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BACKGROUND Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge. METHODS The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression. RESULTS Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001). CONCLUSION Paravertebral blocks are associated with decreased pain score at the time of hospital discharge. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background Several approaches have been proposed for ultrasound-guided thoracic paravertebral block, but the best approach remains unclear. Objective We compared two ultrasound-guided in-plane approaches using a microconvex probe, transverse and parasagittal. We assessed whether either approach would facilitate successful catheter placement in the paravertebral space. Design Randomised controlled trial. Setting University hospital, July 2015 to March 2016. Patients Sixty patients scheduled to undergo thoracotomy were randomly allocated into two groups. Interventions A microconvex probe was placed transversely between adjacent ribs (transverse) or sagittally between adjacent transverse processes (parasagittal). When the Tuohy needle reached the paravertebral space, a catheter was inserted to a depth of 4 cm. Then, 0.5-ml radiocontrast was injected through the catheter under fluoroscopy. Main outcome measures The primary outcome was successful catheter placement in the paravertebral space; secondary outcomes were 0 to 100 mm visual analogue scale pain score and morphine consumption in the first 24 h. Results All patients received the allocated paravertebral block. Correct catheter placement occurred in 23 (77%) and 24 patients (80%) using the transverse (n=30) and parasagittal approaches (n=30), respectively (P = 1.00). Five patients were excluded due to changes in surgical procedure. Postoperative pain, represented by median [IQR] visual analogue scale score, was 19.5 [12 to 25] at rest and 55 [44 to 77] on movement with the transverse approach (n=28) vs. 22 [12 to 33.5] at rest and 59 [41.5 to 75] on movement with the parasagittal approach (n=27) (P = 0.57 at rest, P = 0.76 on movement). Median morphine consumption was 11.5 [5 to 21] and 11 [5 to 18] mg in the transverse and parasagittal approaches, respectively (P = 0.99). Conclusion There were no clinically significant differences between approaches for continuous ultrasound-guided thoracic paravertebral block using a microconvex probe, and both approaches achieved a high rate of correct catheter placement. Trial registration UMIN Clinical Trials Registry identifier: UMIN000015988.

Editor’s PerspectiveWhat We Already Know about This TopicWhat This Article Tells Us That Is NewBackgroundThoracic paravertebral block is the preferred regional anesthetic technique for breast cancer surgery, but concerns over its invasiveness and risks have prompted search for alternatives. Pectoralis-II block is a promising analgesic technique and potential alternative to paravertebral block, but evidence of its absolute and relative effectiveness versus systemic analgesia (Control) and paravertebral block, respectively, is conflicting. This meta-analysis evaluates the analgesic effectiveness of Pectoralis-II versus Control and paravertebral block for breast cancer surgery.MethodsDatabases were searched for breast cancer surgery trials comparing Pectoralis-II with Control or paravertebral block. Postoperative oral morphine consumption and difference in area under curve for pooled rest pain scores more than 24 h were designated as coprimary outcomes. Opioid-related side effects, effects on long-term outcomes, such as chronic pain and opioid dependence, were also examined. Results were pooled using random-effects modeling.ResultsFourteen randomized trials (887 patients) were analyzed. Compared with Control, Pectoralis-II provided clinically important reductions in 24-h morphine consumption (at least 30.0 mg), by a weighted mean difference [95% CI] of −30.5 mg [−42.2, −18.8] (P < 0.00001), and in rest pain area under the curve more than 24 h, by −4.7cm · h [−5.1, −4.2] or −1.2cm [−1.3, −1.1] per measurement. Compared with paravertebral block, Pectoralis-II was not statistically worse (not different) for 24-h morphine consumption, and not clinically worse for rest pain area under curve more than 24 h. No differences were observed in opioid-related side effects or any other outcomes.ConclusionsWe found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively when compared with systemic analgesia alone; and it also offers analgesic benefits noninferior to those of paravertebral block after breast cancer surgery. Evidence supports incorporating Pectoralis-II into multimodal analgesia and also using it as a paravertebral block alternative in this population.

