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Paravertebral Block
Rafael Vazquez, MD; Nicole Z. Spence, MD; James Taylor Lloyd, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Abbreviations

              • Paravertebral block (PVB)
              • Paravertebral space (PVS)
              • Transverse process (TP)
              • Superior costotransverse ligament (SCTL)
            • Synonyms

              • Thoracic paravertebral block
              • Paravertebral nerve block
            • Definitions

              • Nerve blockade targeting dorsal and ventral roots of spinal nerves in triangular, wedge-shaped space lateral to spinal foramina
                • Borders of PVS
                  • Posteriorly: TP, SCTL, and internal intercostal membrane laterally (these are contiguous structures)
                  • Anteriorly: Endothoracic fascia and innermost intercostal membrane
                  • Medially: Vertebral body, intervertebral foramen, and epidural space
                • Contents of PVS
                  • Adipose tissue
                  • Anterior (ventral) ramus of spinal (intercostal) nerves
                    • Anterior divisions lie between endothoracic fascia and internal intercostal membrane, continue between innermost and internal intercostal muscles to terminate as anterior cutaneous branches
                    • Lateral branch given off midway between vertebral body and sternum approximately at midaxillary line, which divides into anterior and posterior branches
                  • Posterior (dorsal) ramus of spinal (intercostal) nerves
                    • Posterior divides into medial, intermediate, and lateral branches and supplies muscles and skin of posterior part of chest (upper back)
                  • Sympathetic chain
                  • Rami communicans
                • Thoracic PVS communicates with
                  • Medial: Epidural space
                  • Lateral: Intercostal space
                  • Cranial/superior: Cervical PVS
                  • Caudal/inferior: Transversalis fascia but limited spread due to origin of psoas muscle/arcuate ligament
              • Renders anesthesia to thorax and abdominal wall, corresponding to dermatomal level of injection
              • Provides ipsilateral somatic and visceral analgesia
                • Can provide ipsilateral sympathetic blockade
                • Some spread of local anesthetic toward epidural space
                • If performing bilateral PVB, potential for bilateral epidural spread
                • Epidural or prevertebral spread can cause contralateral anesthesia after single injection thoracic PVB
              • Analgesia for > 12 hours
                • Catheter can be placed if longer analgesia duration desired

