Hindawi

Pain Research and Management

Volume 2018, Article ID 4315931, 8 pages
https://doi.org/10.1155/2018/4315931

Clinical Study
Efficacy of Pectoral Nerve Block Type II for Breast-Conserving
Surgery and Sentinel Lymph Node Biopsy: A Prospective
Randomized Controlled Study

Doo-Hwan Kim ,1 Sooyoung Kim,1 Chan Sik Kim ,1 Sukyung Lee ,1 In-Gyu Lee ,1
Hee Jeong Kim ,2 Jong-Hyuk Lee ,1 Sung-Moon Jeong ,1 and Kyu Taek Choi1
1
Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, Republic of Korea
2
Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, Republic of Korea

Correspondence should be addressed to Jong-Hyuk Lee; [email protected]

Received 2 January 2018; Accepted 16 April 2018; Published 15 May 2018

Academic Editor: Jacob Ablin

Copyright © 2018 Doo-Hwan Kim et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Objectives. The pectoral nerve block type II (PECS II block) is widely used for postoperative analgesia after breast surgery. This
study evaluated the analgesic efficacy of PECS II block in patients undergoing breast-conserving surgery (BCS) and sentinel lymph
node biopsy (SNB). Methods. Patients were randomized to the control group (n � 40) and the PECS II group (n � 40). An
ultrasound-guided PECS II block was performed after induction of anesthesia. The primary outcome measure was opioid
consumption, and the secondary outcome was pain at the breast and axillary measured using the Numerical Rating Scale (NRS) 24
hours after surgery. Opioid requirement was assessed according to tumor location. Results. Opioid requirement was lower in the
PECS II than in the control group (43.8 ± 28.5 g versus 77.0 ± 41.9 g, p < 0.001). However, the frequency of rescue analgesics did
not differ between these groups. Opioid consumption in the PECS II group was significantly lower in patients with tumors in the
outer area than that in patients with tumors in the inner area (32.5 ± 23.0 g versus 58.0 ± 29.3 g, p � 0.007). The axillary NRS was
consistently lower through 24 hr in the PECS II group. Conclusion. Although the PECS II block seemed to reduce pain intensity
and opioid requirements for 24 h after BCS and SNB, these reductions may not be clinically significant. This trial is registered with
Clinical Research Information Service KCT0002509.

1. Introduction pain after breast cancer surgery, it is important to manage

postoperative pain in patients undergoing BCS and SNB [4].
Breast-conserving surgery (BCS) and sentinel lymph node A thoracic epidural block used to be regarded as the gold-
biopsy (SNB) are surgical methods designed to minimize standard method for managing postoperative pain after
intraoperative tissue injury, removing the cancer while breast surgery [5]. However, this technique is associated with
leaving intact as much of the breast as possible. Moreover, serious complications, including intrathecal spread, nerve
because long-term survival rates are similar in patients damage, epidural hematoma, and inadvertent intravascular
undergoing BCS and radical mastectomy [1], the combi- injection [6]. A recently introduced pectoral nerve block
nation of BCS and SNB has become the standard treatment type II (PECS II block) has been found to provide great pain
for patients with early-stage breast cancer [2]. relief and safety in patients undergoing radical mastectomy
Although BCS is minimally invasive surgery, it can lead [7, 8]. Therefore, we hypothesized that the PECS II block
to significant postoperative pain [3]. Because acute post- may effectively alleviate acute postoperative pain in patients
operative pain and BCS may be risk factors for persistent undergoing BCS and SNB. The present study evaluated the
2 Pain Research and Management