Background: Postoperative (post-op) pain following minimally-invasive cardiac surgery (MICS) may complicate outcomes in patients having surgery performed through a right mini-thoracotomy. Regional anaesthesia, by delivery of local anaesthetic agents to the paravertebral space using a paravertebral catheter (paravertebral block, PVB) may be useful to reduce post-op pain, however, few studies have reported outcomes on patients undergoing MICS with the use of a PVB. Methods: Ninety consecutive patients who underwent MICS at Vancouver General Hospital between January 2016 and May 2019 were included in this retrospective study. Data were collected for 53 patients who only had routine pain control (control) and 37 patients who had a PVB (PVB). Primary outcomes were post-op opioid use and hospital length of stay (LOS). Peri-operative (peri-op) death and stroke were secondary outcomes. Statistical analyses were performed using ANOVA single factor and t-tests. Results: Patient demographics and operative times were comparable between the two groups. The average total amount of opioid consumed in the PVB group was lower at 155.3 mg morphine equivalents, compared to 193.9 mg in the control group, however, the difference was not statistically significant (p=0.39) (Figure 1). However, the percentage of patients who did NOT receive any oxycodone was almost double in the PVB group (43.2% vs 24.5%, PVB vs control, respectively. p=0.06). The average LOS for the PVB group was significantly lower than the control group (5.4 vs 8.3 days, PVB vs control, respectively. p=0.006) (Figure 1). There were no peri-op deaths or strokes. Conclusion: In our experience, addition of a regional anesthetic was associated with ~20% reduction in the amount of opioid narcotic required. Although not statistically significant, this may be a clinically important difference, as the LOS was significantly lower in the PVB group. Outcomes in patients undergoing MICS may be improved with the addition of a PVB.

Background Postoperative supraventricular arrhythmias are common in patients after thoracoscopic lobectomy. Inadequate pain control has long been recognised as a significant risk factor for arrhythmias. The performance of ultrasound-guided (USG) thoracic paravertebral block (PVB) is increasing as an ideal technique for postoperative analgesia. Objective We conducted this study to evaluate whether a single-shot USG thoracic PVB would result in fewer postoperative supraventricular tachycardias (SVT) than intercostal nerve blocks (ICNBs) after thoracoscopic pulmonary resection. Design A randomised controlled study. Setting A single university hospital. Patients Sixty-eight patients undergoing thoracoscopic lobectomy were randomised into two equal groups of 34. Interventions For postoperative pain control, all patients received a total of 0.3 ml kg of a mixture containing 0.5% ropivacaine and 1/200 000 epinephrine after placement of needles for either a single thoracic PVB or two individual ICNBs, both guided by ultrasound. Data were obtained during the first 48 postoperative hours. Main outcome measures The primary outcome was the incidence of SVT after thoracoscopic pulmonary resection. Results During the first 48 postoperative hours, the incidences of SVT and atrial fibrillation were lower in the USG thoracic PVB group (14.7 vs. 46.9%, P = 0.004 and 3.0 vs. 18.8%, P = 0.037, respectively). The requirement for β-receptor blockade was more frequent in the ICNBs group than in the PVB group (5.9 vs. 25%, P = 0.033). Conclusion After placement of the needle using ultrasound guidance, a single-shot thoracic PVB is a well tolerated and effective technique to reduce the incidences of postoperative SVT and atrial fibrillation in patients undergoing thoracoscopic pulmonary resection. Trial registration http://www.chictr.org/cn/, registration number: ChiCTR-IOR-17010952.

