Submitted: 08 April, 2022 Accepted: 01 June, 2022 Published: 08 May, 2023 DOI:10.22514/sv.2022.

064

REVIEW

Regional anesthesia for cardiothoracic surgery

Polona Gams1 , Juš Kšela2, *, Maja Šoštarič3

1
Department of Anesthesiology and Abstract
Intensive Care, Surgery Bitenc, 4204
Golnik, Slovenia
Cardiac and thoracic surgery have been connected to high perioperative opioid use for
2
Clinical Department of Cardiovascular a long time. With increasing knowledge of regional anesthesia in the thoracic region,
Surgery, University Medical Center thoracic nerve blocks have become supplemental methods of analgesia. As part of
Ljubljana, 1000 Ljubljana, Slovenia multimodal analgesia, they are important factors of enhanced recovery after surgery and
3
Clinical Department of Anesthesiology
and Intensive care, University Medical
contribute to a diminished opioid use. Myofascial nerve blocks are more superficial
Center Ljubljana, 1000 Ljubljana, than the classic thoracic epidural anesthesia or paravertebral block and are therefore
Slovenia safer for use in anticoagulated patients. In this article, we present a number of thoracic
blocks; the paraneuraxial paravertebral block; the myofascial plane blocks which are the
*Correspondence
[email protected]
retrolaminar block, the erector spinae plane block, the serratus anterior plane block, the
(Juš Kšela) pectoral nerves I and II block, the transversus thoracis plane block and the parasternal
intercostal nerve block; the perineural intercostal nerve block and also local anesthetic
infusion by a wound catheter. We conclude with local experience from a cardiac and
thoracic surgical center.

Keywords
Regional anesthesia; Cardiac anesthesia; Thoracic anesthesia; Nerve block; Pain
management

1. Introduction surgery includes shortening time to tracheal extubation and

hospital discharge [6, 7]. While the efficiency of truncal blocks
Regional anesthesia has found its place in cardiac and thoracic has already been proven in clinical studies, the optimal dosage,
surgery only in recent times. Cardiac and thoracic surgeries concentration and choice of the drugs used in specific truncal
have until recently been connected to high opioid consumption blocks are still investigated [8–10]. Another alternative anal-
with only thoracic epidural anesthesia as an alternative [1, gesic technique is the local wound infiltration with a catheter
2]. Providing adequate analgesia after cardiothoracic surgery after mini-sternotomies and mini-thoracotomies [11, 12]. This
is essential since postoperative complications often postpone article gives information about a variety of truncal blocks in
hospital discharge and are linked to higher morbidity and mor- cardiothoracic surgeries.
tality. Constant respiratory movement of the chest potentiates
the pain from thoracic drainage and the postoperative wound 2. Neuraxial block
[3]. Postoperative pain can contribute to complications, such
as pneumonia, pulmonary atelectasis, prolonged hospital stays Thoracic epidural anesthesia (TEA) has long been the golden
and chronic pain [4, 5]. The most common opioid side effects standard for thoracic surgeries due to its high efficiency [13].
such as respiratory depression, lethargy, nausea, constipation On the other hand, it is very invasive and it causes unwanted
and pruritus also contribute to postoperative complications. arterial hypotension by sympathetic block. As for cardiac
Nowadays, multimodal analgesic techniques are gaining pop- anesthesia, the use of TEA is still controversial because of con-
ularity in a desire to reduce the use of opioids. comitant anticoagulant use and the risk of epidural hematoma
Regional anesthetic techniques emerged with the develop- [14]. TEA reduces the risk of perioperative myocardial in-
ment of ultrasound, awareness of the opioid side effects and farction, respiratory depression and atrial arrhythmias when
their potential long-term abuse. Ultrasound-guided interven- used for cardiac surgery [15, 16]. In a large meta-analysis,
tions enable more exact injection of the local anesthetics to researchers compared the risks and benefits of cardiothoracic
desired locations with fewer complications, which results in TEA from 66 randomized studies. They concluded it provides
more efficient pain relief. The golden standard, which used excellent analgesia for cardio-thoracic surgery with a reduction
to be thoracic epidural anesthesia, is now accompanied by in mortality (number needed to treat (NNT) = 70). No cases of
thoracic wall blocks (Fig. 1). They can reduce the total post- epidural hematoma have been reported [17].
operative opioid consumption and contribute to faster recovery To reduce the risk of epidural hematoma, TEA must be
after surgery. Fast track recovery after cardiac and thoracic administered at least 18 hours prior cardiac surgery. When

This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

Signa Vitae 2023 vol.19(3), 21-29 ©2023 The Author(s). Published by MRE Press. www.signavitae.com
22

surgery has statistically been evaluated at 1:1528 for epidural

and 1:3610 for spinal block. However, authors of the study
have not found any of these complications recorded [19].

