Bilateral thoracolumbar erector spinae plane blocks for postoperative pain relief in TRAM flap breast reconstruction: A case report

Post-mastectomy breast reconstruction is associated with significant postoperative pain due to the involvement of both the thoracic recipient site and the abdominal donor site. Effective analgesic strategies are essential to optimise recovery, reduce opioid exposure, and support enhanced recovery after surgery (ERAS) pathways. We report the perioperative analgesic management of a patient undergoing mastectomy with immediate breast reconstruction using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap. A multimodal regional anaesthesia strategy based on bilateral multilevel thoracolumbar erector spinae plane blocks (ESPB), supplemented by a serratus anterior plane block, was employed to address wide thoracoabdominal dermatomal pain distribution. The regional analgesic approach was associated with effective postoperative pain control and minimal systemic opioid requirements during the early postoperative period. Pain scores remained low at rest and during movement, and no block-related complications were observed. This case illustrates the feasibility of combining bilateral multilevel ESPB with adjunct interfascial plane blocks as part of a multimodal analgesic strategy for pedicled TRAM flap reconstruction. While no conclusions regarding comparative efficacy or reproducibility can be drawn from a single case, this experience supports further investigation of ESPB-based approaches within ERAS pathways for autologous breast reconstruction.