Chapter 48. Paravertebral Anesthesia

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.

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

Paravertebral nerve blockade (PVB) involves injection of local anesthetic close to the spinal nerve roots 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.

Thoracic Paravertebral Anatomy

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.1-7

Figure 48-1 illustrates 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 (Fig. 48-2). 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.

The PVS is continuous medially with the epidural space via the intervertebral foramen; in addition, dural sleeves may extend into the PVS.1,5,8 Laterally, the thoracic PVS is continuous with the intercostal space, lateral to the transverse processes. Communication with the contralateral PVS may occur by contact through the prevertebral9,10 or epidural spaces.2 The PVS is continuous superiorly and inferiorly across the heads and necks of adjacent ribs. The precise cranial limit of the PVS has not been fully elucidated; however, cervical spread ...