3. Paraneuraxial block
According to the Italian VATS (Video-assisted thoracic
surgery) association, paravertebral block (PVB) is the first
choice of regional anesthesia in thoracic surgery, because
it provides a unilateral block and causes less hemodynamic
compromise in comparison to TEA [20]. Local anesthetic
is injected into the paravertebral space at one or more levels
(Fig. 2). Paravertebral space is wedge-shaped in transverse
cross-section and is limited by the bodies of thoracic vertebrae
and intervertebral foramina medially, the parietal pleura
anteriorly and by the transverse processes, head and neck of
the rib and the upper costotransverse ligament posteriorly.
Local anesthetic, injected into the paravertebral space, diffuses
medially into the epidural space, laterally into the intercostal
space and cranio-caudally to adjacent paravertebral spaces
[21]. The PVB causes sensory, motoric and sympathetic
block, depending on the volume and concentration of the
injected local anesthetic. Contraindications for PVB are
infection at the injection site, empyema or pleural tumor or a
tumor of the paravertebral space. Coagulation disorders are
F I G U R E 1. Thoracic myofascial plane blocks marked considered a relative contraindication. Specific complications
on a cross section of the thoracic wall. RLB—retrolaminar of the block are pleural punction and pneumothorax [22].
block, ESPB—erector spinae plane block, ICNB—intercostal Features of thoracic regional anesthetic techniques are listed
nerve block, SAPB—serratus anterior plane block, PECS— in Table 1.
pectoral nerves block, TTPB—transversus thoracis plane
block, PSIB—parasternal intercostal nerve block.

anticoagulants are continued in the postoperative period, the

epidural catheter can only be removed after a certain period of
time. The catheter can be removed 4 hours after discontinuing
therapeutical doses of non-fractioned heparin and the activated
partial thromboplastin time is at normal value. Non-fractioned
heparin infusion can be continued one hour after the catheter
removal. For low-molecular-weight (LMW) heparin, 18 hours
must pass from the last application before the epidural catheter
removal. LMW heparin can be continued in a preventive dose
6 hours after the catheter removal, whereas therapeutical doses
may only be administered 48 hours after the catheter removal
[18]. Authors believe the fear of neurologic complications F I G U R E 2. The paravertebral block. Legend: 1—m.
following TEA in cardiothoracic surgery is too high. TEA is trapezius, 2—m. rhomboideus, 3—m. erector spinae, TP—
safe when administered in a correct timeline with anticoagulant transverse process, P—pleura. The needle pathway is marked
drugs. Anesthesiologist should educate all the medical team yellow.
members for a better compliance with the chosen anesthetic
method. Several meta-analyses have shown that thoracic PVB may
Spinal anesthesia, on the other hand, has not found its be as effective as TEA for post-thoracotomy pain relief and
place in cardiothoracic surgery. In a large meta-analysis, is also associated with fewer complications. Yeung and col-
researchers concluded that spinal analgesia does not improve leagues executed a meta study of 14 studies with almost 700
perioperative morbidity or mortality in patients undergoing participants and proved that PVB reduced the risks of devel-
cardiac surgery. Clinicians avoid intrathecal administration of oping minor complications compared to TEA. PVB was as
local anesthetics or opioids because of the increased risk of effective as TEA in controlling acute pain. However, there
neuraxial hematoma formation, which can lead to paraplegia was no difference in 30-day mortality, major complications,
in patients receiving heparin during surgery. The risk of spinal or length of hospital stay [23]. In another meta-analysis of
hematoma because of central neuraxial anesthesia in cardiac 12 clinical trials, they concluded that thoracic PVB may be as
 23

TA B L E 1. Thoracic regional anesthetic techniques.