analgesic efficacy of PECS II block in patients undergoing e Ultrasound, GE Healthcare, USA) was positioned below
BCS and SNB. In addition, this study assessed the efficacy of the lateral third of the clavicle. The positions of the axillary
PECS II block according to breast cancer location and its artery and vein were confirmed, and the ultrasound probe
comparative effects on breast and axillary pain. was moved inferolaterally until the pectoralis major and
minor and the serratus anterior muscles were identified in
2. Methods one plane at the level between the third and fourth ribs. A 23-
gauge Quincke type spinal needle (TaeChang Industrial Co.,
2.1. Patients. This study enrolled patients with early breast Korea) was advanced in plane view of the ultrasound probe
cancer scheduled to undergo BCS and SNB between July from the medial to lateral direction until it reached the
2016 and May 2017. The trial was approved by the In- interfascial plane between the pectoralis major and minor
stitutional Review Board (2016-0738) of Asan Medical muscles. After the position of the needle tip was confirmed,
Center and was registered at the Clinical Research In- 10 ml of 0.25% ropivacaine was administered. The needle
formation Service (KCT 0002509). All patients provided was subsequently advanced further until its tip was located
written informed consent. in the interfascial plane between the pectoralis minor and
Patients were included if they were aged 20–70 years and serratus anterior muscles, and an additional 20 ml of 0.25%
had American Society of Anesthesiologists (ASA) physical ropivacaine was administered above the serratus anterior
status I and II. Patients were excluded if they had used an muscles (Figure 1). All of these nerve block procedures were
anticoagulant, did not cooperate with the study protocol, performed by two anesthesiologists who were proficient and
were allergic to local anesthetics, had serious neurological or experienced in ultrasound-guided PECS II block.
psychiatric disorders, or were pregnant or breastfeeding.
Patients with one and three incision sites were also excluded.
Patients were randomized to two groups according to 2.4. Outcome Measures and Data Collection. All baseline and
a computer-generated randomization schedule. Patients in postoperative measurements were evaluated by an in-
the PECS II group received a PECS II block following the dependent physician who was blinded to treatment allo-
induction of general anesthesia, whereas patients in the cation. Postoperative pain intensity was assessed using
control group did not receive any regional analgesia during a single 11-point NRS (in which 0 � no pain and 10 � worst
the perioperative period. pain imaginable). The NRS was measured separately on
the breast and axilla. To obtain a valid NRS value after the
operation, all participants were instructed before the
2.2. Process of Anesthesia and Analgesia. Anesthesia was
procedure about how to check the NRS correctly. Doses
induced by administration of propofol (2 mg/kg). After the
of all opioids administered to patients were converted
patient lost consciousness, rocuronium (0.6 mg/kg) was
to intravenous fentanyl equianalgesic doses according
injected for smooth tracheal intubation. Desflurane and
to published conversion factors (intravenous fentanyl
remifentanil were also used for induction. Remifentanil was
100 μg � meperidine 100 mg � tramadol 100 mg) [10]. An-
administrated via target-controlled infusion using Orchestra
algesic consumption and the NRS were measured 0, 0.5, 1, 2,
(Fresenius Vial, Brezins, France). Anesthesia was main-
6, 9, 18, and 24 hours after the end of surgery. Opioid re-
tained with desflurane 5-6% in 50% oxygen and 2–2.5 ng/ml
quirements were analyzed as a function of breast cancer
of effect-site remifentanil concentration. After surgery, the
location (quadrants, outer and inner areas, and upper and
patients were moved to the postanesthetic care unit (PACU)
lower area; Figure 2). Complications associated with the
and administered fentanyl (0.4 µg/kg) when in need of
PECS II block and with analgesics, such as pneumothorax,
analgesics or when analgesia was insufficient (Numerical
hematoma, nausea, vomiting, and urinary retention, were
Rating Scale (NRS) ≥ 4). Injection of fentanyl in the PACU
recorded. Vital signs (e.g., oxygen saturation, blood pres-
was repeated until the patient was satisfied with analgesia.
sure, heart rate, and electrocardiography) were measured
Upon being moved to the general ward, patients were ad-
during the first 24 hours postoperatively. Differences in
ministered 30 mg of the nonsteroidal anti-inflammatory
mean blood pressure and heart rate from before to after the
drug (NSAID) ketorolac to reduce postoperative pain. Pa-
incision were calculated. The sensory level of the block was
tients with sustained inadequate analgesia were adminis-
evaluated using the cold test, performed by an independent
tered meperidine 25 mg or tramadol 50 mg until 24 hours
physician after the operation.
after surgery.
A medical bandage was applied to the site of needle
insertion in the PECS II group after the operation. To ensure
2.3. Ultrasound-Guided PECS II Block. Ultrasound-guided patients were unaware whether the PECS II block had been
PECS II block was performed following general anesthesia to performed, a bandage was also applied to a similar site in the
obviate any pain and anxiety associated with a regional block control group.
in conscious patients. This procedure was conducted The primary study outcome was the difference in 24-hour
according to the techniques described by Blanco et al. and postoperative opioid consumption between the PECS II and
therefore also included a PECS I block [9]. Patients were control groups. Secondary outcomes included the NRS for
placed in the supine position on an operating table with their each breast and axilla, changes in vital signs at incision, opioid
arm abducted. After sterile preparation for the procedure, requirements according to breast cancer location, side effects
a 12 MHz linear ultrasound probe (NextGen LOGIQ of analgesics (nausea, vomiting, dizziness, pruritus, sleeping
Pain Research and Management 3