            PREPROCEDURE

            • Indications

              • Contraindications

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Equipment Preparation

                      • Procedure Steps

                        • Findings and Reporting

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Expected Outcome

                              • Things to Do

                                • Things to Avoid

                                  OUTCOMES

                                  • Problems

                                    • Complications

                                      Selected References

                                      1. Chen L et al: Comparison of programmed intermittent bolus infusion and continuous infusion for postoperative patient-controlled analgesia with thoracic paravertebral block catheter: a randomized, double-blind, controlled trial. Reg Anesth Pain Med. 44(2):240-5, 2019
                                      2. Hong B et al: Thoracic paravertebral block with adjuvant dexmedetomidine in video-assisted thoracoscopic surgery: a randomized, double-blind study. J Clin Med. 8(3), 2019
                                      3. D'Ercole F et al: Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth. 32(2):915-27, 2018
                                      4. Hutchins JL et al: Thoracic paravertebral block versus thoracic epidural analgesia for post-operative pain control in open pancreatic surgery: a randomized controlled trial. J Clin Anesth. 48:41-5, 2018
                                      5. Xu J et al: Multilevel thoracic paravertebral block using ropivacaine with/without dexmedetomidine in video-assisted thoracoscopic surgery. J Cardiothorac Vasc Anesth. 32(1):318-24, 2018
                                      6. Galvagno SM Jr et al: Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 81(5):936-51, 2016
                                      7. Parikh RP et al: Preoperative paravertebral block improves postoperative pain control and reduces hospital length of stay in patients undergoing autologous breast reconstruction after mastectomy for breast cancer. Ann Surg Oncol. 23(13):4262-9, 2016
                                      8. Agarwal RR et al: Single-injection thoracic paravertebral block and postoperative analgesia after mastectomy: a retrospective cohort study. J Clin Anesth. 27(5):371-4, 2015
                                      9. Krediet AC et al: Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology. 123(2):459-74, 2015
                                      10. Gazzera C et al: Role of paravertebral block anaesthesia during percutaneous transhepatic thermoablation. Radiol Med. 119(8):549-57, 2014
                                      11. Marqués A et al: Ultrasound-guided paravertebral block for management of abdominal pain after transarterial embolization using drug-eluting beads loaded with irinotecan. J Vasc Interv Radiol. 24(9):1416-7, 2013
                                      12. Cheung Ning M et al: Right thoracic paravertebral anaesthesia for percutaneous radiofrequency ablation of liver tumours. Br J Radiol. 84(1005):785-9, 2011
                                      13. Gulbahar G et al: A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg. 37(2):467-72, 2010
                                      14. Olivier JF et al: A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 10(5):E357-62, 2007
                                      15. Culp WC et al: Paravertebral block: an improved method of pain control in percutaneous transhepatic biliary drainage. Cardiovasc Intervent Radiol. 29(6):1015-21, 2006
                                      16. Culp WC Jr et al: Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol. 16(10):1397-400, 2005
                                      17. VanSonnenberg E et al: Radiofrequency ablation of thoracic lesions: part 2, initial clinical experience--technical and multidisciplinary considerations in 30 patients. AJR Am J Roentgenol. 184(2):381-90, 2005
                                      18. Karmakar MK: Thoracic paravertebral block. Anesthesiology. 95(3):771-80, 2001
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Preprocedure

                                          • Procedure

                                            • Post Procedure

                                              • Outcomes

                                                TERMINOLOGY

                                                • Abbreviations

                                                  • Paravertebral block (PVB)
                                                  • Paravertebral space (PVS)
                                                  • Transverse process (TP)
                                                  • Superior costotransverse ligament (SCTL)
                                                • Synonyms

                                                  • Thoracic paravertebral block
                                                  • Paravertebral nerve block
                                                • Definitions

                                                  • Nerve blockade targeting dorsal and ventral roots of spinal nerves in triangular, wedge-shaped space lateral to spinal foramina
                                                    • Borders of PVS
                                                      • Posteriorly: TP, SCTL, and internal intercostal membrane laterally (these are contiguous structures)
                                                      • Anteriorly: Endothoracic fascia and innermost intercostal membrane
                                                      • Medially: Vertebral body, intervertebral foramen, and epidural space
                                                    • Contents of PVS
                                                      • Adipose tissue
                                                      • Anterior (ventral) ramus of spinal (intercostal) nerves
                                                        • Anterior divisions lie between endothoracic fascia and internal intercostal membrane, continue between innermost and internal intercostal muscles to terminate as anterior cutaneous branches
                                                        • Lateral branch given off midway between vertebral body and sternum approximately at midaxillary line, which divides into anterior and posterior branches
                                                      • Posterior (dorsal) ramus of spinal (intercostal) nerves
                                                        • Posterior divides into medial, intermediate, and lateral branches and supplies muscles and skin of posterior part of chest (upper back)
                                                      • Sympathetic chain
                                                      • Rami communicans
                                                    • Thoracic PVS communicates with
                                                      • Medial: Epidural space
                                                      • Lateral: Intercostal space
                                                      • Cranial/superior: Cervical PVS
                                                      • Caudal/inferior: Transversalis fascia but limited spread due to origin of psoas muscle/arcuate ligament
                                                  • Renders anesthesia to thorax and abdominal wall, corresponding to dermatomal level of injection
                                                  • Provides ipsilateral somatic and visceral analgesia
                                                    • Can provide ipsilateral sympathetic blockade
                                                    • Some spread of local anesthetic toward epidural space
                                                    • If performing bilateral PVB, potential for bilateral epidural spread
                                                    • Epidural or prevertebral spread can cause contralateral anesthesia after single injection thoracic PVB
                                                  • Analgesia for > 12 hours
                                                    • Catheter can be placed if longer analgesia duration desired