Regional Puncture site Local anesthetic spread Clinical use
anesthetic
technique
Thoracic Sagittal or parasagittal in the The epidural space approx. 6 The golden standard of analgesia for
epidural level Th6–7 levels around the puncture site, thoracotomy, (un)wanted bilateral
anesthesia spreading 1:2 cranio-caudal sympathetic and sensory block,
(TEA) hypotension, greater fluid requirements,
specific anticoagulation precautions
Paravertebral One or more puncture sites Paravertebral space First choice for VATS surgeries; pleural
block (PVB) parasagittal in the level of puncture is a possible complication
operative wound
Erector spinae Above the transverse process of Myofascial plane between the One of the safest and most efficient
plane block vertebrae Th4–5 erector spinae muscle and thoracic plane blocks in alternative to
(ESPB) lateral process of the thoracic TEA with the puncture site far from
vertebrae pleura, lungs or spinal cord. Safe for use
in anticoagulated patients.
Retrolaminar Multiple puncture sites above Myofascial plane between Less efficient than ESPB, lack of RCTs
block (RLB) the thoracic lamina, 1 cm thoracic lamina and
parasagittal paraspinous muscles
Serratus Midaxillary in the level of the Above for the superficial and Most suitable for anterior thoracotomy, rib
anterior plane 5th rib below for the deep block fracture or breast surgery
block (SAPB)
Pectoral PECS I between the pectoralis PECS I: medial and lateral Most suitable for breast surgery,
nerves block major and minor muscles, US pectoral nerves between the pacemaker or implantable
landmark is the pectoral branch pectoralis major and minor cardioverter-defibrillator insertion
of the thoracoacromial artery; muscles, PECS II also under
an additional lateral injection at the pectoralis minor muscle
the anterior axillary line at the (between the clavipectoral
level of the fourth rib between fascia and the superficial border
the pectoralis minor and the of the serratus muscle)
serratus anterior muscle for
PECS II
Transversus Parasagittal medial to the Myofascial plane between the Sternotomy, sternal fractures, medial
thoracis plane mid-clavicular line over the 3rd transversus thoracis muscle and coverage for breast surgery or for tunneled
block (TTPB) and 4th rib, needle tip located the internal intercostal muscles pacemaker or implantable
parasternal to block the anterior branches cardioverter-defibrillator insertion
of Th2–Th6 intercostal nerves
Parasternal 2 cm lateral to the midline in Between the pectoral major and Median sternotomy
intercostal the 3rd and 5th parasternal external intercostal muscles
nerve block intercostal spaces
(PSIB)
Intercostal Multiple injections Between the medial and For rib fractures, chest and upper
nerve block transcutaneous parasagittal innermost intercostal muscles abdominal surgery such as thoracotomy,
(ICNB) around the level of surgical mastectomy or gastrostomy
incision or intrathoracic by the
surgeon
Th—thoracic, RCT—randomized controlled trial, US—ultrasound, VATS—video-assisted thoracic surgery, PECS —pectoral
nerves block.

effective as TEA for post-thoracotomy pain relief with a visual showed that the numerical rating scale (NRS) score for resting
analogue pain score (VAS) on activity at 48 h significantly pain was higher in the thoracic paravertebral block (TPVB)
better in the PVB group. They also reported less hypotension group than in the TEA group at 1–2 hours and 4–6 hours after
and urinary retention in the PVB group [24]. On the other hand, surgery. Giving a closer look, the difference is statistically
a meta-analysis of 5 studies involving thoracoscopic surgeries significant, but clinically irrelevant (mean difference (MD) =
24

0.44, 95% coincidence interval (CI) = 0.24 to 0.64, p < 0.0001, patients [37]. In a meta-analysis from 2020 which included 14
I2 = 0%; MD = 0.47, 95% CI = 0.23 to 0.70, p < 0.0001, I2 = studies, they proved a significant reduction in opioid consump-
0%) [25]. tion, smaller pain scores and less post operative nausea and
Bilateral PVB for cardiac surgery was researched by El vomiting (PONV) in patients with ESPB compared to those
Shora and colleagues, who proved its analgesic efficiency for without regional anesthesia for thoracic surgery [38]. Bilateral
median sternotomy. 140 patients were divided into groups ESPB with a catheter is a comparable method to TEA for
receiving either PVB or TEA. No statistically significant dif- patients undergoing cardiac surgery, with similar results not
ference in VAS was measured at 12, 24, and 48 hours post only regarding pain scores, but also postoperative incentive
operation, rendering the PVB comparable but not superior to spirometry, ventilator-dependency duration and intensive care
TEA [26]. unit length of stay [39].

