Chapter 43

Thoracic paravertebral block (TPVB) is the technique of injecting local anesthetic alongside the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramen.1,2 This produces unilateral, segmental, somatic, and sympathetic nerve blockade,3 which is effective for anesthesia and in treating acute and chronic pain of unilateral origin from the chest and abdomen.1 Hugo Sellheim of Leipzig (1871–1936) is believed to have pioneered TPVB in 1905.1,2 Kappis, in 1919, developed the technique of paravertebral injection, which is comparable to the one in present-day use. Although paravertebral block was fairly popular in the early 1900s, it seemed to have fallen into disfavor during the mid and later part of the century, the reason for which is not known. In 1979 Eason and Wyatt rekindled interest by describing a technique of paravertebral catheter placement.4 Our understanding of the safety and efficacy of TPVB has improved significantly in the last 25 years, and there has been a gradual renewal of interest in this technique. Currently it is used not only for analgesia but also for surgical anesthesia,5–7 and its application has been extended to children.8–10

### Anatomy

The thoracic paravertebral space (TPVS) is a wedge-shaped space located on either side of the vertebral column (Figure 43–1). The parietal pleura forms the anterolateral boundary. The base is formed by the vertebral body, intervertebral disc, and the intervertebral foramen with its contents. The transverse process and the superior costotransverse ligament form the posterior boundary. Lying in between the parietal pleura anteriorly and the superior costotransverse ligament posteriorly is a fibroelastic structure, the endothoracic fascia, which is the deep fascia of the thorax (Figure 43–1, 43–2, and 43–3). Medially the endothoracic fascia is attached to the periosteum of the vertebral body. A layer of loose areolar connective tissue, the subserous fascia, lies between the parietal pleura and the endothoracic fascia. Therefore there are two potential fascial compartments in the TPVS: the anterior extrapleural paravertebral compartment and the posterior subendothoracic paravertebral compartment (see Figures 43–1 and 43–2). The TPVS contains adipose tissue within which lie the intercostal (spinal) nerve, the dorsal ramus, intercostal vessels, rami communicantes, and anteriorly the sympathetic chain. The spinal nerves are segmented into small bundles and lie freely in the adipose tissue of the TPVS, which make them accessible to local anesthetic solutions injected into the TPVS.16

###### Fig. 43-1

Anatomy of the thoracic paravertebral space. SP, spinous process; TP, transverse process; VB, vertebral body. The blue shaded area represents the paravertebral space.

###### Fig. 43-2

The endothoracic fascia and its anatomic relation to the structures in the thoracic paravertebral space. Note the fascial compartments and the location of the ...

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