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Ultrasound-Guided Thoracic Paravertebral Block

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Regional Nerve Blocks in Anesthesia and Pain Therapy

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Abstract

Thoracic paravertebral block (TPVB) is the technique of injecting local anaesthetic alongside the thoracic vertebra and close to where the spinal nerves emerge from the intervertebral foramen. It produces ipsilateral, somatic and sympathetic nerve blockade in multiple contiguous thoracic dermatomes that is effective in managing pain of unilateral origin from the thorax and abdomen. TPVB has also been used to provide surgical anaesthesia for primary breast cancer and hernia surgery. Bilateral TPVB has also been described. TPVB is traditionally performed using surface anatomical landmarks, but recent years have seen an increase in interest in the use of ultrasound for TPVB, and several variations of the technique have been described. This chapter briefly outlines the basic principles of TPVB, the sonoanatomy of the thoracic paravertebral space and the technique of ultrasound-guided TPVB.

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Abbreviations

IICM:

Internal intercostal membrane

LA:

Local anaesthetic

PICS:

Posterior intercostal space

SCTL:

Superior costotransverse ligament

TP:

Transverse process

TPVB:

Thoracic paravertebral block

TPVS:

Thoracic paravertebral space

USG:

Ultrasound-guided

Suggested Reading

  • Abdallah FW, Brull R. Off side! A simple modification to the parasagittal in-plane approach for paravertebral block. Reg Anesth Pain Med. 2014;39:240–2.

    CAS  PubMed  Google Scholar 

  • Antonakakis JG, Sites BD, Shiffrin J. Ultrasound-guided posterior approach for the placement of a continuous interscalene catheter. Reg Anesth Pain Med. 2009;34:64–8.

    PubMed  Google Scholar 

  • Ben-Ari A, Moreno M, Chelly JE, Bigeleisen PE. Ultrasound-guided paravertebral block using an intercostal approach. Anesth Analg. 2009a;109:1691–4.

    PubMed  Google Scholar 

  • Ben-Ari A, Moreno M, Chelly JE, Bigeleisen PE. USG PVB using an intercostal approach. Anesth Analg. 2009b;109:1691–4.

    PubMed  Google Scholar 

  • Cheema SPS, Ilsley D, Richardson J, Sabanathan S. A thermographic study of paravertebral analgesia. Anaesthesia. 1995;50:118–21.

    CAS  PubMed  Google Scholar 

  • Conacher ID. Resin injection of thoracic paravertebral spaces. Br J Anaesth. 1988;61:657–61.

    CAS  PubMed  Google Scholar 

  • Conacher ID, Kokri M. Postoperative paravertebral blocks for thoracic surgery. A radiological appraisal. Br J Anaesth. 1987;59:155–61.

    CAS  PubMed  Google Scholar 

  • Coveney E, Weltz CR, Greengrass R, Iglehart JD, Leight GS, Steele SM, Lyerly HK. Use of paravertebral block anesthesia in the surgical management of breast cancer—experience in 156 cases. Ann Surg. 1998;227:496–501.

    CAS  PubMed  PubMed Central  Google Scholar 

  • Dugan DJ, Samson PC. Surgical significance of the endothoracic fascia. The anatomic basis for empyemectomy and other extrapleural technics. Am J Surg. 1975;130:151–8.

    CAS  PubMed  Google Scholar 

  • Evans PJ, Lloyd JW, Wood GJ. Accidental intrathecal injection of bupivacaine and dextran. Anaesthesia. 1981;36:685–7.

    CAS  PubMed  Google Scholar 

  • Fagenholz PJ, Bowler GM, Carnochan FM, Walker WS. Systemic local anaesthetic toxicity from continuous thoracic paravertebral block. Br J Anaesth. 2012;109:260–2.

    CAS  PubMed  Google Scholar 

  • Fujii T, Shibata Y, Shinya S, Nishiwaki K. Transverse vs. parasagittal in-plane approaches in ultrasound-guided paravertebral block using a microconvex probe: a randomised controlled trial. Eur J Anaesthesiol. 2020;37:752–7.

