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PECS 1 and PECS 2 Blocks
Rafael Vazquez, MD; Nicole Z. Spence, MD
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KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Abbreviations

            • Brachial plexus (BP)
            • Lateral pectoral nerve (LPN)
            • Medial pectoral nerve (MPN)
            • Pectoralis major muscle (PMM)
            • Pectoralis minor muscle (PmM)
            • Intercostobrachial nerve (ICBN)
            • Long thoracic nerve (LTN)
            • Serratus anterior muscle (SAM)
          • Synonyms

            • Pectoral nerve block
            • PECS 1 block; PECS 2 block
          • Definitions

            • PECS 1: Fascial plane block of anterior chest wall targeting LPN and branches of MPN
              • Provides somatic analgesia to anterolateral chest wall
              • LPN originates from lateral cord of BP (C5, C6, C7) or from anterior divisions of upper and middle trunks of BP
              • In chest wall, LPN passes across axillary artery and vein, pierces clavipectoral (coracoclavicular) fascia, and courses over PmM to split into several branches that innervate lateral portion of PMM
              • LPN is located adjacent to pectoral branch of thoracoacromial artery (landmark for block)
              • Branches of MPN pierce PmM and innervate medial portion of PMM
            • Modified PECS 1 a.k.a. PECS 2: Extended PECS 1 block that also covers ICBN, LTN, lateral cutaneous branches of intercostal nerves (T2-T6)
              • Provides somatic analgesia to anterolateral chest wall, including axilla
              • MPN arises from medial cord (C8-T1) and sometimes directly from anterior division of inferior trunk of BP
              • MPN pierces chest wall, then enters deep surface of PmM, where it divides into number of branches that supply muscle; branches pierce through muscle and into sternocostal head of PMM; MPN pierces both PmM and sternocostal head of PMM
              • ICBN originates as lateral cutaneous branch of T2 intercostal nerve and innervates axilla and cutaneous medial arm and courses through 2nd intercostal space and exits at lateral chest wall, piercing intercostal muscles and SAM and traveling into medial upper arm to provide sensation to axilla and medial arm
              • LTN originates from trunk of BP (C5, C6, C7), innervates SAM and provides sensation to lateral wall, and courses over SAM at midaxillary line adjacent to lateral thoracic vessels
                • Anesthetizing LTN causes anesthesia of SAM and consequential winged scapula for duration of local anesthetic

          PREPROCEDURE

          • Indications

            • Contraindications

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Equipment Preparation

                    • Procedure Steps

                      • Findings and Reporting

                        • Alternative Procedures/Therapies

                          POST PROCEDURE

                          • Expected Outcome

                            • Things to Do

                              • Things to Avoid

                                OUTCOMES

                                • Problems

                                  • Complications

                                    Selected References

                                    1. SoberĂ³n JR Jr et al: Novel use of the pecs II block in major vascular surgery: a case report. A A Pract. 13(4):145-7, 2019
                                    2. Goswami S et al: Pectoral nerve block1 versus modified pectoral nerve block2 for postoperative pain relief in patients undergoing modified radical mastectomy: a randomized clinical trial. Br J Anaesth. 119(4):830-5, 2017
                                    3. Henry BM et al: Origin, branching, and communications of the intercostobrachial nerve: a meta-analysis with implications for mastectomy and axillary lymph node dissection in breast cancer. Cureus. 9(3):e1101, 2017
                                    4. Fusco P et al: The association between the ultrasound-guided serratus plane block and PECS I block can represent a valid alternative to conventional anesthesia in breast surgery in a seriously ill patient. Minerva Anestesiol. 82(2):241-2, 2016
                                    5. Kikuchi M et al: [Difference in the spread of injectate between ultrasound guided pectoral nerve block I and II. a cadaver study.] Masui. 65(3):314-7, 2016
                                    6. Kulhari S et al: Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial. Br J Anaesth. 117(3):382-6, 2016
                                    7. Bouzinac A et al: Bilateral association of pecs I block and serratus plane block for postoperative analgesia after double modified radical mastectomy. Minerva Anestesiol. 81(5):589-90, 2015
                                    8. Fujiwara S et al: Pectral nerve blocks and serratus-intercostal plane block for intractable postthoracotomy syndrome. J Clin Anesth. 27(3):275-6, 2015
                                    9. Fujiwara A et al: Pectoral nerves (PECS) and intercostal nerve block for cardiac resynchronization therapy device implantation. Springerplus. 3:409, 2014
                                    10. Leiman D et al: Medial and lateral pectoral nerve block with liposomal bupivacaine for the management of postsurgical pain after submuscular breast augmentation. Plast Reconstr Surg Glob Open. 2(12):e282, 2014
                                    11. Purcell N et al: Novel use of the PECS II block for upper limb fistula surgery. Anaesthesia. 69(11):1294, 2014
                                    12. Blanco R: The 'pecs block': a novel technique for providing analgesia after breast surgery. Anaesthesia. 66(9):847-8, 2011
                                    13. Evans SR et al: Surgical Pitfalls: Prevention and Management. Philadelphia, PA: Saunders/Elsevier. 475-87, 2009
                                    14. Bertelli JA et al: Long thoracic nerve: anatomy and functional assessment. J Bone Joint Surg Am. 87(5):993-8, 2005
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Procedure

