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KEY POINTS

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KEY POINTS

  1. A paravertebral nerve block involves conduction block of the spinal nerve within the paravertebral space.

  2. Dense sensory, motor, and sympathetic block results.

  3. Unilateral or bilateral, thoracic, or lumbar segmental block can be obtained.

  4. Common indications include thoracic surgery, breast surgery, and hernia repair.

  5. Benefits include diminished stress response to surgery; decreased opioid consumption; reduced opioid-related side effects (nausea, vomiting, sedation); and hemodynamic stability, as well as preservation of pulmonary mechanics, lower extremity strength, and bladder function, and potentially, a decreased incidence of postthoracotomy and postmastectomy chronic pain.

  6. Potential adverse effects are rare and include pleural puncture, pneumothorax, epidural or intrathecal injection, and local anesthetic toxicity.

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INTRODUCTION

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Paravertebral nerve blockade (PVB) involves injection of local anesthetic at the nerve rootlets within the paravertebral space (PVS). The resultant unilateral or bilateral segmental anesthesia and analgesia of thoracic or lumbar dermatomes have multiple applications. In this chapter, paravertebral anatomy and PVB techniques are described. The physiologic effects are discussed in relation to the advantages, disadvantages, and contraindications for PVB. The existing literature outlining the use of PVB for a variety of surgical procedures is summarized.

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PARAVERTEBRAL ANATOMY

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THORACIC PARAVERTEBRAL ANATOMY

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The thoracic PVS is a wedge-shaped space that lies on each side of the vertebral column. Detailed descriptions of the anatomic features of the PVS are available.1-8

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Figures 43-1 and 43-2 illustrate the wedge-shaped boundaries of the thoracic PVS. Posteriorly, the space is limited by the superior costotransverse ligament. At each thoracic level, the superior costotransverse ligament extends from the lower border of the transverse process above to the upper border of the rib below (Figure 43-3). Anterolaterally, the thoracic PVS is limited by the parietal pleura. The medial base of the thoracic PVS is defined by the posterolateral segment of the vertebral body, the intervertebral disk, the intervertebral foramen, and its contents.

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FIGURE 43-1.

Transverse section of the thoracic spine depicting the boundaries, contents, and structures surrounding the paravertebral space. [Reproduced with permission from Eason MJ, Wyatt R. Paravertebral thoracic block-a reappraisal. Anaesthesia. 1979 Jul-Aug;34(7):638-642.]

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FIGURE 43-2.

Thoracic paravertebral space at thoracic level T5. The thoracic paravertebral space is highlighted in turquoise in both the transversal plane (left side of body) and the sagittal plane (right side of body). es, erector spinae muscle; r, rib; SCTL, superior costotransverse ligament; SP, spinous process; TP, transverse process; trap = trapezius muscle. [Reproduced with permission from Krediet AC, Moayeri N, van Geffen G-J, et al: Different Approaches to Ultrasound-guided Thoracic Paravertebral Block: An Illustrated Review. Anesthesiology. 2015 Aug;123(2):459-474.]

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FIGURE 43-3.

Posterior view of the thoracic spine depicting the relationship between the superior costotransverse ligament and the ...

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