Background Thoracoscopic lobectomy is less painful than normal thoracotomy, but pain management is still an issue in the postoperative period. Thoracic epidural analgesia (TEA) is considered as the gold standard for post-thoracotomy pain control, but is associated with numerous risks. Methods A total of 114 patients undergoing thoracoscopic lobectomy were randomly divided into three groups. Patients in the PVB-R group received a single-dose 0.5% ropivacaine paravertebral block (PVB), combined with patient-controlled intravenous analgesia (PCIA) after extubation during the 48-h postoperative period; those in the PVB-RD group received a single-dose 0.5% ropivacaine and dexmedetomidine (1 μg/kg) PVB, combined with the same PCIA scheme; and those in the TEA group received intraoperative thoracic epidural anesthesia with 0.5% ropivacaine, and a single dose of epidural morphine (0.03 mg/kg) after extubation combined with the same PCIA scheme. The dose and first time of postoperative analgesia, verbal rating score (VRS), change in catecholamine, cortisol and cytokine levels, change in hemodynamic parameters, and side effects during the postoperative period were recorded. Results Compared to the PVB-R group, the dose of postoperative analgesia and VRS were lower and the first time of postoperative analgesia were longer in the PVB-RD and TEA group. Patients in the PVB-RD group had a lower incidence of side effects compared to those in the TEA group. Conclusions Single-dose 0.5% ropivacaine combined with dexmedetomidine (1 μg/kg) PVB provides satisfactory postoperative pain control after thoracoscopic lobectomy, and can reduce the incidence of postoperative side effects.

Nonobstetric surgery during pregnancy is common. Administration of safe anesthesia to a pregnant patient, while minimizing its side effects on the fetus, is a major challenge for the anesthesiologist. Both general anesthesia and central neuraxial block are associated with risks during early pregnancy. Regional nerve blocks are being explored as possible alternatives whenever feasible. This report emphasizes the usefulness of ultrasound-guided, modified bilateral paravertebral block in a first-trimester pregnant patient undergoing microdiscectomy for cauda equina syndrome.

Various analgesic modalities have been tried to prolong the duration and to improve the quality of postoperative analgesia for the early rehabilitation and discharge from hospital after nephrectomy. Using local anaesthetic along with perineural steroids as adjuvant may prove promising for peripheral nerve block, especially paravertebral block (PVB). This article aims to assess the efficacy of dexamethasone with bupivacaine as adjuvant for single bolus injection of thoracic PVB in patients undergoing elective nephrectomy. Sixty patients of American Society of Anesthesiologists physical status I and II were randomly assigned to 2 groups of 30 patients each. Group D patients received 8 mg (2 mL) of dexamethasone mixed to 18 mL of 0.25% bupivacaine, whereas patients in group B received 18 mL of 0.25% bupivacaine and 2 mL of 0.9% saline as placebo to make a total volume of 20 mL infiltrated in PVB. Degree of analgesia achieved and duration of analgesia were recorded in each group along with total dose requirement of rescue analgesic and side effects in first 24 hours postoperatively. Group D patients with dexamethasone had VAS score of 0-3 after 09 minutes of block up to 610.48 ± 12.24 minutes and after 16 minutes up to 402.34 ± 28.12 minutes in another group B patient, respectively. The total dose of intravenous fentanyl in the first 24 hours postoperatively in group D was 98.6 ± 14.14 μg as compared with 147.6 ± 18.22 μg in group B. No other significant side effects were noted except for nausea and vomiting in 5 patients of placebo group. Dexamethasone, along with bupivacaine as adjunct for thoracic PVB, helps in improving the quality and enhancing the postoperative analgesia duration in patients undergoing nephrectomy.

Left ventricular assist device (LVAD) implantation is increasingly being used as a bridging therapy to heart transplantation. Infection is a major complication in patients with implanted LVADs, and it is associated with short- and long-term mortality. Surgical management for infection control is sometimes necessary; however, providing pain management during the surgical procedures is challenging. Anesthesiologists may be able to contribute to better pain management during surgical interventions to treat LVAD infections. We successfully performed a continuous thoracic paravertebral block (TPVB) for perioperative pain relief during invasive surgical procedures on three patients with infections of implanted LVADs. Despite several limitations that need to be addressed in the future, TPVB was able to relieve surgical pain in these patients without obvious complications.

