Paravertebral block: An overview

The Role of Acupuncture in Interventional Pain Management

Objective: Interventional pain management has been recognized over the last couple of decades for treating chronic-pain syndromes. Acupuncture is a nonpharmacologic therapeutic option for pain management and may be an option for different patients with contraindications for interventional pain management. This review explores this options. Method: This limited review examines the role of acupuncture for managing head-and-neck pain and lower-back pain, according to interventional pain management. Conclusions: Acupuncture at various points, corresponding to the stellate ganglion, which is ST 10 Shuitu, and corresponding to the splanchnic nerve and the facet joint of the lumbar vertebra-which are Ex-B2 paravertebra-can be applied for pain management in the head-and-neck area and in the lower-back area. According to various research findings, acupuncture is effective and safe for reducing pain in the head and neck area, as well as in the lower back.

Complication rate of ultrasound-guided paravertebral block for breast surgery

Background and objectives

Thoracic paravertebral blockade is often used as an anesthetic and/or analgesic technique for breast surgery. With ultrasound guidance, the rate of complications is speculated to be lower than when using landmark-based techniques. This investigation aimed to quantify the incidence of pleural puncture and pneumothorax following non-continuous ultrasound-guided thoracic paravertebral blockade for breast surgery.

Methods

Patients who received thoracic paravertebral blockade for breast surgery were identified by retrospective query of our institution’s electronic database over a 5-year period. Data collected included patient demographics, level of block, type and volume of local anesthetic, occurrence of pleural puncture, occurrence of pneumothorax, evidence of local anesthetic toxicity, and patient vital signs. The incidence of block complications, including pleural puncture, pneumothorax, and local anesthetic toxicity, were ascertained.

Results

529 patients underwent 2163 thoracic paravertebral injections. Zero pleural punctures were identified during block performance; however, two patients were found to have a pneumothorax on postoperative chest X-ray (3.6 per 1000 surgeries, 95% CI 0.5 to 13.6; 0.9 per 1000 levels blocked, 95% CI 0.1 to 3.3). There were no cases of local anesthetic systemic toxicity or associated lipid emulsion therapy administration.

Conclusions

Pneumothorax following non-continuous ultrasound-guided thoracic paravertebral block using a parasagittal approach is an uncommon occurrence, with a similar rate to pneumothorax following breast surgery alone.

Tissue classification in intercostal and paravertebral ultrasound using spectral analysis of radiofrequency backscatter

Paravertebral and intercostal nerve blocks have experienced a resurgence in popularity. Ultrasound has become the gold standard for visualization of the needle during injection of the analgesic, but the intercostal artery and vein can be difficult to visualize. We investigated the use of spectral analysis of raw radiofrequency (RF) ultrasound signals for identification of the intercostal vessels and six other tissue types in the intercostal and paravertebral spaces. Features derived from the one-dimensional spectrum, two-dimensional spectrum, and cepstrum were used to train four different machine learning algorithms. In addition, the use of the average normalized spectrum as the feature set was compared with the derived feature set. Compared to a support vector machine (SVM) (74.2%), an artificial neural network (ANN) (68.2%), and multinomial analysis (64.1%), a random forest (84.9%) resulted in the most accurate classification. The accuracy using a random forest trained with the first 15 principal components of the average normalized spectrum was 87.0%. These results demonstrate that using a machine learning algorithm with spectral analysis of raw RF ultrasound signals has the potential to provide tissue characterization in intercostal and paravertebral ultrasound.

Ultrasound-guided thoracic paravertebral block for closed loop ileostomy repair in severe COPD: a case report

Background and objectives

Ultrasound-guided thoracic paravertebral block is usually considered a good alternative to epidural thoracic for anesthesia and pain control in thoracic and breast surgery. Furthermore it has also been used during abdominal surgery lately, especially hepatic and renal surgery. However, its role is poorly defined in this context. The purpose of this report was to highlight the role of thoracic paravertebral block in providing effective anesthesia and analgesia during both the abdominal surgical intervention and pain control in post-operative period, avoiding possible complications which general anesthesia may arise, which are fairly common in patients with chronic obstructive pulmonary disease and similar comorbidities.

Case report

The authors present a case of abdominal surgery successfully performed on a woman affected by severe chronic obstructive pulmonary disease requiring closed loop ileostomy repair performed with ultrasound guided thoracic paravertebral block without any complications.

