Pain management after major oncological breast surgery: an updated systematic review and procedure specific postoperative pain management (PROSPECT) recommendations
In brief
Single-shot nerve blocks replace continuous paravertebral for breast surgery pain
Updated PROSPECT guidance for major oncologic breast surgery endorses paracetamol, NSAIDs or COX-2 inhibitors, dexamethasone and single-shot regional blocks-including erector spinae, interpectoral, serratus and paravertebral techniques-while dropping gabapentin and continuous paravertebral infusions. The recommendations stress that these one-time blocks provide adequate coverage of the acute pain peak, but equivalence among the various single-shot approaches remains unproven.
- Journal
- Anaesthesia (Q1)
- Published
- 12 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Neel Desai, Dan S Dirzu, Danaja Zolger, Desire N Adansi, Marc Van de Velde, Girish P Joshi
- PMID
- 42581686
- DOI
- 10.1111/anae.70313
Why clinicians should know about it
- Picked for Anesthesiology and Pain Medicine (top studies of the week, 16 August 2026): Updated PROSPECT recommendations for major oncological breast surgery analgesia
Abstract
INTRODUCTION: Major oncological breast surgery can be associated with significant postoperative pain. The aim of this systematic review was to update existing recommendations for postoperative pain management after major oncological breast surgery. METHODS: A systematic review was undertaken following PROcedure SPECific postoperative pain managemenT (PROSPECT) methodology. Randomised controlled trials and systematic reviews that investigated peri-operative analgesic, anaesthetic and surgical interventions were included. The evidence for these interventions was reviewed using a modified Delphi process for their invasiveness, efficacy, adverse effects and complications. RESULTS: In total, 176 randomised controlled trials and eight systematic reviews were included. Analgesia with paracetamol, nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors, and dexamethasone continues to be advocated. Given the occurrence of problematic adverse effects, gabapentin is no longer recommended. Single-shot erector spinae plane block; interpectoral plane and pectoserratus plane block; superficial serratus anterior plane block; deep serratus anterior plane block; thoracic paravertebral block; and local infiltration analgesia are recommended. We no longer recommend a continuous thoracic paravertebral block, as single-shot regional analgesic modalities are sufficient to cover the worst part of the acute pain trajectory. Physiotherapy in the pre-operative and postoperative period is recommended. No perineural adjuncts; specific surgical techniques; or complementary medicine therapies are recommended. DISCUSSION: The updated PROSPECT recommendations for pain management following major oncological breast surgery include pre- or intra- and postoperative administration of paracetamol; nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors; dexamethasone; single-shot regional analgesic techniques; and physiotherapy. The value of regional analgesic techniques is underlined, but the listed single-shot regional analgesic techniques are considered equivalent to each other.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.