REVIEW QUESTION/OBJECTIVE The objective of the systematic review is to synthesize the best available evidence on the effectiveness of thoracic paravertebral block compared with the use of systemic analgesia on postoperative pain in patients who have undergone a thoracotomy procedure.

While it has been shown that a paravertebral block provides effective postoperative analgesia for patients undergoing thoracic surgeries, including first rib resection, this is the first reported case of a paravertebral catheter used for perioperative analgesia in a patient undergoing first rib resection. We present the case of a 76-year-old woman with right upper extremity swelling who underwent infraclavicular first rib resection for venous thoracic outlet syndrome. Continuous infusion of ropivacaine through a T1 paravertebral catheter, which was placed before induction of general anesthesia but after T1 and T2 paravertebral blocks, provided effective postoperative pain control. Our experience suggests that paravertebral catheter infusions of local anesthetics may be effective adjuncts to general anesthesia in patients undergoing first rib resection and warrants further investigation.

Objective: To assess the effectiveness of paravertebral block for the percutaneous nephrolithotomy (PCNL) patients. Method: This study will be implemented from May 2021 to March 2022 at Affiliated Hospital of Youjiang Medical University for Nationalities and it was granted through the Research Ethics Committee of Affiliated Hospital of Youjiang Medical University for Nationalities (No.60192038). This study includes a total of 100 patients. The criteria for inclusion of patients involves: 1. patients over 60 years old; 2. American Society of Anaesthesiologists I or II classification. The criteria for exclusion involves: 1. skin infection at injection site, spinal deformity, abnormal coagulation function; 2. patient refusal, and known drug allergy. The visual analogue scores, heart rate, the diastolic and systolic blood pressure, complications, and side effects, the consumption of opioid and extra analgesic needs are recorded in rehabilitation room 1 hour after the surgery and in the first 24 hours of urological service. Results: Table 1 shows the postoperative data among 2 groups. Conclusion: In comparison with traditional analgesia, the ultrasound-guided paraventric block is an effective analgesic approach in PCNL, and no additional complications are encountered. Trial registration number: research registry 6259.

Supplemental Digital Content is available in the text, Background: Delirium is a common postoperative complication in older patients undergoing thoracic surgery and presages poor outcomes. Postoperative pain is an important factor in the progression of delirium. The purpose of this study was to test whether continuous thoracic paravertebral block (PVB), a more effective approach for analgesia, could decrease the incidence of delirium in elderly patients undergoing esophagectomy. Methods: A total of 180 geriatric patients undergoing esophagectomy were randomly divided into 2 groups and treated with PVB or patient-controlled analgesia (PCA). Perioperative plasma CRP, IL-1β, IL-6, and TNF-α levels were detected in all patients. Pain intensity was measured by a numerical rating scale. Delirium was assessed using the confusion assessment method. Results: The incidence of postoperative delirium was significantly lower in the PVB group than in the PCA group. Patients in the PVB group had lower plasma CRP, IL-1β, IL-6, and TNF-α levels and less pain when coughing after surgery. Conclusions: Ultrasound-guided continuous thoracic paravertebral block improved analgesia, reduced the inflammatory reaction and decreased the occurrence of delirium after surgery.

Given the fast development and increasing clinical relevance of ultrasound guidance for thoracic paravertebral blockade, this review article strives (1) to provide comprehensive information on thoracic paravertebral space anatomy, tailored to the needs of a regional anesthesia practitioner, (2) to interpret ultrasound images of the thoracic paravertebral space using cross-sectional anatomical images that are matched in location and plane, and (3) to briefly describe and discuss different ultrasound-guided approaches to thoracic paravertebral blockade. To illustrate the pertinent anatomy, high-resolution photographs of anatomical cross-sections are used. By using voxel anatomy, it is possible to visualize the needle pathway of different approaches in the same human specimen. This offers a unique presentation of this complex anatomical region and is inherently more realistic than anatomical drawings.