                                                PREPROCEDURE

                                                • Indications

                                                  • Contraindications

                                                    • Getting Started

                                                      PROCEDURE

                                                      • Patient Position/Location

                                                        • Equipment Preparation

                                                          • Procedure Steps

                                                            • Findings and Reporting

                                                              • Alternative Procedures/Therapies

                                                                POST PROCEDURE

                                                                • Expected Outcome

                                                                  • Things to Do

                                                                    • Things to Avoid

                                                                      OUTCOMES

                                                                      • Problems

                                                                        • Complications

                                                                          Selected References

                                                                          1. Chen L et al: Comparison of programmed intermittent bolus infusion and continuous infusion for postoperative patient-controlled analgesia with thoracic paravertebral block catheter: a randomized, double-blind, controlled trial. Reg Anesth Pain Med. 44(2):240-5, 2019
                                                                          2. Hong B et al: Thoracic paravertebral block with adjuvant dexmedetomidine in video-assisted thoracoscopic surgery: a randomized, double-blind study. J Clin Med. 8(3), 2019
                                                                          3. D'Ercole F et al: Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth. 32(2):915-27, 2018
                                                                          4. Hutchins JL et al: Thoracic paravertebral block versus thoracic epidural analgesia for post-operative pain control in open pancreatic surgery: a randomized controlled trial. J Clin Anesth. 48:41-5, 2018
                                                                          5. Xu J et al: Multilevel thoracic paravertebral block using ropivacaine with/without dexmedetomidine in video-assisted thoracoscopic surgery. J Cardiothorac Vasc Anesth. 32(1):318-24, 2018
                                                                          6. Galvagno SM Jr et al: Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 81(5):936-51, 2016
                                                                          7. Parikh RP et al: Preoperative paravertebral block improves postoperative pain control and reduces hospital length of stay in patients undergoing autologous breast reconstruction after mastectomy for breast cancer. Ann Surg Oncol. 23(13):4262-9, 2016
                                                                          8. Agarwal RR et al: Single-injection thoracic paravertebral block and postoperative analgesia after mastectomy: a retrospective cohort study. J Clin Anesth. 27(5):371-4, 2015
                                                                          9. Krediet AC et al: Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology. 123(2):459-74, 2015
                                                                          10. Gazzera C et al: Role of paravertebral block anaesthesia during percutaneous transhepatic thermoablation. Radiol Med. 119(8):549-57, 2014
                                                                          11. Marqués A et al: Ultrasound-guided paravertebral block for management of abdominal pain after transarterial embolization using drug-eluting beads loaded with irinotecan. J Vasc Interv Radiol. 24(9):1416-7, 2013
                                                                          12. Cheung Ning M et al: Right thoracic paravertebral anaesthesia for percutaneous radiofrequency ablation of liver tumours. Br J Radiol. 84(1005):785-9, 2011
                                                                          13. Gulbahar G et al: A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg. 37(2):467-72, 2010
                                                                          14. Olivier JF et al: A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 10(5):E357-62, 2007
                                                                          15. Culp WC et al: Paravertebral block: an improved method of pain control in percutaneous transhepatic biliary drainage. Cardiovasc Intervent Radiol. 29(6):1015-21, 2006
                                                                          16. Culp WC Jr et al: Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol. 16(10):1397-400, 2005
                                                                          17. VanSonnenberg E et al: Radiofrequency ablation of thoracic lesions: part 2, initial clinical experience--technical and multidisciplinary considerations in 30 patients. AJR Am J Roentgenol. 184(2):381-90, 2005
                                                                          18. Karmakar MK: Thoracic paravertebral block. Anesthesiology. 95(3):771-80, 2001