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Chapter 149. Thoracic Paravertebral Blocks

Jan Boublik, MD, PhD

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Surgical procedureLevels to be blocked
ThoracotomyT4–T9
ThoracoscopyT4–T9
Rib fracturesLevel of fracture with one level above and below
Cardiac surgeryT2–T6 bilaterally
Mastectomy, breast surgeryT2–T6
Mastectomy with axillary dissectionT1–T6 with superficial cervical plexus block
Breast biopsyLevel of lesion with one level above and below
Inguinal hernia repairT10–L2
Umbilical hernia repairT9–T11 bilaterally
Incisional hernia repairAccording to level of repair
Ileostomy closureT8–T12
NephrectomyT8–T12
CholecystectomyT6–T10
AppendectomyT10–T12
Adjunct for shoulder surgery (subdeltoid incision)T1–T2
Adjunct for hip surgeryT11–T12 with lumbar plexus block ± parasacral sciatic block
Bone marrow aspirationT11–L2 bilaterally
Iliac crest bone harvestingT11–L1
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Contraindications
Absolute
  • Patient refusal
  • Skin infections/empyema/paravertebral tumor at injection site
  • Local anesthetic allergy
  • Severe hemodynamic instability
Relative
  • Coagulopathy
  • Severe chest deformity
  • Prior thoracotomy
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Advantages of Paravertebral Block
  • Dense sensory, motor, and sympathetic nerve block (“complete” abolition of evoked potentials at the level of the paravertebral injection in 100% of patients, rare with epidural)
  • Unilateral or bilateral segmental block
  • Wide application for various surgical procedures
  • Decreased stress response to surgery
  • Postoperative analgesia similar or better than epidural
  • Low postoperative opioid requirements
  • Infrequent opioid-related side effects (nausea, vomiting, sedation)
  • Hemodynamic stability
  • Preservation of pulmonary function
  • Preservation of lower-extremity motor strength
  • Preservation of bladder function
  • Enhanced perioperative efficiency
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Complications/Side Effects
ComplicationReported incidence (%)
Block failure (no surgical anesthesia)6.1 (multiple injections) to 10.7 (single injection)
Inadvertent vascular puncture3.8–6.8
Hypotension4.0–5.0 (usually mild)
Localized hematoma2.4
Localized pain1.3
Pleural puncture0.8–0.9
Pneumothorax0.3–0.5
Epidural spread1.0–1.1
  • Pulmonary hemorrhage
  • Intrathecal spread
  • Dural puncture headache
  • Brachial plexus block
  • Horner syndrome
  • Local anesthetic toxicity
  • Nerve injury
  • Infection
Case reports
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Local Anesthetic Regimen for Paravertebral Nerve Blocks
  • Bupivacaine 0.25–0.5% and ropivacaine 0.2–0.5% most frequently used agents; duration of analgesia is similar to brachial plexus anesthesia
  • Epinephrine frequently added to indicate intravascular injection; reduce the peak local anesthetic blood level (25% reduction) and to improve analgesia
Single-level injection
  • Adults: 10–20 mL local anesthetic (e.g., 0.5% ropivacaine with epinephrine 1:400,000)
  • Children: 0.5 mL/kg up to 20 mL local anesthetic
Multiple-level injections3–5 mL local anesthetic per segment
Continuous infusion0.1–0.2 mL/kg/h (8–10 mL/h for standard adult) local anesthetic (e.g., 0.2% ropivacaine, 0.06% bupivacaine, 0.25% lidocaine)

(See Figures 149-2, 149-6, and 149-7)

  • Wedge-shaped space:
    • Anterolateral border: parietal pleura; medial: vertebral body/intervertebral disc
    • Posterior border: transverse process of vertebra, costotransverse ligament
  • Two fascias:
    • Endothoracic fascia: fibroelastic, between superior costotransverse ligament (posterior) and parietal pleura anteriorly; endothoracic fascia thus divides the thoracic paravertebral space (TPVS) into two potential fascial compartments:
      • The anterior extrapleural paravertebral compartment
      • The posterior subendothoracic paravertebral compartment
    • Subserous fascia: layer of loose areolar connective tissue
      • ...

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