Alternative for Nerve Block?

I_Spy

I am scheduled for a PBMX in July. The nurse practitioner in the bs office told me about the paravertebral block done in the thoracic spine, in order to shut off feeling to the chest for like 72 hours and reduce the need for pain meds and increase comfort, etc. Ok so here is my problem: I have been dealing with an artery/vein issue in my spinal cord that was going to paralyze me (too complex to explain), and I had to have vascular neurosurgery to repair it. I am not really into someone who is not a neurosurgeon sticking a needle anywhere near my spinal cord. I am going to talk to my neurosurgeon about how he feels about it, but kind of regardless of what he says I'm feeling like "No, I'm good, don't stick needles near my spinal cord." Is there an alternative that anyone has had? When I had my hysterectomy in 2006 I got a Q-Ball in the incision for a week that had me feeling no pain (it was like morphine directly into the incision). Anyone else get something other than a nerve block or in addition to it?

SpecialK

Paravertebral block anesthetic is not the norm, or standard of care, for breast surgery- it's just that some surgeons and anesthesiologists like to use it. Just let them know you prefer to use regular general anesthetic and a different method of pain control. I did have a block for my surgery but the vast percentage who post here did not have it.

I_Spy

so you guys that had the nerve block -- it was instead of general anesthesia??

marketingmama

I had general (never knew there was an alternative). Doc also gave me Experel, which numbs the area for about 72 hours. I imagine it helped but I still needed standard pain meds (low threshold)

muska

I had both the so-called nerve block and general anesthesia. "Nerve block" is not a replacement for general anesthesia and is offered as an additional pain control. "Nerve block" is just a shot - or two shots, one on each side - but if I recall correctly it does not go near your spinal cord. It worked very well for me but if you don't want it you simply tell them you don't want it. That can be done during pre-op consult or call with the anesthesiology department.

I_Spy

Okay that makes sense. I have a pre-op appointment with anesthesia (but as I recall from my past surgery it was a useless appointment where they just did an EKG and made sure I could take a deep breath). I think I'll call my bs office and talk to the NP and ask about the Qball or Experell...

I_Spy

Very interesting kayb, thank you for posting that. Obviously 77 patients is not enough for a compelling study, as the physician mentioned in the article. But it makes sense that not having pain would increase the body's ability to heal and kill cancer cells. I was interested in this part:

However, Dr. Carlsson said anesthesiologists at his hospital now use a different postoperative pain relief system for cancer surgery. The ON-Q PainBuster (I-Flow Corp) system allows them to infuse local anesthetic into the surgical wound through a catheter with a balloon, which is left in place for 1 to 2 days. They switched techniques, he said, because "it is easier and safer than paravertebral block and achieves the same amount of pain relief."

I just do not want injections anywhere near my spine. Obviously it isn't supposed to go into the spinal cord, but sh** happens. In my case, An artery from the right side of my mid back leading into my spinal cord was bleeding out into a vein in my spinal cord. So the whole thoracic region of my back was effected, and I'm just too squeamish. So I'm going to call the bs on Monday and ask about the Qball. If I didn't have this (extremely rare) condition (btw it's called an acquired dural arterio-venous fistula, in case anyone is interested) I would have gone for the nerve block.

muska

Hi kayb, I don't think it has anything to do with the amount of general anesthesia one gets, it reduces immediate post-surgery pain. With that "blockade" shot you need very little pain control if any in the first 16 - 18 hours post surgery. As I said before, this is offered as an option and only if you want it.

Generally speaking BMX is not a difficult surgery in terms of recovery. Immediate reconstruction if you are having it makes it a bit more complicated but even so if you tolerate general anesthesia well enough you will be fine and able to function very quickly.

SpecialK

I definitely had both the block (by catheter like an epidural, not injections) and general anesthetic.  The rationale behind nerve block use is also that the body is quieter during surgery because there is no pain experience.  Even though you are anesthetized your body still experiences pain - and this is reflected by elevated vital signs.  My BS found that vitals stay more controlled with the block.  I would probably hesitate to use it if you have an existing co-morbidity, I would rely on traditional GA for this surgery.  Ask about Exparel, but know that not all doctors use it - it is a form of local pain control, like you get at the dentist.  Also, On-Q is not used universally - I was given oral pain meds post-surgically.

