Comparison of erector spinae plane, paravertebral, and pectoral nerve blocks on postoperative analgesia and Quality of Recovery-15 in patients undergoing mastectomy: a prospective randomized trial

BACKGROUND: Modified radical mastectomy (MRM) is frequently associated with moderate to severe postoperative pain, which may negatively affect recovery and quality of life. Regional anesthesia techniques such as the erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and pectoral nerve block (PECS) have been increasingly used as part of multimodal analgesia strategies for breast surgery. However, their comparative effects on analgesic efficacy and quality of recovery remain unclear. METHODS: The study included 90 female patients undergoing unilateral elective MRM. Patients were randomly allocated into three groups (n = 30 each) to receive ESPB, TPVB, or PECS block preoperatively with 0.25% bupivacaine. All patients subsequently underwent standardized general anesthesia. Postoperative pain was assessed using the Visual Analog Scale (VAS) at 0, 1, 3, 6, 12, and 24 h. The primary outcome was total morphine consumption at 24 h. Secondary outcomes included time to first morphine request, incidence of rescue fentanyl use, postoperative nausea and vomiting, patient satisfaction, and scores. RESULTS: Demographic characteristics and operative durations were comparable among the groups (p > 0.05). Total 24-hour morphine consumption was significantly higher in the ESPB group (median 10 mg) compared with TPVB (9 mg, p = 0.009) and PECS (9 mg, p = 0.018) groups. Kaplan-Meier analysis revealed that the time to first morphine request was significantly shorter in the ESPB group (p < 0.001), while TPVB provided the longest analgesic duration. No significant differences were found in postoperative pain scores, rescue opioid requirements, or nausea-vomiting incidence (p > 0.05). QoR-15 scores were significantly lower in the ESPB group compared with TPVB and PECS groups (p < 0.001). CONCLUSION: Both PECS and TPVB provided superior postoperative analgesia and better quality of recovery scores compared to ESPB in patients undergoing modified radical mastectomy. These findings support the use of PECS or TPVB as effective components of multimodal analgesia strategies for breast cancer surgery. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN17247698.