Continuous lumbar plexus block (LPB) is a well-accepted technique for regional analgesia after THA. However, many patients experience considerable quadriceps motor weakness with this technique, thus impairing their ability to achieve their physical therapy goals.We asked whether L2 paravertebral block (PVB) provides better postoperative analgesia (defined as decreased postoperative opioid consumption and lower pain scores), better preservation of motor function, and decreased length of hospital stay (LOS) compared to LPB in patients undergoing THA.Sixty patients undergoing minimally invasive THA under standardized spinal anesthesia were enrolled in this randomized controlled study. After exclusions, 53 patients were randomized into the L2 PVB (n = 27) and LPB (n = 26) groups. Patient-controlled analgesia was available for 24 hours. Motor and pain assessments were performed in the recovery room and at the end of 24 hours. LOS was also noted.Postoperative opioid consumption during the first 24 hours was less in the LPB group (mean ± SD: 24 ± 15 mg morphine) than in the L2 PVB group (32 ± 15 mg morphine; p = 0.005); however, postoperative pain scores were not different between groups. Postoperative motor and rehabilitation outcomes and LOS were also similar.Our study demonstrates that use of a LPB results in slightly less morphine consumption but comparable pain scores when compared with continuous L2 PVB. No difference was noted in terms of motor preservation or LOS. Although the difference in morphine consumption was only slightly in favor of the LPB group, the advantage of L2 PVBs noted by previous authors as preservation of motor function, was not seen. At our institute where LPBs have been performed for years, there seems to be no real advantage in switching to L2 PVBs. However, L2 PVB could be a reasonable alternative for operators who are wary of LPBs due to their high potential for complications and/or requiring advanced skills for its placement. But, since L2 PVBs are relatively new, not much is known about their complication profile. We recommend a thorough understanding of both techniques before attempting to place them.Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background:Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection.Methods:Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time.Results:Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced.Conclusion:Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

INTRODUCTION The analgesic efficacy of paravertebral block for percutaneous nephrolithotomy remains controversial. We conduct a systematic review and meta-analysis to explore the analgesic efficacy of paravertebral block for patients with percutaneous nephrolithotomy. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases, and randomized controlled trials (RCTs) assessing analgesic efficacy of paravertebral block for percutaneous nephrolithotomy are included in this meta-analysis. RESULTS Five RCTs are included in the meta-analysis. Overall, compared with control group after percutaneous nephrolithotomy, paravertebral block is associated with the decrease in analgesic consumption (standard mean difference (Std. MD) = -1.55; 95% confidence interval (CI) = -2.18 to -0.92; P