    CAS  PubMed  Google Scholar 

  • Greengrass R, O’Brien F, Lyerly K, Hardman D, Gleason D, D'Ercole F, Steele S. Paravertebral block for breast cancer surgery. Can J Anaesth. 1996;43:858–61.

    CAS  PubMed  Google Scholar 

  • Hara K, Sakura S, Nomura T. [Use of ultrasound for thoracic paravertebral block]. Masui. 2007;56:925–31.

    Google Scholar 

  • Hara K, Sakura S, Nomura T, Saito Y. Ultrasound guided thoracic paravertebral block in breast surgery. Anaesthesia. 2009;64:223–4.

    CAS  PubMed  Google Scholar 

  • Karmakar M. Thoracic paravertebral block. Anesthesiology. 2001;95:771–80.

    CAS  PubMed  Google Scholar 

  • Karmakar MK. Ultrasound-guided thoracic paravertebral block. Tech Reg Anesth Pain Manag. 2009;13:142–9.

    Google Scholar 

  • Karmakar M, Chung D. Variability of a thoracic paravertebral block. Are we ignoring the endothoracic fascia? Reg Anesth Pain Med. 2000;25:325–7.

    CAS  PubMed  Google Scholar 

  • Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of contralateral spread anterior to the vertebral bodies. Br J Anaesth. 2000;84:263–5.

    CAS  PubMed  Google Scholar 

  • Karmakar M, Gin T, Ho A. Ipsilateral thoraco-lumbar anaesthesia and paravertebral spread after low thoracic paravertebral injection. Br J Anaesth. 2001;87:312–6.

    CAS  PubMed  Google Scholar 

  • Karmakar MK, Critchley LA, Ho AM, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest. 2003;123:424–31.

    PubMed  Google Scholar 

  • Kittredge RD. Computed tomographic evaluation of the thoracic prevertebral and paravertebral spaces. J Comput Tomogr. 1983;7:239–50.

    CAS  PubMed  Google Scholar 

  • Klein SM, Greengrass RA, Weltz C, Warner DS. Paravertebral somatic nerve block for outpatient inguinal herniorrhaphy: an expanded case report of 22 patients. Reg Anesth Pain Med. 1998;23:306–10.

    CAS  PubMed  Google Scholar 

  • Krediet AC, Moayeri N, van Geffen GJ, Bruhn J, Renes S, Bigeleisen PE, Groen GJ. Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology. 2015;123:459–74.

    PubMed  Google Scholar 

  • Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest. 1995;108:1345–8.

    CAS  PubMed  Google Scholar 

  • Lonnqvist PA, Hildingsson U. The caudal boundary of the thoracic paravertebral space—a study in human cadavers. Anaesthesia. 1992;47:1051–2.

    CAS  PubMed  Google Scholar 

  • Lonnqvist PA, Mackenzie J, Soni AK, Conacher ID. Paravertebral blockade—failure rate and complications. Anaesthesia. 1995;50:813–5.

    CAS  PubMed  Google Scholar 

  • Luyet C, Herrmann G, Ross S, Vogt A, Greif R, Moriggl B, Eichenberger U. Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go? Br J Anaesth. 2011;106:246–54.

    CAS  PubMed  Google Scholar 

  • Marhofer P, Kettner SC, Hajbok L, Dubsky P, Fleischmann E. Lateral ultrasound-guided paravertebral blockade: an anatomical-based description of a new technique. Br J Anaesth. 2010;105:526–32.

    CAS  PubMed  Google Scholar 

  • Marhofer D, Marhofer P, Kettner SC, Fleishmann E, Prayer D, Schernthaner M, Lackner E, Willschke H, Schwetz P, Zeitlinger M. Magnetic resonance imaging analysis of the spread of local anesthetic solution after ultrasound-guided lateral thoracic paravertebral blockade. Anesthesiology. 2013;118:1106–12.