PM
PM
Pm Pm LA
Sm Sm
R4
R3 R4

R3

(a) (b)

PM
Pm

Sm
LA
R4

R3

(c)

Figure 1: Ultrasound images of the introduction of a PECS II block. (a) Target areas of the PECS II block. (b) First injection of the PECS II
block, showing spreading of local anesthetic in the interfascial plane between the pectoralis major and pectoralis minor muscles. (c) Second
injection of the PECS II block, showing spreading of local anesthetic in the interfascial plane between the pectoralis minor and serratus
anterior muscles. PM, pectoralis major muscle; Pm, pectoralis minor muscle; SA, serratus anterior muscle; LA, local anesthetic; R3, third rib;
R4, fourth rib. The arrow indicates the 23-gauge Quincke needle.

Ax Ax Ax

12° 12°

Upper area (N = 28)

UOQ (N = 11) UIQ (N = 12) (46.6 μg)
Outer Inner
(33.6 μg) (58.8 μg) area
area
9° 3° (N = 20) (N = 15) 9° 3°
SA (32.5 μg) (58.0 μg)∗
LOQ (N = 7) LIQ (N = 3)
Lower area (N = 10)
(36.4 μg) (55.0 μg)
(42.0 μg)

6° 6°

(a) (b) (c)

Figure 2: Opioid consumption as a function of breast cancer location. (a) Opioid consumption according to the quadrants of the breast.
Patients with cancers located at 12, 3, 6, and 9 o’clock were not excluded because of the ambiguity of location. UOQ, upper outer quadrant;
UIQ, upper inner quadrant; LOQ, lower outer quadrant; LIQ, lower inner quadrant; SA, subareolar; Ax, axilla; N, number of patients; values
within parentheses denote mean fentanyl consumption. (b) Opioid consumption according to tumor location in the outer and inner areas of
the breast, as determined by a line connecting the 12 o’clock and 6 o’clock positions. Patients with cancers located at 12 o’clock and 6 o’clock
were not excluded, ∗ p value < 0.05. (c) Opioid consumption according to tumor location in the upper and lower areas of the breast, as
determined by a line connecting the 3 o’clock and 9 o’clock positions. Patients with cancers located at 3 o’clock and 9 o’clock were not
excluded.
4 Pain Research and Management

Eligibility (N = 88)
Exclusion (N = 8)
Refused to consent (N = 3)
Not meeting inclusion criteria (N = 5)
Randomization (N = 80)

PECS II group (N = 40) Control group (N = 40)

Exclusion (N = 2)
One incision site (N = 1)
Three incision sites (N = 1)
Completed study and Completed study and
analyzed (N = 40) analyzed (N = 38)

Figure 3: Study flow chart.

Table 1: Baseline demographic and clinical characteristics of study subjects.

PECS II group (n  40) Control group (n  38)
Age (years) 45.4 ± 9.9 45.2 ± 11.9
BMI (kg/m2) 22.8 ± 2.8 23.9 ± 3.1
ASA class (I/II) 36 (90.0%)/4 (10.0%) 29 (76.3%)/9 (23.7%)
Neoadjuvant CTx 6 (15.0%) 6 (15.8%)
Surgical time (min) 93.5 ± 19.9 89.7 ± 24.9
Intraoperative remifentanil dosage (μg) 491.0 (440.0; 571.0) 477.0 (420.0; 600.0)
Tumor location (left/right) 14 (35.0%)/26 (65.0%) 21 (55.3%)/17 (44.7%)
Tumor location (quadrant)
UOQ/LOQ 11 (27.5%)/7 (17.5%) 15 (39.5%)/7 (18.4%)
UIQ/LIQ 12 (30.0%)/3 (7.5%) 7 (18.4%)/3 (7.9%)
12 o’clock/6 o’clock 5 (12.5%)/0 (0.0%) 1 (2.6%)/1 (2.6%)
3 o’clock/9 o’clock 0 (0.0%)/2 (5.0%) 2 (5.2%)/1 (2.6%)
Subareolar 0 (0.0%) 1 (2.6%)
Data are expressed as mean ± SD (standard deviation), number (%), or median (interquartile range). BMI, body mass index; ASA, American Society of
Anesthesiologists Physical Status Classification; CTx, chemotherapy; UOQ, upper outer quadrant; LOQ, lower outer quadrant; UIQ, upper inner quadrant;
LIQ, lower inner quadrant.