Two articles in this month’s Anesthesia & Analgesia address safety of regional anesthesia and analgesia in pediatrics.1,2 At first glance, one is very reassuring, the other is frightening. In this Editorial, we will recommend a middle ground. Practitioners of pediatric regional anesthesia should be careful and vigilant but can be confident that many types of complications can be made extremely rare by adopting some recommended practice patterns. Over the past 30 years, pediatric applications of postoperative regional anesthesia and analgesia have expanded rapidly.3 There is now a substantial body of studies regarding techniques, pharmacokinetics, and clinical outcomes. Agerelated trends in local anesthetic pharmacokinetics have been characterized, and safe dosing guidelines have been established.4 Most regional anesthesia in adults is performed awake or with doses of sedatives and analgesics that maintain verbal responsiveness, permitting patient reporting of paresthesias, severe pain with needle movement or injection, immediate symptoms of systemic local anesthetic effect, and progression of sensory and motor blockade over the minutes after injections. Textbooks, review articles, and consensus documents often strongly criticize performing most types of major peripheral or neuraxial blocks in adults under deep sedation or general anesthesia.5 In contrast, most, but not all, regional anesthesia in children is performed under either deep sedation or general anesthesia. Advocates of pediatric regional anesthesia have cited a series of retrospective and prospective safety studies to support their contention that the widespread practice of performing regional anesthesia under general anesthesia is safe.6–8 Polaner et al. report on the first 3 years of prospective registry data from PRAN, the Pediatric Regional Anesthesia Network, a consortium of North American pediatric centers. This report has a number of strengths. The data collection and analysis plan was generally thoughtfully constructed. There is a good degree of detail and new information regarding how procedures are performed and regarding most adverse events. The methodology for data gathering is likely to be fairly complete for intraoperative serious adverse events and for events occurring during patients’ inpatient stay. There are several scenarios that could potentially lead to underreporting of peripheral nerve injuries, most notably partial nerve injuries in nonverbal or nonambulatory children that might evade detection by parents and physicians. For example, a thoracic nerve root or an intercostal nerve injury following thoracic epidural or thoracic paravertebral block might not be detected in a preverbal child. In addition, for a patient in a cast, a deficit might not be apparent until days to weeks postoperatively. The methodology for postoperative surveillance in this registry is likely to omit some cases with delayed detection. Despite these possible sources for underreporting, the PRAN investigators make a good case for the overall very good safety of pediatric neuraxial and peripheral blocks as performed by clinicians in these hospitals. In contrast to the conclusion of the PRAN investigators that “nothing really bad happened,” Meyer et al. showed admirable courage and forthrightness in reporting on 4 cases of neurologic injury following epidural anesthesia in children. All 4 cases involve care by experienced anesthesiologists with extensive experience in pediatric epidural analgesia and acute and chronic pain management. Based on the incomplete information available in this case report, we would tend to agree with the authors’ general contention that there was “absence of proof of medical negligence.” A more important question, which the authors have addressed in their discussion, might be phrased as follows: “Based on these cases and other available knowledge, do we have ways to modify our practice to prevent similar complications in the future?” We consider the 4 cases in this light, taking advantage of “20–20 hindsight.” Among the 4 cases, case 1 was perhaps the most frightening, because the patient was healthy and uncomplicated, the epidural catheter placement proceeded uneventfully at a lumbar level below the terminus of the spinal cord, the duration of general anesthesia was short, and there were no hemodynamic clues intraoperatively to raise concerns. The test dose was appropriate (0.1 mL/kg). E EDITORIAL

While ultrasound imaging of the thoracic paravertebral space in 2-dimensional (D) mode allows examination of the paravertebral anatomy in the transverse or sagittal axis, volumetric 3D ultrasound imaging provides multiplanar images in several orthogonal (perpendicular) planes and may provide additional anatomical information. In this imaging study we assessed the feasibility of 3D ultrasound imaging of the anatomical area relevant to the thoracic paravertebral block.Four healthy young adult volunteers were recruited. With the volunteer in the sitting position, the C7 spinous process and the spinous processes of the T1 to 5 vertebra were identified. All images were obtained using a Philips iU22 ultrasound system with a high-frequency 3D 4D volume linear array transducer (13 to 5 MHz). A 3D volumetric scan of the right thoracic paravertebral region was performed with the sagittal plane as the data acquisition plane.With 3D multiplanar scanning, the sagittal, transverse, and coronal views of the paravertebral anatomy were simultaneously visualized in all subjects. Unlike 2D images, the articulation between the neck of the rib and the transverse process was well delineated in the sagittal and coronal images of the multiplanar scans. The rendered 3D volume allowed an in-depth view of the paravertebral anatomy from all sides (i.e., top, bottom, front, back, left, and right).Volumetric 3D ultrasound imaging of the thoracic paravertebral space is feasible and provides more detailed spatial anatomical information than 2D ultrasound imaging.

