetists with extensive experience in this field (Jiali Yu and Yi Qi).\u003c/p\u003e \u003cp\u003eAll patients received a dose of midazolam (2 mg) and sufentanil (5 \u0026micro;g) via standard monitoring and oxygenation via a facemask before the nerve block. Standard monitoring methods include electrocardiography, peripheral pulse oximetry, noninvasive blood pressure (BP) measurement, temperature measurement, and the bispectral index (BIS). Anesthesia was induced following successful nerve block puncture. Following the successful administration of a nerve block, all patients were preoxygenated with 100% oxygen for three minutes before induction. General anesthesia was induced using 2 mg kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e propofol and 0.5 \u0026micro;kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e sufentanil, with 0.6 mg kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e rocuronium administered to promote muscle relaxation. The anesthesia was maintained with an oxygen/air mixture (FiO2\u0026thinsp;=\u0026thinsp;0.5, fresh gas flow rate 3/L min\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e) and sevoflurane [1.0 to 1.5 minimum alveolar concentration (MAC)] to a BIS of 40 to 60. An endotracheal tube with a 7.0-mm internal diameter and a cuffed endotracheal tube were used for tracheal intubation. The initial respiratory rate was 12 breaths per minute, the positive end-expiratory pressure was 5 cmH₂O, and the tidal volume was 6 ml per ideal body weight. The respiratory rate was adjusted to maintain end-tracheal carbon dioxide (ETCO2) levels between 35 and 45 mmHg. Vasoactive drugs were administered intraoperatively based on alterations in blood pressure and heart rate. All patients received a preoperative dose of dexamethasone (4 mg) and ondansetron (0.1 mg/kg) to prevent postoperative nausea and vomiting (PONV). When the patient's depth of anesthesia was adequate and the heart rate and blood pressure were 20% above normal, 5 \u0026micro;g of sufentanil was given. Tramadol 50 mg or 100 mg was given to the patient after extubation when the postoperative NRS score was greater than 4. If tramadol was not controlled, morphine (0.1mg kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e) was given.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe primary outcomes included postoperative 24-hour NRS scores (resting and movement), postoperative 24 morphine consumption, and postoperative quality of recovery. The primary outcome measure was the quality of recovery, which was evaluated at 24 hours postoperatively via the Chinese version of the QoR-40. The QoR-40 is composed of two parts: the QoR-40A and the QoR-40B. The questionnaire comprises 40 items that assess five dimensions of recovery: emotional state (9 items), physical comfort (12 items), psychological support (7 items), physical independence (5 items), and pain (7 items).\u003c/p\u003e \u003cp\u003eThe secondary outcomes included post-extubation, postoperative 2-hour, and postoperative 48-hour NRS scores (resting and movement) and intraoperative sufentanil consumption (excluding sufentanil given before intubation), number of intraoperative users of sufentanil and postoperative 24-hour tramadol, incidence of intraoperative adverse events such as hypotension, arrhythmia, and pneumothorax, PONV, and average length of stay.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eOur sample size was calculated for two-tailed testing. A pre-experimental analysis revealed that the postoperative 24-hour QoR-40 scores for RIB, PVB, and SAPB were 178.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.01, 175.11\u0026thinsp;\u0026plusmn;\u0026thinsp;4.17, and 174.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.61, respectively. One-way analysis of variance allowing unequal variances (a\u0026thinsp;=\u0026thinsp;0.05 and β\u0026thinsp;=\u0026thinsp;0.1) in the PASS (21.03, USA) was used for the analysis. A sample size of 37 participants per group was deemed necessary. In consideration of a 20% dropout rate, 44 participants were required per group[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStatistical analyses were conducted via SPSS 25.0 software (SPSS, Chicago, IL, USA). The distribution of continuous data was initially evaluated via the Shapiro‒Wilk test and Q‒Q plots. Data with a normal distribution were analyzed via one-way ANOVA or repeated-measures ANOVA, and the results are expressed as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SDs). Data with a nonnormal distribution were analyzed via the Kruskal‒Wallis test, and the results are expressed as medians and interquartile ranges(IQR). Comparisons between groups were made via Kruskal‒Wallis one-way ANOVA. Categorical variables were analyzed via the χ\u003csup\u003e2\u003c/sup\u003e test or Fisher's exact test, with the results described as numbers (%). Post hoc analyses were performed via the Bonferroni correction. The \u003cem\u003eP\u003c/em\u003e value for significant differences was adjusted to 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eThe clinical trial was conducted between March 2016 and June 2017 at Chongqing University Cancer Hospital. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents a summary of the study flow according to the Consolidated Standards of Reporting Trials (CONSORT) statement. A total of 143 participants were first evaluated for eligibility to participate in the study. Seven did not meet the inclusion criteria, and three declined to participate, leaving 132 individuals available for enrollment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Baseline personal and clinical characteristics and perioperative global QoR-40 scores were comparable between the groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the patients at baseline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRIB group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSPAB group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePVB group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF/χ2values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.61\u0026thinsp;\u0026plusmn;\u0026thinsp;7.