tendency, urinary retention, and respiratory depression), and 3. Results

complications of the PECS II block.
Eighty patients were enrolled in this study, 40 in the PECS II
group and 40 in the control group. Two patients in the
2.5. Statistical Analysis. The sample size was calculated based control group, one with a single incision site and one with
on our pilot study. If the mean ± standard deviation (SD) three incision sites, were excluded (Figure 3). The baseline
difference in opioid consumption between the PECS II and demographic and clinical characteristics of the two groups
control groups was 48 ± 64 μg of fentanyl, with a significance are shown in Table 1. As expected, the changes in mean
level of 0.05 and a power of 0.9, and assuming a dropout rate blood pressure and heart rate (from before to after the
of 5%, then 80 patients (40 per group) should be sufficient. incision) were greater in the control than in the PECS II
Data were analyzed using the Statistical Package for the Social group. The side effect rates of analgesics were similar in the
Sciences (SPSS version 21.0, SPSS Inc., Chicago, IL). Normal two groups (Table 2).
distribution of data was tested using the Kolmogorov– Opioid consumption during the first 24 hours after
Smirnov test. Normally distributed continuous data were surgery was significantly lower in the PECS II group than in
reported as mean ± SD and compared using Student’s t-tests. the control group (43.8 ± 28.5 µg versus 77.0 ± 41.9 µg,
Nonparametric continuous data were presented as median p < 0.001), but the frequency of rescue NSAIDs did not differ
and interquartile range and compared using Mann–Whitney between these groups. The rates of side effects of analgesics
U tests. Categorical data were presented as numbers and were also similar in the two groups (Table 2). Analysis of
percentages and compared using the chi-square test or patients in the PECS II group showed that opioid consumption
Fisher’s exact test. Opioid consumption as a function of breast was unrelated to the quadrant in which the breast cancer was
cancer location was determined using the Kruskal–Wallis test. located, that is, whether the tumor was located in the upper or
A p value below 0.05 was considered statistically significant. lower area of the breast. However, opioid consumption was
Pain Research and Management 5

Table 2: Opioid requirements, frequency of rescue NSAIDs, and incidence of side effects of analgesics in the PECS II and control groups
during the 24 hours after the operation.
PECS II group (n  40) Control group (n  38) p value
Total opioid requirements (μg) 43.8 ± 28.5 77.0 ± 41.9 <0.001
Frequency of rescue NSAIDs 1.0 (0.0; 1.0) 1.0 (1.0; 1.0) 0.213
MBP after incision − MPB before incision (mmHg) 5.0 (1.0; 10.5) 16.0 (9.0; 24.0) <0.001
HR after incision − HR before incision (beats per
0.0 (−2.0; 2.5) 3.0 (1.0; 5.0) 0.002
minute)
Side effects of analgesics (%) 7 (17.5%) 10 (26.3%) 0.504
Data are expressed as mean ± SD (standard deviation), median (interquartile range), or number (%). NRS, Numerical Rating Scale; NSAID, nonsteroidal
anti-inflammatory drug; MBP, mean blood pressure; HR, heart rate.