I_Spy

Okay SpecialK good to know. Also, while we're on the subject of regional anesthesia, I just found this warning letter sent to the makers of Exparel, wherein the FDA is warning them to stop advertising that Exparel is tested and approved for any surgery other than hemorrhoid and bunion surgery!

The efficacy of EXPAREL was compared to placebo in two multicenter, randomized, double-blinded clinical trials. One trial evaluated the treatments in patients undergoing bunionectomy; the other trial evaluated the treatments in patients undergoing hemorrhoidectomy. EXPAREL has not been demonstrated to be safe and effective in other procedures.

Here is the link to the pdf of the letter: http://www.fda.gov/downloads/Drugs/GuidanceComplia...

So it hasn't even been approved for breast surgery. It is true that doctors use drugs off label all the time, but this is just data for everyone.

I_Spy

ok kayb! I had a Qball as part of my hysterectomy surgery when it was still in clinical trial. It was awesome. When I had oopherectomy I didn't have one and owiiiieeeeeeeeeee it hurt after surgery. I'm calling bs office on Monday about the Qball for sure.

windingshores

I had the paravertebral block and general anesthesia for my single mastectomy. I am pretty sure that they did not intubate me with the anesthesia and kept it pretty light. Unfortunately they also gave me needless dilaudid after surgery and I had some episodes of vomiting. I am having another surgery to take off the other breast, and will make sure to say I don't want any pain meds. I had no pain the first week but the second and third were tough and I did use oxycodone once a day. The pain got better quickly though.

I had a great experience with the combination of block and GA, but understand the reluctance to have anything near your spine. I have a couple of thoracic vertebral fractures and was nervous about those until I read that the injection was not in the spine.

I_Spy

Also don't forget anti-nausea medication like zofran. I can't take any narcotic without zofran!

I_Spy

Yes, God bless zofran! Well, I called and spoke to the nurse practitioner for my bs, the way to get to the bs, and she asked me to send an email which she would forward (we have a website where we can send emails to our doctor). So I wrote in the email that I didn't want the nerve block, and asked if the doctor used On-Q, and I provided a link to a study saying the On-Q was effective in mastectomy surgeries. So the NP emails me back this morning: "Doctor says you don't have to have the nerve block." Gee, thanks for telling me I can refuse medical treatment, duh, but that wasn't my question. So I called the NP and said that wasn't my question, and after 10 minutes of wasted conversation got her to agree to ask doctor if she uses On-Q. The NP doesn't think she does, but I finally got it across that regardless of what the NP thinks, let's ask the doctor. She said she would. I am going to call the ps office tomorrow because I think the ps will be the one closing the incision, and that's when the On-Q is put in. So I will report back here with what I discover when I finally get my question answered by the doctor!

I_Spy

Ok Kay that is good to know!

I_Spy

Okay so this is what I have learned today, and it is a lot:

My neurosurgeon says not to worry at all about the nerve block. This was a message via his physician's assistant via text message, so I didn't get any nuances haha. But he said "not a concern at all". I still feel weird about having injections near my spine. Call me crazy, but when you've almost been a paraplegic, injections near your spine will seem intolerable.

My plastic surgeon, via the physician's assistant, says that she does not use the On-Q system and for a very interesting reason: it increases the chance of infection because the tubing is going into your body and is just one more chance for bacteria to enter your system. That makes total sense to me.

However, my ps did say that after I'm under general anesthesia, they can give me a "rib block" , which is an injection into the nerves of your ribs (on the front). So if I don't want the nerve block injection into my back, I can have it done into my front during surgery. She said that is what they used to do before paravertrebral nerve blocks. So I will now do research on that.

I mean, my NCI comprehensive cancer center has a regional anesthesia team that does pv nerve blocks all day long. So I am going to try to read up on it and handle myself on getting it, since my neurosurgeon is not concerned about it so why should I be, right? ugh.