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.62\u0026thinsp;\u0026plusmn;\u0026thinsp;8.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.63\u0026thinsp;\u0026plusmn;\u0026thinsp;7.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight, kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.44\u0026thinsp;\u0026plusmn;\u0026thinsp;7.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.99\u0026thinsp;+\u0026thinsp;9.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.26\u0026thinsp;\u0026plusmn;\u0026thinsp;6.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154.60\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e154.61\u0026thinsp;\u0026plusmn;\u0026thinsp;5.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, Kg/m2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.27\u0026thinsp;+\u0026thinsp;3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.77\u0026thinsp;+\u0026thinsp;3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.86\u0026thinsp;+\u0026thinsp;2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA physical status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅡ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(77.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(65.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(68.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅢ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(34.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(31.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(38.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(38.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(27.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMastectomy with sentinel lymph node biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(27.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(38.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMastectomy with axillary lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24(35.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(31.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22(32.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129.1\u0026thinsp;\u0026plusmn;\u0026thinsp;23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134.8\u0026thinsp;\u0026plusmn;\u0026thinsp;31.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e135.8\u0026thinsp;\u0026plusmn;\u0026thinsp;28.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative intravenous fluid, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1300(1200,1700)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1300(1200,1600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1300(1200,1600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative urine Output, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200(150,250)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e200(150,300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e300(200,337.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative blood loss, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80(50,80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(80,80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80(80,80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative sevoflurane, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.68\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.40\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.32\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative propofol, mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.68\u0026thinsp;\u0026plusmn;\u0026thinsp;8.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.86\u0026thinsp;\u0026plusmn;\u0026thinsp;11.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.14\u0026thinsp;\u0026plusmn;\u0026thinsp;12.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.677\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, median (interquartile range), or number (percentage); N: none\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eQoR-40 scores\u003c/h2\u003e \u003cp\u003eThe RIB, SAPB and RIB groups had statistically significant global QoR-40 scores at 24 hours postoperatively. A comparison of each group revealed that the global QoR-40 scores for the RIB group (median: 186; IQR: 177, 190.5) and the PVB group (median: 186.5; IQR: 176.25, 190.5) were significantly higher than those for the SAPB group (median: 168; IQR: 163.25, 172) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no statistically significant difference in global QoR-40 scores between the RIB and SAPB groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.54). Among the QoR-40 scores, the comfort and pain scores were significantly different across the groups. A comparison of the comfort and pain scores within each group revealed that the RIB and PVB groups had significantly higher comfort scores than did the SAPB group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no statistically significant difference in the comfort or pain scores between the RIB and SAPB groups. There were no statistically significant differences in the other scores between the groups in terms of the postoperative 24-hour QoR-40 scores. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the global QoR-40 scores at 24 hours postoperatively. The detailed scores of the QoR-40 are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe QoR-40 and dimensions scores at postoperative 24 hours\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRIB(n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSPAB (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePVB(n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(16,18) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(15.16) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(15.25,18) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.735\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(13,15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(12,14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(13,15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24(23,24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(23,24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(23,24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(28,30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(27.25,30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(28,30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.911\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart A total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85(81,87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81(79.25,83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.5(81.25,86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39(38,39) a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(26,25) b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39(38,39) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e86.621\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(25,28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(25,28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(25,28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(4,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(4,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(4,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.911\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33(29.5,34.75) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(25,32) b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.5(28,34) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart B total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102(95.5,104) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.5(83,89.75) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100(94.5,105.75) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69.464\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobal total scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186(177,190.5) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168(163.25,172) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e186.5(176.25,190.5) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: Data are presented median (interquartile range); For within-group comparisons, comparison between a and a: no statistical significance between the two groups(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05); comparison between a and b: statistical significance between the two groups(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05);\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative NRS score\u003c/h2\u003e \u003cp\u003eThe RIB, SAPB, and RIB groups had statistically significant NRS scores after extubation (resting: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01; movement: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). A comparison of each group revealed that the RIB [median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 1 (movement)] and PVB groups [median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 0.75 (movement)] had significantly lower post-extubation NRS scores than did the SAPB group [median: 1; IQR: 0, 1 (resting), median: 1; IQR: 1, 2 (movement)] (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). There was no statistically significant difference in NRS scores after extubation between the RIB and SAPB groups. There was no statistically significant difference in NRS scores between the RIB, SAPB, and PVB groups at 2, 24, and 48 hours postoperatively, respectively. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the postoperative NRS scores.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative sufentanil consumption\u003c/h2\u003e \u003cp\u003eThere was a statistically significant difference in intraoperative sufentanil consumption among the RIB, SAPB, and PVB groups. A comparison of each group revealed that the intraoperative consumption of sufentanil was significantly lower in the RIB (median: 0; IQR: 0, 0) and PVB groups (median: 0; IQR: 0, 5) than in the SAPB group (median: 0; IQR: 0, 5) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and there was no statistically significant difference in intraoperative sufentanil consumption between the RIB and PVB groups. Furthermore, the number of patients requiring sufentanil intraoperatively was significantly greater in the SAPB group (40.9%) than in the RIB (11.4%) and PVB groups (13.6%) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no statistically significant difference in the number of patients requiring sufentanil intraoperatively between the RIB and PVB groups. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the intraoperative sufentanil consumption.