Efficacy of paravertebral block techniques in thoracic surgery: systematic literature review
Postoperative pain in thoracic surgery in adults is usually severe, and to control it there are many analgesic methods that include paravertebral blockade (PVB). Until now, there is no clarity on which is the most effective technique to perform this blockade.
To describe the different PVB techniques and its analgesic effect in thoracic surgery.
A systematic review of the literature was performed. We included studies that analyzed patients in open chest surgery and used PVB as analgesic technique. The Cochrane and Grading of Recommendation Assessment, Development and Evaluation strategies were used to analyze biases and evidence. The results are presented graphically by means of a visual analog scale (VAS) pain and opioid consumption equivalent to morphine for each technique found. We summarize the results with a qualitative approach without meta-analysis.
A total of 38 articles were analyzed (2188 patients). 13 using PVB guided by surface anatomy (SA-PVB), 7 Ultrasound-guided PVB (US-PVB), 1 neurostimulation guided PVB (NE-PVB) and the remaining using PVB performed under direct visualization by the surgeon (S-PVB). A VAS of less than 3 was found in studies with SA-PVB and US-PVB, and greater than 5 in studies with S-PVB; however, opioid consumption in the postoperative period was similar between the techniques described.
PVB can be performed through 4 techniques. Techniques of US-PVB or SA-PVB have shown better consistency to manage postoperative acute pain in thoracic surgery.
2. Mesbah A, Yeung J, Gao F. Pain after thoracotomy. BJA Educ 2016;16:1-7.
3. Soto RG, Fu ES. Acute pain management for patients undergoing thoracotomy. Ann Thorac Surg 2003;75:1349-1357.
4. Tiippana E, Nilsson E, Kalso E. Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study. Acta Anaesthesiol Scand 2003;47:433-438.
5. Norum HM, Breivik H. A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy. Scand J Pain 2010;1:12-23.
6. D’Ercole F, Arora H, Kumar PA. Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth 2018;32:915-927.
7. Groen GJ, Ph D. Different approaches to ultrasound-guided thoracic paravertebral block. Anesthesiology 2015;123:459-474.
8. Eason MJ, Wyatt R. Paravertebral thoracic block-a reappraisal. Anaesthesia 1979;34:638-642.
9. Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001;95:771-780.
10. Hutchins J, Apostolidou I, Shumway S, et al. Paravertebral catheter use for postoperative pain control in patients after lung transplant surgery: a prospective observational study. J Cardiothorac Vasc Anesth 2017;31:142-146.
11. Komatsu T, Kino A, Inoue M, et al. Paravertebral block for video-assisted thoracoscopic surgery: analgesic effectiveness and role in fast-track surgery. Int J Surg 2014;12:936-939.
12. Ammar AS, Mahmoud KM. Does the addition of magnesium to bupivacaine improve postoperative analgesia of ultrasound-guided thoracic paravertebral block in patients undergoing thoracic surgery? J Anesth 2014;28:58-63.
13. Bauer C, Pavlakovic I, Mercier C, et al. Adding sufentanil to ropivacaine in continuous thoracic paravertebral block fails to improve analgesia after video-assisted thoracic surgery: a randomized controlled trial. Eur J Anaesthesiol 2018;35:766-773.
14. Dutta V, Kumar B, Jayant A, et al. Effect of continuous para-vertebral dexmedetomidine administration on intraoperative anesthetic drug requirement and post-thoracotomy pain syndrome after thoracotomy: a randomized controlled trial. J Cardiothorac Vasc Anesth 2017;31:159-165.
15. Hassan M, Mahran E. Evaluation of the role of dexmedetomidine in improvement of the analgesic profile of thoracic paravertebral block in thoracic surgeries: a randomized prospective clinical trial. Indian J Anaesth 2017;61:826-831.
16. Fibla JJ, Molins L, Mier JM, et al. Comparative analysis of analgesic quality in the postoperative of thoracotomy: paravertebral block with bupivacaine 0.5% vs ropivacaine 0.2%. Eur J Cardio-thoracic Surg 2008;33:430-434.
17. Fibla JJ, Molins L, Mier JM, et al. A prospective study of analgesic quality after a thoracotomy: paravertebral block with ropivacaine before and after rib spreading. Eur J Cardio-thoracic Surg 2009;36:901-905.