4. Thoracic myofascial plane blocks

4.1 Retrolaminar block
For the retrolaminar block (RLB), local anesthetic is injected
between the lamina of thoracic vertebrae and paraspinal mus-
cles, approximately 1 cm lateral to the sagittal plane (Fig. 3).
For a better block efficiency, a large volume must be injected,
that is at least 30 mL [27]. Cranio-caudal spread is limited
to 2–4 segments and the transverse spread to approx. 2.5
cm. The main action site is the interfascial plane, where it
blocks the lateral cutaneous branches of the intercostal nerves.
Its spread often excludes the paravertebral space, so it does
not block the spinal nerves [28, 29]. The utility of the RLB
was described only in case reports, while large randomized
prospective clinical studies are still missing. In a retrospective
analysis, they compared the analgesic efficacy of continuous
RLB compared to TEA for VATS marginal lung resection. F I G U R E 3. The retrolaminar block. 1—m. trapezius,
They proved comparable analgetic efficacy, post-operative 2—m. rhomboideus, SP—spinous process, TP—transverse
pain scores and similar use of rescue analgesia in comparison process. The needle pathway is marked yellow.
to TEA [30]. However, not all studies are in favor of the RLB.
In a prospective study of patients undergoing minor VATS
procedures, they described the RLB as inferior compared to
PVB [31].
Bilateral thoracic RLB was used for pediatric open cardiac
surgery via median sternotomy in a study by Abdelbaser,
where they confirmed a significantly smaller postoperative
opioid consumption compared to the placebo group [32].

4.2 Erector spinae plane block

The erector spinae plane block (ESPB) was initially described
as rescue analgesia for serial rib fracture [33]. Its use later
spread to surgeries that involve the chest wall [34]. ESPB
can be used as a single shot or continually with a catheter.
Local anesthetic is injected into the myofascial layer between
the erector spinae muscle and the lamina of thoracic vertebrae
on the level Th4 or Th5 (Fig. 4). Local anesthetic diffuses into
the paravertebral space, where it blocks the dorsal and ventral
branches of thoracic spinal nerves, lateral branches of spinal F I G U R E 4. The erector spinae plane block. Legend:
nerves that innervate the skin and communicant branches that 1—m. trapezius, 2—m. rhomboideus, 3—m. erector spinae,
innervate the sympathetic chain [35]. ESPB blocks multiple TP—transverse process, P—pleura. The needle pathway is
levels with a single injection as the local anesthetic spreads marked yellow.
cranio-caudally, usually from Th2 to Th9 or even C7 to Th10,
depending on the volume of injectate and the level of injection
site [36]. The main advantage of the ESPB is its safety profile,
4.3 Serratus anterior plane block
because the injection site is far from the spinal cord, pleura
and lungs. If an inadvertent vascular puncture occurs, the site Serratus anterior plane block (SAPB) has emerged as a regional
can be locally compressed, so it is safe to use in anticoagulated anesthetic technique for surgery on the anterolateral wall of the
 25