8 4.9 ± 1.6, p < 0.001) and 0.5 (3.6 ± 1.5 versus 5.1 ± 1.8,
∗ p < 0.001) hours after the procedure. Median NRS value of
∗ the breast was not statistically lower in the PECS II than in
6
the control group starting 1 hour after surgery. Median NRS
value of the axilla, however, was significantly lower in the
NRS on breast

PECS II than in the control group throughout the first 24

4
hours after surgery (Figure 4). None of these patients re-
ported complications associated with the PECS II block.
2
4. Discussion
0 This study had two main findings. First, although the PECS
0 0.5 1 2 6 9 18 24 II block seemed to reduce pain severity and opioid con-
Time (h) sumption in patients undergoing BCS and SNB, it may not
PECS II group have clear clinical efficacy. Second, the PECS II block had
Control group a significantly greater effect in reducing axillary pain.
(a) Since the introduction of PECS II block, several ran-
8
domized controlled trials have shown that the PECS II block
is effective in reducing pain in patients undergoing mas-
tectomy [7–9, 11, 12]. To our knowledge, the present study is
∗ the first to test the efficacy of PECS II block only in patients
6
undergoing BCS and SNB. The mean difference in opioid
∗
requirement between the two groups was only 33.2 μg of
NRS on axilla

∗ fentanyl. In other studies of interfascial plane block, the

4
minimum difference in opioid consumption between the
∗ ∗ ∗ ∗ nerve block and control groups was 13 mg of morphine or
∗ 100 μg of fentanyl [13, 14]. The 33 μg difference in fentanyl
2
consumption over 24 hours in the present study was less
than 2 μg per hour, a quantitative difference lower than in
other studies of regional analgesia. Similar to our results, two
0
0 0.5 1 2 6 9 18 24
previous studies also found that the mean differences in 24-
Time (h)
hour postoperative morphine consumption between the
PECS II and control groups were 5.81 mg and 3.67 mg
PECS II group [12, 15]. Moreover, the frequency of rescue NSAIDs and the
Control group side effects of analgesics in the present study did not differ in
(b) the PECS II and control groups. These findings indicate that,
although the PECS II block seemed to statistically signifi-
Figure 4: NRS of the breast (a) and axilla (b) in the PECS II and cantly reduce rescue analgesic use, the difference may not
control groups. Data are expressed as the median (interquartile
have clinical significance. The present study also showed that
range). ∗ p value < 0.05.
the breast pain score was lower in the PECS II group than in
the control group only for the first 30 min postoperatively.
significantly greater in PECS II patients with tumors in the Moreover, the median difference in the NRS score between
inner area than in the outer area of the breast (58.0 ± 29.3 µg these groups was less than 1 at all other time points. This
versus 32.5 ± 23.0 µg, p  0.007; Figure 2). difference did not meet the threshold for a minimal clinically
Mean NRS value of the breast was significantly lower in important difference in acute postoperative pain (i.e., a
the PECS II than in the control group at 0 (3.0 ± 1.5 versus difference ≥10 on the 100 mm pain visual analogue scale)
6 Pain Research and Management

Supraclavicular
nerves

Medial branches of
thoracic intercostal
nerves
Lateral branches of
thoracic intercostal
nerves

Figure 5: Diagrammatic representation of the nerves innervating the female breast and axilla. MPN, medial pectoral nerve; LPN, lateral
pectoral nerve; MBCN, medial brachial cutaneous nerve; ICBN, intercostobrachial nerve; LTN, long thoracic nerve.