18. Garutti I, González-Aragoneses F, Biencinto MT, et al. Thoracic paravertebral block after thoracotomy: comparison of three different approaches. Eur J Cardio-thoracic Surg 2009;35: 829-832.
19. Kaya FN, Turker G, Mogol EB, et al. Thoracic paravertebral block for video-assisted thoracoscopic surgery: single injection versus multiple injections. J Cardiothorac Vasc Anesth 2012;26:90-94.
20. Biswas S, Verma R, Bhatia VK, et al. Comparison between thoracic epidural block and thoracic paravertebral block for post thoracotomy pain relief. J Clin Diagnostic Res 2016;10:UC08-UC12.
21. Ouerghi S, Frikha N, Mestiri T, et al. A prospective, randomized comparison of continuous paravertebral block and continuous intercostal nerve block for post-thoracotomy pain. S Afr J Anaesth Analg 2008;14:19-23.
22. Pintaric TS, Potocnik I, Hadzic A, et al. Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med 2011;36:256-260.
23. Vogt A, Stieger DS, Theurillat C, et al. Single-injection thoracic paravertebral block for postoperative pain treatment after thoracic surgery. Br J Anaesth 2005;95:816-821.
24. Dango S, Harris S, Offner K, et al. Combined paravertebral and intrathecal vs thoracic epidural analgesia for post-thoracotomy pain relief. Br J Anaesth 2013;110:443-449.
25. Hill SE, Stafford-Smith M, Keller RA, et al. Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracic procedures. Anesthesiology 2006;104:1047-1053.
26. Kosinski S, Fryzlewicz E, Wilkojc M, et al. Comparison of continuous epidural block and continuous paravertebral block in postoperative analgaesia after video-assisted thoracoscopic surgery lobectomy: a randomized, non-inferiority trial. Anaesthesiol Intensive Ther 2016;48:280-287.
27. Lockwood GG, Cabreros L, Banach D, et al. Continuous bilateral thoracic paravertebral blockade for analgesia after cardiac surgery: a randomized, controlled trial. Perfus 2017;32:591-597.
28. Luyet C, Siegenthaler A, Szucs-Farkas Z, et al. The location of paravertebral catheters placed using the landmark technique. Anaesthesia 2012;67:1321-1326.
29. Mehta , Yatin Arora D, Mishra Y, et al. Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery. Ann Card Anaesth 2009;11:91.
30. Messina M, Boroli F, Landoni G, et al. Comparison of epidural vs. paravertebral blockade. Minerva Anestesiol 2009;75:616-621.
31. Neuburger PJ, Kline RP, Grossi EA, et al. A prospective randomized study of paravertebral blockade in patients undergoing robotic mitral valve repair. J Cardiothorac Vasc Anest 2015;29:930-936.
32. El-Dawlatly A, Alnassar SA, Omar AB, et al. Ultrasound-guided thoracic paravertebral block for postoperative pain treatment after thoracic surgery. Int J Ultrasound Appl Technol Perioper Care 2010;1:23-26.
33. Li X-L, Zhang Y, Dai T, et al. The effects of preoperative single-dose thoracic paravertebral block on acute and chronic pain after thoracotomy. Medicine 2018;97:e11181.
34. Kadomatsu Y, Mori S, Ueno H, et al. Comparison of the analgesic effects of modified continuous intercostal block and paravertebral block under surgeon’s direct vision after video-assisted thoracic surgery: a randomized clinical trial. Gen Thorac Cardiovasc Surg 2018;66:425-431.
35. Kobayashi R, Mori S, Wakai K, et al. Paravertebral block via the surgical field versus epidural block for patients undergoing thoracotomy: a randomized clinical trial. Surg Today 2013;43: 963-969.
36. Matthews PJ, Govenden V. Comparison of continuous para-vertebral and extradural infusions of bupivacaine for pain relief after thoracotomy. Br J Anaesth 1989;62:204-205.
37. Perttunen K, Nilsson E, Heinonen J, et al. Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain. Br J Anaesth 1995;75:541-547.
38. Raveglia F, Rizzi A, Leporati A, et al. Analgesia in patients undergoing thoracotomy: epidural versus paravertebral technique. A randomized, double-blind, prospective study. J Thorac Cardiovasc Surg 2014;147:469-473.