Objectives To assess the effect of paravertebral administration of dexmedetomidine as an adjuvant to local anesthetic on the intraoperative anesthetic drug requirement and incidence of post-thoracotomy pain syndrome. Design Prospective, randomized, controlled, double-blind trial. Setting Single university hospital. Participants The study comprised 30 patients who underwent elective thoracotomy and were assigned randomly to either the Ropin or Dexem group (n = 15 each). Interventions All patients received the study medications through paravertebral catheter. Patients in the Ropin group received a bolus of 15 mL of 0.75% ropivacaine over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine at 0.1 mL/kg/hour. Patients in the Dexem group received 15 mL of 0.75% ropivacaine plus dexmedetomidine, 1 µg/kg bolus over 3-to-5 minutes followed by an infusion of 0.2% ropivacaine plus 0.2 µg/kg/hour of dexmedetomidine at 0.1 mL/kg/hour. Measurements and Main Results The primary outcome of the study was intraoperative anesthetic drug requirement. The secondary outcome was the incidence of post-thoracotomy pain syndrome 2 months after surgery. The amount of propofol required for induction of anesthesia was significantly less in the Dexem group (Dexem 49.33±20.51 v 74.33±18.40 in the Ropin group, p = 0.002). End-tidal isoflurane needed to maintain target entropy was significantly less in the Dexem group at all time points. Intraoperative fentanyl requirement was lower in the Dexem group (Dexem 115.33±33.77 v 178.67±32.48 in the Ropin group, p = 0.002). Postoperative pain scores and morphine consumption were significantly less in the Dexem group (p Conclusions Paravertebral dexmedetomidine administration resulted in decreased intraoperative anesthetic drug requirement, less pain, and lower requirements of supplemental opioid in the postoperative period. However, it had no effect on the incidence of post-thoracotomy pain syndrome.

Background The efficacy of thoracic paravertebral block for thoracoscopic surgery remains controversial. We conduct a systematic review and meta-analysis to explore the impact of thoracic paravertebral block on thoracoscopic surgery. Methods We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through August 2018 for randomized controlled trials (RCTs) assessing the effect of thoracic paravertebral block on thoracoscopic surgery. This meta-analysis is performed using the random-effect model. Results Six RCTs involving 300 patients are included in the meta-analysis. Overall, compared with control group for thoracoscopic surgery, thoracic paravertebral block results in significantly reduced pain scores within 6 hours (Std. MD = -2.15; 95% CI = -3.67 to -0.62; P = .006), postoperative anesthesia consumption during 48 hours (Std. MD = -1.81; 95% CI = -3.05 to -0.58; P = .004), and hospital stay (Std. MD = -1.19; 95% CI = -2.13 to -0.26; P = .01), but has no important impact on pain scores at 24 hours (Std. MD = -1.10; 95% CI = -2.77-0.57; P = .20), and 48 hours (Std. MD = -1.25; 95% CI = -2.86-0.36; P = .13). Conclusions Thoracic paravertebral block can substantially enhance pain management for thoracoscopic surgery.

Background Dexmedetomidine (DEX) improves postoperative pain scores and prolongs the duration of blockage when combined with local anesthetics (LAs) for neuraxial and brachial plexus block; however, there is little information about the effectiveness of DEX as an adjuvant to LAs in paravertebral block (PVB). Therefore, a systematic review and meta-analysis were performed to evaluate the safety and efficacy of DEX combined with LAs in PVB. Method An electronic database search from inception date to February 2018 was performed. Randomized controlled trials (RCTs) comparing DEX as an adjuvant to LAs with LAs alone for PVB in adult patients were included. Postoperative pain scores, duration of analgesia, cumulative perioperative analgesic consumption, and adverse events were analyzed. Result We identified 7 trials enrolling 350 patients and found that DEX reduced pain scores at rest by standardized mean differences (SMD) −0.86 cm (95% confidence interval [CI] [−1.55, −0.17], P = .01) and SMD −0.93 cm (95% CI [−1.41, −0.26], P =.008) at postoperative 12 hours and 24 hours, respectively. DEX reduced pain scores while dynamic by SMD −1.63 cm (95% CI [−2.92, −0.34], P =.01) and SMD −1.78 cm (95% CI [−2.66, −0.90], P =.007) for postoperative 12 hours and 24 hours, respectively. DEX extended the duration of analgesia by weighted mean differences (WMD) 201.53 minutes (95% CI [33.45, 369.61], P =.02); and reduced cumulative postoperative analgesic consumption by WMD −7.71 mg (95% CI [−10.64, −4.78], P