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSecondary outcomes during the study period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRIB group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSPAB group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePVB group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF/χ2values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative sufentanil consumption, \u0026micro;g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0,0) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0,5) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0,0) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of intraoperative sufentanil users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(11.4%) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(40.9%) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(13.6%) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU tramadol, mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 24-hour tramadol, mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0,100) \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0,100) \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0,0) \u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20(40.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(48.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(54.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative bradycardia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15(35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.972\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative arrhythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eterms of the time to extubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(3,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(3,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(2,5.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.661\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePONV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(11.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(13.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital length of stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.14\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNotes: Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, median (interquartile range), or number (percentage). For within-group comparisons, comparison between a and a, 1 and 2 or 1 and 3: no statistical significance between the two groups(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05); comparison between a and b or 2 and 3: statistical significance between the two groups(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05); comparison between a and c: statistical significance between the two groups(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Multiple comparisons within groups have been adjusted for significance values by Bonferroni correction for multiple tests; PONV: postoperative nausea and vomiting.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative tramadol and morphine consumption\u003c/h2\u003e \u003cp\u003eThere was no statistically significant difference in PACU tramadol consumption among the RIB (median: 0; IQR: 0, 0), SAPB (median: 0; IQR: 0, 0), and PVB (median: 0; IQR: 0, 0) groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.77). There was a statistically significant difference in tramadol consumption among the RIB (median: 0; IQR: 0, 100), SAPB (median: 0; IQR: 0, 100), and PVB (median: 0; IQR: 0,0) groups at 24 hours postsurgery(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046). A comparison of each group revealed that the postoperative 24 hours consumption of tramadol was significantly lower in the PVB group than in the SAPB group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.041), and there was no statistically significant difference in postoperative 24 hours tramadol consumption between the SPAB and PVB groups than in the RIB group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.334 and 1). The only one patient used morphine(5mg) at postoperative 24 hours, we did not perform statistical analyses. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the tramadol consumption.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAdverse events\u003c/h2\u003e \u003cp\u003eThere were no significant differences between RIB, SAPB, or PVB in the incidence of intraoperative hypotension, arrhythmia, or bradycardia. There were no significant differences among the three groups in terms of the time to extubation, PONV, or average length of stay. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the incidence of adverse events.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, we found that postoperative 24-hour QoR-40 scores were significantly higher in the RIB and PVB groups than in the SAPB group. In addition, post-extubation NRS scores for the number of patients requiring sufentanil intraoperatively and, intraoperative sufentanil consumption were significantly lower in the RIB and PVB groups than in the SAPB group. Furthermore, there were no significant differences in the QoR-40 scores, analgesic medication consumption, or postoperative NRS scores between the RIB and PVB groups. There was no significant difference in the NRS score among the three groups at 2 h, 24 h, or 48 h after surgery. We did not find any adverse events associated with RIB, PVB, or SAPB.