Paravertebral Nerve Block

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Paravertebral nerve block was a popular technique in the early 20th century. However, for some reason, paravertebral nerve block lost popularity and was almost extinct until the late 1970s, when there was a renewed interest in the technique. Recently, this technique was reviewed and found to be safe and efficacious. ^[1]

A paravertebral block is essentially a unilateral block of the spinal nerve, including the dorsal and ventral rami, as well as the sympathetic chain ganglion. These blocks can be performed at any vertebral level. However, they are most commonly performed at the thoracic level because of anatomic considerations. Therefore, this topic primarily focuses on thoracic paravertebral blockade.

Paravertebral nerve blocks are indicated for surgical procedures requiring unilateral analgesia or anesthesia. Common cases benefitting from unilateral paravertebral blocks are breast surgery, thoracotomy, herniorrhaphy, open cholecystectomy, and open nephrectomy. Bilateral paravertebral blocks can be a viable option for midline abdominal surgery. ^[2]

The clinician may consider thoracic paravertebral blockade over thoracic epidural analgesia in patients for whom bilateral sympathectomy and subsequent hypotension would be especially detrimental. ^{[3, 4, 5]} For example, the use of thoracic paravertebral blockade in a patient with severe aortic stenosis has been reported. ^[6] In another study, thoracic paravertebral blockade resulted in more stable hemodynamics and equivalent analgesia when compared to thoracic epidural analgesia in thorocotomy patients. ^[7] However, because bilateral spread can occur ^[8] , which may cause hemodynamic compromise similar to epidural blockade.

Another unique feature of thoracic paravertebral blockade compared with thoracic epidural analgesia is the relative safety when performing these blocks on patients with a marginal coagulation cascade. This does not mean, however, that thoracic paravertebral blockade can be performed on patients with coagulopathy without caution. According to the American Society of Regional Anesthesia and Pain Medicine’s evidence-based guidelines, in the patient receiving antithrombotic or thrombolytic therapy, the exact same precautions should be taken when placing thoracic paravertebral blockade as when placing an epidural. However, if bleeding occurs in the thoracic paravertebral space, significant blood loss will be the likely complication rather than epidural hematoma and neurologic deficit. ^[9]

Contraindications to paravertebral nerve blocks include the following:

Patient refusal

Severe coagulopathy

Local infection

Allergy to local anesthetics (rare, usually the allergy is to the preservative)

Severe hypovolemia (especially for bilateral blocks)

Untreated sepsis

The thoracic paravertebral space is a triangular- or wedge-shaped space running the length of the thoracic vertebral column bilaterally (see the image below).

It is bounded posteriorly by the superior costotransverse ligament (a continuation of the internal intercostal muscle); anteriolaterally by the parietal pleura; and medially by the vertebral bodies, intervertebral foramina, and the intervertebral discs.

In contrast to cervical and lumbar regions, the thoracic paravertebral space is in continuity with adjacent vertebral levels, allowing for spread of local anesthetic. This anatomic property explains why the thoracic paravertebral space may have more utility than cervical or lumbar paravertebral blocks.

Complications of paravertebral nerve blocks may include the following:

Failed block

Hypotension

Vascular puncture

Pleural puncture

Pneumothorax

Failure rate may be lower with ultrasound, but this has not been studied.

The patient should be consented for the procedure. The risks, benefits, and alternatives should be adequately discussed.

All supplies and equipment should be gathered, including:

Emergency airway supplies

Emergency drugs, including 20% intralipid

Ultrasound machine (if ultrasound guidance is planned) with sterile probe cover

Local anesthetic to be used for the block

For continuous catheter insertion, the following equipment is needed:

Surgical mask, hat, and sterile gloves

Commercial epidural tray containing skin prep, lidocaine, drape, 25-G needle, 17-G Tuohy needle (see the image below)

For single shot block, the following equipment is needed:

Sterile gloves

Skin prep solution

Syringe with lidocaine and 25-G needle for local

22-G nerve block needle (see the image below)

Note that 0.5% bupivacaine will last approximately 12-18 hours.

The thoracic paravertebral space is highly vascular and rapid systemic absorption can occur.

Use of epinephrine 1:200,000 may slow absorption and decrease the peak plasma concentration. ^[10]

Anesthesia

The block may be done with local anesthetic infiltration and sedation or under general anesthesia.

Midazolam and fentanyl may be titrated to patient comfort.

Positioning

The patient may be positioned prone, lateral, or sitting.

Patients should be monitored for at least 30 minutes after the block for signs of local anesthetic toxicity, hypotension, or other complications.

Many techniques for accessing the paravertebral space have been described, including:

Loss of resistance ^[11]

Advancing the needle 1.5-2 cm beyond the transverse process ^[12]

Nerve stimulation ^[13]

Ultrasound guidance ^[14]

Fluoroscopic guidance ^[15]

Examples of thoracic paravertebral block using sagittal and transverse imaging are shown in the following videos.

Intravenous access should be obtained and standard monitors applied, including pulse oximetry, blood pressure, and electrocardiograph.

The patient is positioned, sedated, prepped, and draped, as shown in the image below.

