Reply to “Ultrasound-guided sub transverse interligamentary (STIL) block versus erector spinae plane (ESP) block for postoperative analgesia in patients undergoing modified radical mastectomy (MRM)”

Dear Editor, We thank the authors for their interest in our published article.[1] First, the authors have raised a query on preoperative and surgical factors.[2] Randomisation with concealed allocation ensured balanced distribution of confounders. Baseline demographics were comparable, and exclusion of patients with chronic pain, psychotropic use, or major co-morbidities minimised heterogeneity.[1] The suggestion of bias from unmeasured variables is speculative. Secondly, the query was raised on pain assessment and ketorolac timing. All patients received a standardised multi-modal analgesic regimen including intravenous paracetamol (15 mg/kg thrice a day) and ketorolac (0.5 mg/kg twice a day) for the first 48 h. The ketorolac doses were administered at fixed intervals (every 12 h) rather than being timed specifically with pain assessments. The 12 and 24 h and 24-hour pain assessments were conducted before the scheduled ketorolac doses to minimise direct analgesic interference with pain scoring. Third, the point was raised on total dosages of opioid consumption. In our study, the secondary outcome was the number of dosages of rescue tramadol use rather than the dose of tramadol needed. The reduction in tramadol usage clearly exceeds minimal clinically important differences and represents tangible opioid sparing, irrespective of morphine-equivalent conversion. Finally, in reply to the point raised on enhanced recovery after surgery (ERAS), our study was designed and powered to test analgesic efficacy, not the full ERAS spectrum. Nevertheless, reduced pain scores, opioid use, and rescue requirements strongly imply improved recovery quality, in line with PROSPECT recommendations. In summary, our randomised trial provides the first high-quality evidence that STIL block confers superior analgesia over ESP block in MRM patients.[3] Presentation at conferences/CMEs and abstract publication The interim result of the original study was presented at AORA, India in 2023 held at Pune and won 1st prize. Study data availability De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors’ institution’s policy. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references. Authors contributions NA: Concepts, AR: Design, Definition of intellectual content, R.: literature search, DA: manuscript preparation, AH: Editing, SB: review and approval. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.