\u003c/p\u003e \u003cp\u003eThe breast is innervated by the lateral and anterior cutaneous branches of the second to sixth thoracic intercostal nerve branches and several branches of the supraclavicular nerve[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The SAPB is one of the most common interfacial blocks and is superficial and easy to perform. SAPB relieves postoperative pain and benefits patient recovery after breast surgery[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A meta-analysis by Chong et al. revealed that SAPB provides significant analgesia and reduces opioid consumption in patients undergoing breast cancer surgery. Nevertheless, the analgesic effect of SAPB is inferior to that of PVB[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our study reached similar conclusions. Compared with PVB, SAPB was associated with significantly lower QoR-40 scores at 24 hours postoperatively, higher NRS scores, and increased intraoperative sufentanil consumption. SAPB is performed by blocking the lateral cutaneous branches of the intercostal nerve, which provides analgesia to the anteromedial and partial posterior thoracic wall (T2-T9) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, the anterior branch of the intercostal nerve provides innervation to the anteromedial chest wall, and it is unlikely that the SAPB adequately covers this area[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This may result in incomplete relief of pain from the medial breast wound and cause significant pain and discomfort.\u003c/p\u003e \u003cp\u003eThe RIB, as first described by Elsharkawy et al. in 2016[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], has been demonstrated to facilitate the spread of dye from caudad to cephalad, encompassing the T2 to T8 tissue plane and extending to the lateral branches of the intercostal nerves T3 to T8, the posterior primary rami close to the midline, and the clavipectoral fascia within the axilla[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, RIB can provide superior analgesia for axillary surgery. Some studies have shown that RIB improves the QoR-40 score and reduces the postoperative pain score and the consumption of opioids[\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Our study revealed that RIB produced similar QoR-40 scores, postoperative pain scores, and analgesic consumption as PVB did. Jiang et al. compared the effects of RIB, SAPB, and ESPB on analgesia in breast cancer surgery and reported that the analgesic effects of RIB and ESPB were superior to those of SAPB[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Our study revealed that the analgesic effect of RIB was superior to that of SAPB. The RIB is in the posterior chest wall and is superficial, easily localized via ultrasound, and distant from the surgical site. Therefore, it may be an optimal alternative to PVB for an interfacial block.\u003c/p\u003e \u003cp\u003e Our study is the first to perform ultrasound-guided nerve blocks for preoperative comparison of the efficacy of RIB, PVB, and SAPB in providing intraoperative analgesia. A single nerve block was performed, with additional sufentanil administered based on the patient's requirements. Approximately 13% of patients who underwent RIB and PVB required additional intraoperative sufentanil, whereas 40.9% of those who underwent SAPB required additional sufentanil. Therefore, RIB and PVB have the potential to reduce the total amount of intraoperative opioids required and provide an effective analgesic strategy for opioid-free anesthesia. We found fewer patients with postoperative pain greater than 4 in all three groups, indicating that nerve blocks are effective in reducing postoperative pain. Only 1 patient required morphine 24 hours postoperatively. Therefore, PVB was associated with significantly lower tramadol consumption than SAPB was, but RIB was not significantly different from PVB or SAPB at 24 hours postoperatively. We did not use PCA for postoperative analgesia, and postoperative tramadol consumption may be subject to patient and doctor intervention. A single nerve block does not provide continuous analgesia and may result in a burst of pain. Consequently, there was no significant difference in pain scores among the three groups after 2 hours. There were differences in the QoR-40 scores among the three groups, which were due mainly to differences in patient comfort and pain scores 24 hours after surgery. We did not find any nerve block-related complications, indicating that ultrasound-mediated RIB, SAPB, and PVB are safe and effective nerve blocks.\u003c/p\u003e \u003cp\u003eOur study had several limitations: First, our study revealed statistically significant differences in only the QoR-40 scores and analgesic effects among the three groups but did not reveal clinical differences. Second, our study used nerve blocks selected based on a previous network analysis and did not compare the analgesic effects of the other nerve blocks with those of the RIB. Third, postoperative tramadol consumption may be subject to human error. Fourth, we observed only QoR-40 scores at 24 hours postoperatively and did not observe long-term QoR-40 scores or the incidence of chronic pain. Fifth, we used the Chinese version of the QoR-40, which may have impacted the results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the current study, RIB and PVB were superior to SAPB in terms of the quality of recovery and perioperative analgesia in patients undergoing breast surgery. In addition, RIB and PVB significantly reduced NRS scores after extubation. There was no significant difference between RIB and PVB in terms of the quality of recovery and analgesia indicating that RIB may be an optimal alternative nerve block to PVB.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDisclosure\u003c/h2\u003e \u003cp\u003eNo potential conflict of interest relevant to this article was reported.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by Technology innovation and application development project in Chongqing Shapingba District (No. 2023114), the Key R \u0026amp; D project of Chongqing Science and Technology Bureau (No. cstc2020jscx‑dxwtBX0010) and the Key R \u0026amp; D project of the Ministry of Science and Technology of China (No: 2018YFC0116704).