                                        • Post Procedure

                                          • Outcomes

                                            TERMINOLOGY

                                            • Abbreviations

                                              • Brachial plexus (BP)
                                              • Lateral pectoral nerve (LPN)
                                              • Medial pectoral nerve (MPN)
                                              • Pectoralis major muscle (PMM)
                                              • Pectoralis minor muscle (PmM)
                                              • Intercostobrachial nerve (ICBN)
                                              • Long thoracic nerve (LTN)
                                              • Serratus anterior muscle (SAM)
                                            • Synonyms

                                              • Pectoral nerve block
                                              • PECS 1 block; PECS 2 block
                                            • Definitions

                                              • PECS 1: Fascial plane block of anterior chest wall targeting LPN and branches of MPN
                                                • Provides somatic analgesia to anterolateral chest wall
                                                • LPN originates from lateral cord of BP (C5, C6, C7) or from anterior divisions of upper and middle trunks of BP
                                                • In chest wall, LPN passes across axillary artery and vein, pierces clavipectoral (coracoclavicular) fascia, and courses over PmM to split into several branches that innervate lateral portion of PMM
                                                • LPN is located adjacent to pectoral branch of thoracoacromial artery (landmark for block)
                                                • Branches of MPN pierce PmM and innervate medial portion of PMM
                                              • Modified PECS 1 a.k.a. PECS 2: Extended PECS 1 block that also covers ICBN, LTN, lateral cutaneous branches of intercostal nerves (T2-T6)
                                                • Provides somatic analgesia to anterolateral chest wall, including axilla
                                                • MPN arises from medial cord (C8-T1) and sometimes directly from anterior division of inferior trunk of BP
                                                • MPN pierces chest wall, then enters deep surface of PmM, where it divides into number of branches that supply muscle; branches pierce through muscle and into sternocostal head of PMM; MPN pierces both PmM and sternocostal head of PMM
                                                • ICBN originates as lateral cutaneous branch of T2 intercostal nerve and innervates axilla and cutaneous medial arm and courses through 2nd intercostal space and exits at lateral chest wall, piercing intercostal muscles and SAM and traveling into medial upper arm to provide sensation to axilla and medial arm
                                                • LTN originates from trunk of BP (C5, C6, C7), innervates SAM and provides sensation to lateral wall, and courses over SAM at midaxillary line adjacent to lateral thoracic vessels
                                                  • Anesthetizing LTN causes anesthesia of SAM and consequential winged scapula for duration of local anesthetic

                                            PREPROCEDURE

                                            • Indications

                                              • Contraindications

                                                • Getting Started

                                                  PROCEDURE

                                                  • Patient Position/Location

                                                    • Equipment Preparation

                                                      • Procedure Steps

                                                        • Findings and Reporting

                                                          • Alternative Procedures/Therapies

                                                            POST PROCEDURE

                                                            • Expected Outcome

                                                              • Things to Do

                                                                • Things to Avoid

                                                                  OUTCOMES

                                                                  • Problems

                                                                    • Complications

                                                                      Selected References

                                                                      1. SoberĂ³n JR Jr et al: Novel use of the pecs II block in major vascular surgery: a case report. A A Pract. 13(4):145-7, 2019
                                                                      2. Goswami S et al: Pectoral nerve block1 versus modified pectoral nerve block2 for postoperative pain relief in patients undergoing modified radical mastectomy: a randomized clinical trial. Br J Anaesth. 119(4):830-5, 2017
                                                                      3. Henry BM et al: Origin, branching, and communications of the intercostobrachial nerve: a meta-analysis with implications for mastectomy and axillary lymph node dissection in breast cancer. Cureus. 9(3):e1101, 2017
                                                                      4. Fusco P et al: The association between the ultrasound-guided serratus plane block and PECS I block can represent a valid alternative to conventional anesthesia in breast surgery in a seriously ill patient. Minerva Anestesiol. 82(2):241-2, 2016
                                                                      5. Kikuchi M et al: [Difference in the spread of injectate between ultrasound guided pectoral nerve block I and II. a cadaver study.] Masui. 65(3):314-7, 2016
                                                                      6. Kulhari S et al: Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial. Br J Anaesth. 117(3):382-6, 2016
                                                                      7. Bouzinac A et al: Bilateral association of pecs I block and serratus plane block for postoperative analgesia after double modified radical mastectomy. Minerva Anestesiol. 81(5):589-90, 2015
                                                                      8. Fujiwara S et al: Pectral nerve blocks and serratus-intercostal plane block for intractable postthoracotomy syndrome. J Clin Anesth. 27(3):275-6, 2015
                                                                      9. Fujiwara A et al: Pectoral nerves (PECS) and intercostal nerve block for cardiac resynchronization therapy device implantation. Springerplus. 3:409, 2014
                                                                      10. Leiman D et al: Medial and lateral pectoral nerve block with liposomal bupivacaine for the management of postsurgical pain after submuscular breast augmentation. Plast Reconstr Surg Glob Open. 2(12):e282, 2014
                                                                      11. Purcell N et al: Novel use of the PECS II block for upper limb fistula surgery. Anaesthesia. 69(11):1294, 2014
                                                                      12. Blanco R: The 'pecs block': a novel technique for providing analgesia after breast surgery. Anaesthesia. 66(9):847-8, 2011
                                                                      13. Evans SR et al: Surgical Pitfalls: Prevention and Management. Philadelphia, PA: Saunders/Elsevier. 475-87, 2009
                                                                      14. Bertelli JA et al: Long thoracic nerve: anatomy and functional assessment. J Bone Joint Surg Am. 87(5):993-8, 2005