chest, including breast surgery [40, 41]. Local anesthetic is compared to systemic analgesia alone; it also offers anal-
injected under serratus anterior muscle for the deep or above gesic benefits non-inferior to those of PVB after breast cancer
the same muscle for the superficial block. Studies comparing surgery. Evidence supports incorporating PECS II as an alter-
the deep and the superficial block showed superiority of the native to PVB for breast cancer surgery [48].
latter, that lasts longer and has a higher success rate [42]. The It is also a useful anesthetic method for the implantation of
needle insertion site is at the level of 5th intercostal space, cardiovascular electronic devices, such as pacemakers or im-
residing in the mid-axillary line (Fig. 5). The SAPB blocks plantable cardioverter-defibrillators [49]. Large meta-analyses
the lateral cutaneous branches of the intercostal nerves from of the method for major cardiac surgeries are still missing.
Th2 to Th7–9. According to cadaveric studies, the local A study comparing bilateral PECS II block with intravenous
anesthetic also spreads to n. pectoralis lateralis and medialis, analgesia only for coronary artery bypass grafting surgeries
n. thoracicus longus and n. thoracodorsalis (Fig. 6). A greater or coronary valve surgeries via median sternotomy showed
block area is connected to larger injected volumes, up to 40 mL that pain scores evaluated at rest and cough were substantially
of local anesthetic [43]. lower in the PECS group at times 0, 3, 6, 12, and 18 hours from
The use of SAPB after thoracic surgery was researched in extubation [50].
a meta-analysis of 8 studies. They discovered a statistically
significant reduction in pain levels and reduced opioid use than 4.5 Transversus thoracis plane block
in the control group without regional anesthesia, which also
The transversus thoracis plane block (TTPB) is a regional anes-
experienced more PONV [44]. The use of continuous deep
thetic method for relieving post-sternotomy pain. The local
SAPB was investigated by Toscano et al. [45], who confirmed
anesthetic is administered as a single shot into the myofascial
its analgesic and opioid sparing effect in patients undergoing
plane between the transversus thoracis muscle and the internal
mini-thoracotomy mitral valve replacement.
intercostal muscles in order to block the anterior branches of
Th2–Th6 intercostal nerves [51–53].
A study by Shokri et al. [54] compared cardiac surgery
patients receiving bilateral TTPB with those receiving general
anesthesia only. In the first 24 hours after surgery, they
found that the proportion of patients needing extra opioid
analgetic doses, total postoperative opioid demand and pain
scores were substantially lower in the group which received
TTPB than in the comparative group with general anesthesia
only. Ventilation time and intensive care unit stay in the TTPB
group were substantially shorter. Between the study groups,
they found no distinctive differences in postoperative com-
plications. Abdelbaser and colleagues studied the analgesic
potency of TTPB when used in pediatric cardiac surgery. They
discovered its use decreased perioperative opioid consumption
and reduced postoperative pain intensity in comparison to
general anesthesia only [55].
F I G U R E 5. The serratus anterior plane block. P—
pleura. The needle pathway is marked yellow. 4.6 Parasternal intercostal nerve block
Parasternal intercostal nerve block (PSIB) targets the anterior
and posterior intercostal nerves that reside on the inferior side
4.4 Pectoral nerves block
of each rib lateral to the sternum (Fig. 7). The technique is typ-
The pectoral nerves (PECS) block was initially described for ically performed by the surgeon at the time of sternal closure
postoperative anesthesia in breast surgery [46]. The PECS by multiple injections of local anesthetic into the parasternal
block is divided into two different nerve blocks. The PECS I intercostal spaces between the pectoral major and external
targets the medial and lateral pectoral nerves. Local anesthetic intercostal muscles, but can also be performed pre-operatively
is injected between the pectoralis major and minor muscles. under ultrasound guidance [15].
The main landmarks to identify the point of injection under Preoperative PSIB was studied for use in coronary artery
ultrasound guidance are the pectoralis major and pectoralis bypass grafting via median sternotomy. The PSIB reduced
minor muscles with the pectoral branch of the thoracoacromial the maximum concentrations of remifentanil and propofol re-
artery. With an additional lateral injection at the anterior quired to maintain hemodynamic stability and depth of anes-
axillary line on the level of the fourth rib between the pectoralis thesia during sternotomy [56]. PSIB was also studied for
minor and the serratus anterior muscle, the PECS II also blocks postoperative analgesia in pediatric patients undergoing car-
upper intercostal nerves, as well as the long thoracic nerve and diac surgery. Time to extubation was significantly lower in
the intercostobrachial nerve [47]. patients who were administered the PSIB with ropivacaine
A meta-analysis of PECS II as analgesia for breast cancer than in the control group. The pain scores were lower in
surgery showed that it reduces pain intensity and morphine the PSIB group with a significantly lower cumulative fentanyl
consumption during the first 24 hours postoperatively when dose requirement over a 24-hour period [57].
26

F I G U R E 6. Comparison of block dermatomal coverage between the erector spinae plane block and the serratus anterior
plane block. ESPB—erector spinae plane block, SAPB—serratus anterior plane block.