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJL Yu: Data curation, Visualization, Investigation, Writing \u0026ndash; original draft. Y Qi: Data curation, Methodology, Formal analysis, Software, Writing \u0026ndash; original draft. D Wang: Validation, Methodology, Formal analysis. Q Chen: Software, Validation, writing-original draft. R An: Conceptualization, Funding acquisition, Methodology, Writing-review\u0026amp; editing. HL Liu: Conceptualization, Methodology, Supervision, Writing-review\u0026amp; editing. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eTo original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSiegel RL, Miller KD, Wagle NS, Jemal A: Cancer statistics, 2023. CA: a cancer journal for clinicians 2023, 73(1):17\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLei S, Zheng R, Zhang S, Wang S, Chen R, Sun K, Zeng H, Zhou J, Wei W: Global patterns of breast cancer incidence and mortality: A population-based cancer registry data analysis from 2000 to 2020. Cancer communications (London, England) 2021, 41(11):1183\u0026ndash;1194.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFecho K, Miller NR, Merritt SA, Klauber-Demore N, Hultman CS, Blau WS: Acute and persistent postoperative pain after breast surgery. Pain medicine (Malden, Mass) 2009, 10(4):708\u0026ndash;715.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAn R, Wang D, Liang XL, Chen Q, Pang QY, Liu HL: The postoperative analgesic efficacy of different regional anesthesia techniques in breast cancer surgery: A network meta-analysis. 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Eplasty 2015, 15:e28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu NQ, He QQ, Qian L, Zhu JH: Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Postoperative Analgesia in Patients Undergoing Breast Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. \u003cem\u003ePain research \u0026amp; management\u003c/em\u003e 2021, 2021:7849623.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeng J, Zhao HY, Zhuo XJ, Shen QH: Postoperative Analgesic Effects of Serratus Anterior Plane Block for Thoracic and Breast Surgery: A Meta-analysis of Randomized Controlled Trials. 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European journal of anaesthesiology 2023, 40(9):652\u0026ndash;659.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCiftci B, Ekinci M, Basim P, Celik EC, Tukac IC, Zenciroglu M, Atalay YO: Comparison of Ultrasound-Guided Type-II Pectoral Nerve Block and Rhomboid Intercostal Block for Pain Management Following Breast Cancer Surgery: A Randomized, Controlled Trial. Pain practice: the official journal of World Institute of Pain 2021, 21(6):638\u0026ndash;645.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang CW, Liu F, Zhou Q, Deng W: Comparison of rhomboid intercostal nerve block, erector spinae plane block and serratus plane block on analgesia for modified radical mastectomy: A prospective randomised controlled trial. International journal of clinical practice 2021, 75(10):e14539.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rhomboid intercostal nerve, Serratus anterior plane block, Paravertebral block, Quality of recovery, Postoperative pain, Breast cancer surgery","lastPublishedDoi":"10.21203/rs.3.rs-4905136/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4905136/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eNerve blocks are among the most important methods of postoperative analgesia in breast cancer surgery. We used a randomized controlled clinical trial to compare the effects of rhomboid intercostal nerve block (RIB), serratus anterior plane block (SAPB), and paravertebral block (PVB) on the postoperative quality of recovery and postoperative analgesia in modified radical mastectomy. A total of 132 breast cancer surgery patients were randomized 1:1:1 into three groups. 0.375% ropivacaine 20 ml for ultrasound-guided RIB (RIB group, n\u0026thinsp;=\u0026thinsp;44), SAPB (SAPB group, n\u0026thinsp;=\u0026thinsp;44), and PVB (PVB group, n\u0026thinsp;=\u0026thinsp;44). The primary outcome was the QoR-40 score at 24 hours after surgery. The postoperative 24-hour QoR-40 scores of the RIB (median: 186; interquartile range: 177, 190.5) and PVB (median: 186.5; interquartile range: 176.25, 190.5) groups were higher than those of the SAPB group (median: 168; interquartile range: 163.25, 172) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition, the intraoperative sufentanil consumption (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), number of intraoperative sufentanil users (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and postintubation NRS scores (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) of the RIB and PVB groups were significantly lower than those of the SAPB group, but there was no statistically significant difference between the RIB and PVB groups.\u003c/p\u003e \u003cp\u003eCompared with SAPB, RIB and PVB improve the quality of postoperative recovery, reduce intraoperative opioid use, and improve early postoperative analgesia. RIB may be one of the best alternatives to PVB as a facial plane block.\u003c/p\u003e","manuscriptTitle":"Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 05:24:42","doi":"10.21203/rs.3.rs-4905136/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"17457d93-bf2c-4787-bb28-d608ecc35667","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":37796441,"name":"Health sciences/Diseases/Cancer/Breast cancer"},{"id":37796442,"name":"Health sciences/Signs and symptoms/Pain"}],"tags":[],"updatedAt":"2025-01-20T05:38:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-15 05:24:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4905136","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4905136","identity":"rs-4905136","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}