39. Richardson J, Sabanathan S, Mearns AJ, et al. A prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery. Br J Anaesth 1995;75:405-408.
40. Tamura T, Mori S, Mori A, et al. A randomized controlled trial comparing paravertebral block via the surgical field with thoracic epidural block using ropivacaine for post-thoracotomy pain relief. J Anesth 2017;31:263-270.
41. Zhang X, Shu L, Lin C, et al. Comparison between intraoperative two-space injection thoracic paravertebral block and wound infiltration as a component of multimodal analgesia for postoperative pain management after video-assisted thoracoscopic lobectomy: a randomized controlled trial. J Cardiothorac Vasc Anesth 2015;29:1550-1556.
42. Baki ED, Öz G, Kokulu S, et al. Comparison of transcutaneous electrical nerve stimulation and paravertebral block for post-thoracotomy pain relief. Thorac Cardiovasc Surg 2015;63:514-518.
43. Fibla JJ, Molins L, Mier JM, et al. The efficacy of paravertebral block using a catheter technique for postoperative analgesia in thoracoscopic surgery: a randomized trial. Eur J Cardiothoracic Surg 2011;40:907-911.
44. Fibla JJ, Hernandez J, Sierra A, et al. A randomized prospective study of analgesic quality after thoracotomy: paravertebral block with bolus versus continuous infusion with an elastomeric pump. Eur J Cardio-Thoracic Surg 2015;47:631-635.
45. Fortier S, Hanna HA, Bernard A, et al. Comparison between systemic analgesia, continuous wound catheter analgesia and continuous thoracic paravertebral block: a randomized, controlled trial of post thoracotomy pain management. Eur J Anaesthesiol 2012;29:524-530.
46. Gulbahar G, Kocer B, Muratli SN, et al. A comparison of epidural and paravertebral catheterization techniques in post-thoracotomy pain management. EurJ Cardio-thoracic Surg 2010;37:467-472.
47. Helms O, Mariano J, Hentz JG, et al. Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study. EurJ Cardio-thoracic Surg 2011;40:902-906.
48. Komatsu T, Sowa T, Takahashi K, et al. Paravertebral block as a promising analgesic modality for managing post-thoracotomy pain. Ann Thorac Cardiovasc Surg 2014;20:113-116.
49. Richardson J, Sabanathan S, Jones J, et al. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth 1999;83:387-392.
50. Richardson J, Lönnqvist PA. Thoracic paravertebral block. Br J Anaesth 1998;81:230-238.
51. Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for post thoracotomy analgesia. Anesth Analg 2008;107:1026-1040.
52. Harky A, Clarke CG, Kar A, et al. Epidural analgesia versus paravertebral block in video-assisted thoracoscopic surgery. Interact Cardiovasc Thorac Surg 2019;28:404-406.
53. Pogatzki-zahn EM, Zahn PK. From preemptive to preventive analgesia. Curr Opin Anaesthesiol 2006;19:551-555.
54. Antonakakis JG, Ting PH, Sites B. Ultrasound-guided regional anesthesia for peripheral nerve blocks: an evidence-based outcome review. Anesthesiol Clin 2011;29:179-191.
55. Costache I, Pawa A, Abdallah FW. Paravertebral by proxy-time to redefine the paravertebral block. Anaesthesia 2018;73:1185-1188. [ Links ]
56. Forero M, Adhikary SD, Lopez H, et al. The erector spinae plane block a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-627.
57. Yang HM, Choi YJ, Kwon HJOJ, et al. Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study. Anaesthesia 2018;73:1244-1250.
58. Gelfand HJ, Ouanes JPP, Lesley MR, et al. Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis. J Clin Anesth 2011;23:90-96.
59. Boretsky K, Visoiu M, Bigeleisen P. Ultrasound-guided approach to the paravertebral space for catheter insertion in infants and children. Paediatr Anaesth 2013;23:1193-1198.
60. Viscusi ER. Liposomal drug delivery for postoperative pain management. Reg Anesth Pain Med 2005;30:491-496.
61. Uppal V, Sondekoppam RV, Sodhi P, et al. Single-injection versus multiple-injection technique of ultrasound-guided paravertebral blocks. Reg Anesth Pain Med 2017;42:575-581.
62. Scarfe AJ, Schuhmann-Hingel S, Duncan JK, et al. Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2016;50:1010-1018.
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