A new approach to pectoralis block

We read the interesting article by Blanco et al. regarding the ultrasonography of interfascial nerve block 1. Ultrasound-guided block of the lateral and medial pectoral nerves, also known as the ‘pecs’ block, is a recently introduced technique that may be useful in multimodal analgesia during breast surgery, and that may provide an alternative to paravertebral blocks or thoracic epidurals, although further clinical studies are still required to determine the efficacy of this block for breast surgery 1, 2. The block itself is easy to perform under sonographic guidance, and can be administered to awake and anaesthetised patients. In our practice, we use a different approach to that of Blanco et al. (Fig. 2). We place the ultrasound probe below the outer third of the clavicle, transverse to the axis of the body, identifying pectoralis major and minor muscles, the thoraco-acromial artery and cephalic vein, before introducing the needle in-plane from medial to lateral, staying as far from structures such as the pleura and blood vessels as possible. We have been performing this block in patients having both major and minor breast surgery in the last year, resulting in decreased systemic peri-operative analgesic requirements, and improved patient satisfaction. We believe that our approach has the following advantages compared with the coracoid level approach. Firstly, the insertion of the needle from medial to lateral reduces the likelihood of accidentally puncturing the acromiothoracic artery, cephalic vein or pleura. Secondly, needle insertion is not restricted by collision with bony structures. Thirdly, identification of the lateral border of pectoralis minor and the suspensory ligament of the axilla is easier than in Blanco et al.'s approach, in which contact with the coracoid process may hinder movement of the ultrasound probe laterally. Finally, placement of catheters between pectoralis major and minor, or within the suspensor ligament, could be feasible with our approach.