A small curvilinear or high frequency linear probe is used for ultrasound guidance (see the image below).

A sagittal or transverse image can be obtained at the appropriate vertebral level. See the images below.

After image optimization, the skin is anesthetized with lidocaine.

The Tuohy needle is advanced in plane until the tip rests in the thoracic paravertebral space. Needle visualization is sometimes difficult due to the steep angle of insonation. Injection of small amounts of fluid (hydrodissection) will aid in needle tip location.

Saline or local anesthetic is injected through the Tuohy needle.

The endpoint for a successful block is anterior displacement of the pleura.

Both single injection and multiple vertebral level injection have been described. ^{[14, 10]}

The catheter is threaded through the Tuohy needle and its position is confirmed by injecting local anesthetic or small air bubbles. Pleural depression should again be noted.

The catheter is secured using a clear adhesive dressing

Intravenous access should be obtained and standard monitors applied including: pulse oximetry, blood pressure, and electrocardiogram.

The patient is positioned, sedated, prepped, and draped.

The spinous processes of the levels to be blocked are identified and marked.

The needle is inserted 2.5-3 cm lateral to the spinous process perpendicular to all planes of the skin.

The transverse process is contacted and the needle is then walked off the transverse process in a cranial or caudal direction. A cranial direction is preferred because the distance between the superior costotransverse ligament and pleura is longer than when using a caudal angulation; therefore, the margin of safety is greater. ^[16]

Using a low resistance syringe, a loss of resistance will be felt when the needle tip passes through the superior costotransverse ligament and enters the paravertebral space.

The local anesthetic is injected and, if desired, a catheter is threaded.

Eid HEA. Paravertebral block: An overview. Curr Anaesth Crit Care. 2009. 20:65-70.

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Bigeleisen PE, Goehner N. Novel approaches in pain management in cardiac surgery. Curr Opin Anaesthesiol. 2015 Feb. 28 (1):89-94. [Medline].

Koyyalamudi VB, Arulkumar S, Yost BR, Fox CJ, Urman RD, Kaye AD. Supraclavicular and paravertebral blocks: Are we underutilizing these regional techniques in perioperative analgesia?. Best Pract Res Clin Anaesthesiol. 2014 Jun. 28 (2):127-38. [Medline].

Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2014 May. 18 (5):626-35. [Medline].

Serpetinis I, Bassiakou E, Xanthos T, Baltatzi L, Kouta A. Paravertebral block for open cholecystectomy in patients with cardiopulmonary pathology. Acta Anaesthesiol Scand. 2008 Jul. 52(6):872-3. [Medline].

Pintaric T, Potocnik I, Hadzic A, Stupnik T, Pintaric M, Jankovic V. Comparison of Continuous Thoracic Epidural With Paravertebral Block on Perioperative Analgesia and Hemodynamic Stability in Patients Having Open Lung Surgery. Regional Anesthesia and Pain Medicine. May-June/11. 36:256-60.

Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of contralateral spread anterior to the vertebral bodies. Br J Anaesth. 2000 Feb. 84(2):263-5. [Medline].

Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010 Jan-Feb. 35(1):64-101. [Medline].

Karmakar MK, Ho AM, Law BK, Wong AS, Shafer SL, Gin T. Arterial and venous pharmacokinetics of ropivacaine with and without epinephrine after thoracic paravertebral block. Anesthesiology. 2005 Oct. 103(4):704-11. [Medline].

Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001 Sep. 95(3):771-80. [Medline].

Greengrass R, O’Brien F, Lyerly K, Hardman D, Gleason D, D’Ercole F, et al. Paravertebral block for breast cancer surgery. Can J Anaesth. 1996 Aug. 43(8):858-61. [Medline].

Wheeler LJ. Peripheral nerve stimulation end-point for thoracic paravertebral block. Br J Anaesth. 2001 Apr. 86(4):598-9. [Medline].

Hara K, Sakura S, Nomura T, Saito Y. Ultrasound guided thoracic paravertebral block in breast surgery. Anaesthesia. 2009. 64:223-5.

Culp WC, McCowan TC, DeValdenebro M, Wright LB, Workman JL, Culp WC Jr. Paravertebral block: an improved method of pain control in percutaneous transhepatic biliary drainage. Cardiovasc Intervent Radiol. 2006 Nov-Dec. 29(6):1015-21. [Medline].

Hidalgo n, Ferrante fm. Complications of Paravertebral, Intercostal Nerve Blocks, and Interpleural Analgesia. finucane b. Complications of Regional Anesthesia. 2. NY, NY: Springer; 2007. 102-120.

Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia. 1995 Sep. 50(9):813-5. [Medline].

Scott W Byram, MD Director, Acute Pain Service, Assistant Professor, Department of Anesthesiology, Loyola University Medical Center

Disclosure: Nothing to disclose.

Michael V Presta, DO Assistant Professor, Department of Anesthesiology, Loyola University Medical Center

Michael V Presta, DO is a member of the following medical societies: American Society of Anesthesiologists

Disclosure: Nothing to disclose.

Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center

Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Paravertebral Nerve Block

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