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
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
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
D'Ercole F et al: Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth. 32(2):915-27, 2018
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
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
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
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
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
Krediet AC et al: Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology. 123(2):459-74, 2015
Gazzera C et al: Role of paravertebral block anaesthesia during percutaneous transhepatic thermoablation. Radiol Med. 119(8):549-57, 2014
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
Cheung Ning M et al: Right thoracic paravertebral anaesthesia for percutaneous radiofrequency ablation of liver tumours. Br J Radiol. 84(1005):785-9, 2011
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
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
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
Culp WC Jr et al: Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol. 16(10):1397-400, 2005
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
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
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
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
D'Ercole F et al: Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth. 32(2):915-27, 2018
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
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
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
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
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
Krediet AC et al: Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology. 123(2):459-74, 2015
Gazzera C et al: Role of paravertebral block anaesthesia during percutaneous transhepatic thermoablation. Radiol Med. 119(8):549-57, 2014
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
Cheung Ning M et al: Right thoracic paravertebral anaesthesia for percutaneous radiofrequency ablation of liver tumours. Br J Radiol. 84(1005):785-9, 2011
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
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
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
Culp WC Jr et al: Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol. 16(10):1397-400, 2005
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