Conclusions

Thoracic paravertebral block may be a safe anesthetic method for abdominal surgery in those patients who would undergo potential severe complications by using general anesthesia.

[Ultrasound-guided thoracic paravertebral block for closed loop ileostomy repair in severe COPD: a case report]

BACKGROUND AND OBJECTIVES

Ultrasound-guided thoracic paravertebral block is usually considered a good alternative to epidural thoracic for anesthesia and pain control in thoracic and breast surgery. Furthermore it has also been used during abdominal surgery lately, especially hepatic and renal surgery. However, its role is poorly defined in this context. The purpose of this report was to highlight the role of thoracic paravertebral block in providing effective anesthesia and analgesia during both the abdominal surgical intervention and pain control in post-operative period, avoiding possible complications which general anesthesia may arise, which are fairly common in patients with chronic obstructive pulmonary disease and similar comorbidities.

CASE REPORT

The authors present a case of abdominal surgery successfully performed on a woman affected by severe chronic obstructive pulmonary disease requiring closed loop ileostomy repair performed with ultrasound guided thoracic paravertebral block without any complications.

CONCLUSIONS

Thoracic paravertebral block may be a safe anesthetic method for abdominal surgery in those patients who would undergo potential severe complications by using general anesthesia.

Effect of Dexmedetomidine Versus Nalbuphine as an Adjuvant on Paravertebral Block to Manage Postoperative Pain After Mastectomies

Background and Objective

Breast cancer is the commonest cancer in women worldwide. Many patients are frequently admitted to the operating theaters for mastectomies. Thoracic paravertebral block (PVB) is increasingly used as an effective means for post-operative pain relief. The present study aimed at evaluating the effectiveness and safety of dexmedetomidine and nalbuphine as an adjuvant to bupivacaine local anesthetic in thoracic paravertebral block in breast cancer surgeries.

Methods

A total of 60 female patients aged 18 to 78 were included in the study, and ASA I, II, III were scheduled for mastectomy. These patients were unsystematically assigned into three 20-member groups: group PB received bupivacaine (0.3 mL/ kg) + 1 mL (0.9% sodium chloride) normal saline; group PBD received bupivacaine (0.3 mL/kg) + dexmedetomidine 1 μg/kg; and Group PBN received bupivacaine (0.3 mL/kg) and 10 mg (1 mL) nalbuphine. Demographic data, intraoperative SPO₂, ETCO₂, HR, SBP and DBP, pain scores (at rest and movement), and sedation scores were recorded every 30 minutes during the initial 2 hours and 4, 8, 24, and 48 hours from T0. Also, postoperative tramadol consumption, the time to the first analgesic request, and any complications were also recorded.

Results

There were no statistically significant differences among the three groups regarding demographic data, SPO₂, ETCO₂, HR, SBP and DBP intraoperatively. Moreover, no significant difference was found in HR, SBP and DBP postoperatively. Postoperative pain scores were significantly higher in group BP, whether at rest or movement. The sedation was significantly higher in PBD group in the first 12 hours postoperatively. There was a significantly lower postoperative tramadol consumption in PBN group and a significantly longer time to the first analgesic request than other groups. No complications were reported in any group.

Conclusions

Addition of nalbuphine 10 mg as an adjuvant to bupivacaine local anesthetic in PVB improved the quality of the block and decreased postoperative analgesic requirements than the bupivacaine only group and dexmedetomidine and bupivacaine group. However, adding dexmedetomidine to bupivacaine increased the time to the first analgesic request and more sedation than bupivacaine and bupivacaine and nalbuphine.

Anesthetic considerations for nontransplant procedures in lung transplant patients

Lung transplantation has become an accepted option for many patients with end-stage pulmonary diseases. Anesthesia and surgery following lung transplantation may be required for various diseases that may affect both systemic organs and the transplanted graft. When a patient with a lung transplant undergoes surgery, there is the potential for interference with lung function, depending on the type of intervention and its anatomical site. Accurate preoperative evaluation, an understanding of the physiology of the transplanted lung, proper airway instrumentation, individualized management of intraoperative ventilation, and fluid balance are essential for a positive perioperative outcome.

[Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]

INTRODUCTION

Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements.

MATERIAL AND METHODS

An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block.

RESULTS

In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II.

CONCLUSIONS

Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.