A study evaluated the effectiveness of ultrasound-guided 5. Perineural block

parasternal intercostal nerve block for postoperative analge-
sia in patients undergoing median sternotomy for mediastinal The intercostal nerve block (ICNB) is performed under ul-
mass resection. They applied local anesthetic in the 3rd and trasound guidance preoperatively by the anesthesiologist or
5th parasternal intercostal spaces bilaterally. The PSIB group at the end of the surgery by the surgeon, when the operative
required 20% less sufentanil added by the patient-controlled field yields access to the intrathoracic injection site. Local
analgesia (PCA) pump compared to the control group and anesthetic is injected in multiple levels paravertebral between
reported lower pain scores in rest and cough 24 hours after the internal and innermost intercostal muscles. 3–5 mL of
surgery [58]. anesthetic is sufficient for each level unilaterally. Contraindi-
cation for the ICNB is infection at the injection site, which also
includes empyema [59–61].
In a meta-analysis of 59 studies, the single shot ICNB
was associated with a reduction of pain during the first 24
hours after thoracic surgery and was clinically non-inferior
to TEA or PVB. However, TEA and PVB were associated
to larger decreases in postoperative opioid use, suggesting
that ICNB may be most beneficial for cases where TEA and
PVB are contraindicated [62]. In a study comparing regional
anesthetic methods for cardiac surgery via thoracotomy, ICNB
was declared inferior to PECS II and SAPB blocks [63].

6. Local anesthesia through a wound

catheter

Local anesthetic, delivered through a wound catheter is a

successful method of postoperative analgesia in most surgical
fields. Nevertheless, it has produced mixed results in car-
diac surgery when used after full sternotomy. In a study by
Mijovski et al. [64], the effectiveness of 0.2% ropivacaine
wound infusion through a catheter delivered by PCA pump was
F I G U R E 7. Anterior and lateral chest wall plane blocks. investigated in 70 patients for mini-thoracotomy aortic valve
PECS I/II—pectoralis nerves block, PSIB—parasternal in- replacement. The cumulative dose of the opioid needed in
the first 48 hour after surgery was significantly lower in the
tercostal nerve block, SAPB—serratus anterior plane block,
group receiving local anesthetic compared to placebo. They
TTPB—transversus thoracis plane block.
reported high patient satisfaction regarding pain relief and
there were no infections of the wound or local anesthetic toxic
 27

side effects. A similar study by Dowling et al. [65] confirmed AVA ILABILITY OF DATA AND MATERIALS
that continuous infusion of local anesthetics improved postop-
Not applicable.
erative pain control while lowering the total opioid analgesia
required in patients who underwent full median sternotomy.
In another study by Agarwal et al. [66], the data safety A UTHOR CONTRIBUTIONS
monitoring board stopped the study after enrolling 85 patients
because of excessive sternal wound infections (9%, n = 44) PG—designed the article and wrote the original draft. JK—
in the ropivacaine group. It is unclear why they provided contributed to the initial concept and article design. MŠ—
contradictory results. contributed to the initial concept, supported the process and
As for thoracic surgery patients, Fiorelli et al. [12] investi- provided expert supervision. All authors reviewed, edited and
gated the effects of local anesthetic through a wound catheter approved the final manuscript.
in patients undergoing muscle-sparing thoracotomy and lung
cancer resection. The local anesthetic group compared with
E THICS APPROVAL AND CONSENT TO
the control (placebo) group had a significant reduction of
postoperative interleukin-6, interleukin-10 and tumor necrosis PA R TICIPATE
factor alpha blood concentration levels, lower pain scores, Not applicable.
and a decrease of additional morphine intake during the entire
postoperative course. Spirometry results, such as the recovery
of the flow expiratory volume in one second % and the forced ACK NOWLEDGMENT
vital capacity % were also reported better in the research than
We would like to thank the researchers conducting all the
in the placebo group.
studies mentioned in the article for exploring the world of
thoracic regional anesthesia.
7. Institutional experience
Anesthesiologists, intensivists and cardiac surgeons at the Uni- F UNDING
versity medical center Ljubljana Cardiovascular surgery de-
partment collaborate in the local anesthetic wound infusion This research received no external funding.
protocol. Patients, undergoing mini sternotomy, receive the
local anesthetic via a pre-programmed PCA pump without a
continuous opioid infusion. In the occasion of breakthrough CONFLICT OF INTEREST
pain, the patients receive a bolus of piritramide. They report The authors declare no conflict of interest.
high patient satisfaction and low opioid consumption [64].
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