    CAS  PubMed  Google Scholar 

  • Naja MZ, Ziade MF, Lonnqvist PA. General anaesthesia combined with bilateral paravertebral blockade (T5–6) vs. general anaesthesia for laparoscopic cholecystectomy: a prospective, randomized clinical trial. Eur J Anaesthesiol. 2004;21:489–95.

    CAS  PubMed  Google Scholar 

  • Niesen AD, Jacob AK, Law LA, Sviggum HP, Johnson RL. Complication rate of ultrasound-guided paravertebral block for breast surgery. Reg Anesth Pain Med. 2020;45:813–7.

    PubMed  Google Scholar 

  • Nunn JF, Slavin G. Posterior intercostal nerve block for pain relief after cholecystectomy. Anatomical basis and efficacy. Br J Anaesth. 1980;52:253–60.

    CAS  PubMed  Google Scholar 

  • O’Riain SC, Donnell BO, Cuffe T, Harmon DC, Fraher JP, Shorten G. Thoracic paravertebral block using real-time ultrasound guidance. Anesth Analg. 2010;110:248–51.

    PubMed  Google Scholar 

  • Pace MM, Sharma B, Anderson-Dam J, Fleischmann K, Warren L, Stefanovich P. Ultrasound-guided thoracic paravertebral blockade: a retrospective study of the incidence of complications. Anesth Analg. 2016;122:1186–91.

    PubMed  Google Scholar 

  • Pangthipampai P, Karmakar MK, Songthamwat B, Pakpirom J, Samy W. Ultrasound-guided multilevel thoracic paravertebral block and its efficacy for surgical anesthesia during primary breast cancer surgery. J Pain Res. 2020;13:1713–23.

    CAS  PubMed  PubMed Central  Google Scholar 

  • Paraskeuopoulos T, Saranteas T, Kouladouros K, Krepi H, Nakou M, Kostopanagiotou G, Anagnostopoulou S. Thoracic paravertebral spread using two different ultrasound-guided intercostal injection techniques in human cadavers. Clin Anat. 2010;23:840–7.

    PubMed  Google Scholar 

  • Patnaik R, Chhabra A, Subramaniam R, Arora MK, Goswami D, Srivastava A, Seenu V, Dhar A. Comparison of paravertebral block by anatomic landmark technique to ultrasound-guided paravertebral block for breast surgery anesthesia: a randomized controlled trial. Reg Anesth Pain Med. 2018;43:385–90.

    PubMed  Google Scholar 

  • Pintaric TS, Veranic P, Hadzic A, Karmakar M, Cvetko E. Electron-microscopic imaging of endothoracic fascia in the thoracic paravertebral space in rats. Reg Anesth Pain Med. 2012;37:215–8.

    Google Scholar 

  • Purcell-Jones G, Pither CE, Justins DM. Paravertebral somatic nerve block: a clinical, radiographic, and computed tomographic study in chronic pain patients. Anesth Analg. 1989;68:32–9.

    CAS  PubMed  Google Scholar 

  • Renes SH, Bruhn J, Gielen MJ, Scheffer GJ, Van Geffen GJ. In-plane ultrasound-guided thoracic paravertebral block: a preliminary report of 36 cases with radiologic confirmation of catheter position. Reg Anesth Pain Med. 2010;35:212–6.

    PubMed  Google Scholar 

  • Renes SH, van Geffen GJ, Snoeren MM, Gielen MJ, Groen GJ. Ipsilateral brachial plexus block and hemidiaphragmatic paresis as adverse effect of a high thoracic paravertebral block. Reg Anesth Pain Med. 2011;36(2):198–201.

    PubMed  Google Scholar 

  • Richardson J, Vowden P, Sabanathan S. Bilateral paravertebral analgesia for major abdominal vascular-surgery—a preliminary-report. Anaesthesia. 1995;50:995–8.

    CAS  PubMed  Google Scholar 

  • Richardson J, Jones J, Atkinson R. The effect of thoracic paravertebral blockade on intercostal somatosensory evoked potentials. Anesth Analg. 1998;87:373–6.