[16]. Therefore, the PECS II block appeared not to be the lateral cutaneous branches of the TICN. Therefore, our
clinically useful. finding suggests that the PECS II block could block the lateral,
The lack of clinical significance of the PECS II block may but not the anterior, cutaneous branches of the TICN.
have been due to its inability to block all the nerves innervating Interestingly, axillary pain scores were significantly
the breast. The breast is innervated by multiple nerve lower in the PECS II group than in the control group for up
branches, including the lateral and anterior cutaneous to 24 hours after surgery. The median difference in NRS
branches of the second to sixth thoracic intercostal nerves between these groups was >1.5 at most evaluation times.
(TICNs) and several branches of the supraclavicular nerves These findings indicated that the PECS II block could be
(Figure 5) [17, 18]. Thus, it is doubtful whether a single useful as regional analgesia for patients undergoing SNB.
blocking method can provide adequate analgesia throughout Local anesthetic administered into the interfascial plane
the entire breast area. The targets of PECS II block include the likely reached the axilla via an axillary port, easily blocking
medial and lateral pectoral nerves, including the lateral cu- the intercostobrachial and medial brachial cutaneous nerves,
taneous branches of the TICNs (Figure 6). Local anesthetics which innervate the axillary area. The spread of local an-
cannot reach the anterior cutaneous branches of the TICNs esthetic into the axilla has been demonstrated by dissection
by piercing the external and internal intercostal muscles. of cadavers and contrast distribution [9, 21]. The pectoral
Therefore, they cannot block anterior cutaneous branches of nerve block was also found to be beneficial for axillary
the second to sixth TICNs and branches of the supraclavicular surgery [22]. Consequently, the PECS II block may be ef-
nerves. Although several recent studies have also mentioned fective at alleviating axillary pain.
these limitations of the PECS II block [15, 19, 20], those In agreement with previous studies, no complications
studies, in contrast to ours, did not demonstrate these were associated with the PECS II block procedure. A PECS II
limitations. block is conducted while patients are in the supine position,
Additionally, we evaluated opioid requirements associ- and the needle is manipulated relatively easily. Moreover,
ated with tumor location in the breast (quadrant, outer/inner, the target areas of a PECS II block are distant from the pleura
and upper/lower areas). Opioid consumption did not differ and epidural space, but relatively close to the skin surface
significantly by breast tumor quadrant or in patients with (Figure 6). Although the thoracoacromial artery may be
tumors in the upper and lower areas. However, opioid re- present at the interfascial plane, it is easily visualized by
quirements were greater in patients with tumors in the inner ultrasonography. Direct intravascular injection of local
area than in the outer area of the breast. The inner area is anesthetics is performed very rarely due to a lack of vas-
primarily innervated by the anterior cutaneous branches of culature at the interfascial plane [23, 24]. Therefore, a PECS
the TICN, whereas the outer area is primarily innervated by II block seems to be a safe procedure.
Pain Research and Management 7

Anterior cutaneous branch

of TICN Breast

Target interfascial planes of

PECS II block

Transversus thoracic muscle

Pectoralis major muscle

Pectoralis minor muscle

Serratus anterior muscle

Lateral cutaneous branch
of TICN

External intercostal muscle

Internal intercostal muscle

Innermost intercostal muscle

Thoracic intercostal nerve (TICN)

Figure 6: Illustration of target areas of the PECS II block. This agent can block the lateral cutaneous branches of the TICN in the interfascial
plane between the pectoralis minor and serratus anterior muscles but cannot block the anterior cutaneous branch of the TICN.

This study had several limitations. First, the PECS II patients who underwent BCS and SNB, PECS II block may
block was performed following the induction of general not be clinically useful. Because PECS II block could not
anesthesia to reduce procedural pain and anxiety, which completely block all the nerves innervating the breast,
may have affected postoperative pain [25]. Sensory level including the anterior cutaneous branch of the TICN, it
tests were performed in the PACU after the operation, with could not provide complete postoperative analgesia after
all patients in the PECS II group showing positive re- BCS and SNB. The PECS II block seemed to be more ef-
actions on the cold test. However, in contrast to findings in ficient at reducing axillary pain than breast pain. Therefore,
a previous study, our patients did not express exact der- PECS II block may lack the ability to provide sufficient
matome against cold tests [20], suggesting that wound postoperative analgesia after breast surgery.
dressing and a surgical brassiere may have interfered with
these sensory examinations. Other reasons for inaccurate
responses to sensory level tests include postoperative pain, Data Availability
the sedative effect of opioids, and anesthetic hangover. The authors will provide data upon request to the first author
However, we speculated that the PECS II block was suc- (Doo-Hwan Kim, e-mail: [email protected]).
cessfully performed based on the changes in mean blood
pressure and heart rate during the incision and the positive
reactions in the cold test. Consequently, this study did not Conflicts of Interest
present sensory test data. A second limitation of this study
was our inability to perform a double-blind, placebo-controlled The authors declare that they have no conflicts of interest.
study. However, the patients and investigators were blin-
ded to group assignment, suggesting that the lack of ability Acknowledgments
to perform a placebo-controlled study had little influence
on the study outcomes. The authors thank the e-medical contents and e-learning
In conclusion, although the PECS II block reduced teams at the Asan Medical Center for helping to draw
pain intensity and opioid requirements for 24 hours in Figures 5 and 6.
8 Pain Research and Management

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