    CAS  PubMed  Google Scholar 

  • Saito T, Den S, Tanuma K, Tanuma Y, Carney E, Carlsson C. Anatomical bases for paravertebral anesthetic block: fluid communication between the thoracic and lumbar paravertebral regions. Surg Radiol Anat. 1999a;21:359–63.

    CAS  PubMed  Google Scholar 

  • Saito T, Den S, Tanuma K, Carlsson C. Extended unilateral anesthesia in humans. Reg Anesth Pain Med. 1999b;24:15.

    Google Scholar 

  • Seidel R, Wree A, Schulze M. Thoracic-paravertebral blocks: comparative anatomical study with different injection techniques and volumes. Reg Anesth Pain Med. 2020;45:102–6.

    PubMed  Google Scholar 

  • Sharrock NE. Postural headache following thoracic somatic paravertebral nerve block. Anesthesiology. 1980;52:360–2.

    CAS  PubMed  Google Scholar 

  • Shaw WM, Hollis NY. Medial approach for paravertebral somatic nerve block. JAMA. 1952;148:742–4.

    CAS  Google Scholar 

  • Shibata Y, Nishiwaki K. Ultrasound-guided intercostal approach to thoracic paravertebral block. Anesth Analg. 2009;109:996–7.

    PubMed  Google Scholar 

  • Taketa Y, Fujitani T. A novel paralaminar in-plane approach for ultrasound-guided continuous thoracic paravertebral block using microconvex array transducer. Reg Anesth Pain Med. 2015;40:390.

    PubMed  Google Scholar 

  • Taketa Y, Fujitani T, Irisawa Y, Sudo S, Takaishi K. Ultrasound-guided thoracic paravertebral block by the paralaminar in-plane approach using a microconvex array transducer: methodological utility based on anatomical structures. J Anesth. 2017;31:271–7.

    PubMed  Google Scholar 

  • Taketa Y, Irisawa Y, Fujitani T. Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: a randomised trial. Acta Anaesthesiol Scand. 2018;62:1274–9.

    CAS  PubMed  Google Scholar 

  • Uppal V, Sondekoppam RV, Sodhi P, Johnston D, Ganapathy S. Single-injection versus multiple-injection technique of ultrasound-guided paravertebral blocks: a randomized controlled study comparing dermatomal spread. Reg Anesth Pain Med. 2017;42:575–81.

    PubMed  Google Scholar 

  • Wu ZW, Ni HD, Hou XM, Lu YP, Zhou XY, Yao M. [Effects of lateral and medial points of thoracic paravertebral nerve block by ultrasound for rapid recovery after laparoscopic cholecystectomy]. Zhonghua Yi Xue Za Zhi. 2019;99:988–92.

    Google Scholar 

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Acknowledgments

The cadaver anatomical sections are courtesy of the Visible Human Server at École Polytechnique Fédérale de Lausanne, Visible Human Visualization Software (http://visiblehuman.epfl.ch) and Gold Standard Multimedia (www.gsm.org).

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Authors and Affiliations

  1. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong

    Ranjith Kumar Sivakumar & Manoj Kumar Karmakar

Authors
  1. Ranjith Kumar Sivakumar
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  2. Manoj Kumar Karmakar
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Correspondence to Manoj Kumar Karmakar .

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Editors and Affiliations

  1. DGS – Cologne – Huerth, Cologne-Hürth, Germany

    Danilo Jankovic

  2. Department of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada

    Philip Peng

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Sivakumar, R.K., Karmakar, M.K. (2022). Ultrasound-Guided Thoracic Paravertebral Block. In: Jankovic, D., Peng, P. (eds) Regional Nerve Blocks in Anesthesia and Pain Therapy. Springer, Cham. https://doi.org/10.1007/978-3-030-88727-8_30

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  • DOI: https://doi.org/10.1007/978-3-030-88727-8_30

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  • Online ISBN: 978-3-030-88727-8

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