Rationale: Evidence from cadaveric studies note that the sympathetic nerves from the second and third thoracic ganglia bypass the stellate ganglion in 20% of the population. We present a novel alternative technique for sympathetic blockade of upper extremity via thoracic epidural approach. Patient concerns: The patient-reported anxiety about “the placement of the needle in the front of the neck” and severe pain secondary to complex regional pain syndrome. Diagnoses: Complex regional pain syndrome type-1 with involvement of upper extremity. Interventions: A patient with upper extremity complex regional pain syndrome underwent sympathetic blockade of the upper extremity via thoracic epidural approach with advancement of a catheter through neural foramen and positioning the catheter tip in the upper thoracic paravertebral space. Outcomes: Clinical signs of successful sympathetic blockade of upper extremity were consistently observed after each block utilizing this alternative technique multiple times in a single patient. Lessons: Thoracic paravertebral block via thoracic epidural approach and catheter use may be an alternative technique for upper extremity sympathetic blockade. Potential advantages of this technique include complete sympathetic blockade of upper extremity for both diagnostic and therapeutic purposes, patient comfort with more effective local anesthetic administration for needle entry site, and potentially reduced risk of pneumothorax and inadvertent intravascular injection.

Background:Patients undergoing thoracotomy frequently experience acute pain and chronic post-thoracotomy pain (CPTP). There are few articles relating to the investigations on the effects of preoperative single-dose thoracic paravertebral block (PSTPVB) on acute pain and CPTP. We tested the h

BACKGROUND:The objective of this review was to assess the safety and efficacy of thoracic and lumbar paravertebral blocks (PVBs) for surgical anesthesia through a systematic review of the peer-reviewed literature. PVBs for surgical anesthesia were compared with general anesthesia (GA) or other regio

BACKGROUND: We developed a technique for ultrasound-guided paravertebral block, which was subsequently applied in the clinical setting. METHODS: An initial cadaver study was used to develop a technique that was used in the clinical setting on patients undergoing breast cancer surgery. RESULTS: Paravertebral catheters were correctly placed in the cadaveric trial in 8 of 10 attempts. In the clinical study, all blocked patients (n = 9) had evidence of thoracic wall sensory block and analgesia postoperatively. CONCLUSIONS: Determined by anatomical dissection, we have described the ultrasound features of the thoracic paravertebral space and performed clinically successful ultrasound-guided paravertebral block.

We describe an ultrasound-guided technique of continuous bilateral paravertebral block using an intercostal approach in 12 patients undergoing elective abdominal surgery. Postoperatively, each of the patient's paravertebral catheters was bolused with 10 mL lidocaine (15 mg/mL), and each of the patient's catheters was infused with 0.2% ropivacaine at 10 mL/h. Using a pinprick test, the median number of dermatomes blocked after the initial bolus was 5 (interquartile range, 4-6), and 23 of 24 catheters produced a local anesthetic block. The median verbal pain score on postoperative day 1 was 5.5 (interquartile range, 3.5-6), and median dose of IV hydromorphone consumed during the first 24 h after surgery was 1.9 mg (interquartile range, 0.7-5.05). All catheters were removed within 72 h after surgery.

Administration of morphine with intravenous patient-controlled analgesia (PCA) is a routine technique in postoperative pain relief on laminectomy. In this study, we aimed to evaulate the effect of preemptive paravertebral somatic block with levobupivacaine on postoperative morphine consumption. After approval of the Medical Faculty Ethics Commitee and patient consent, aged 20-70 years, American Society of Anesthesiologist physical status I-II, 100 patients who were undergoing laminectomy, were included. Patients were randomly divided into 2 groups: 0.1 mg/kg intravenous boluse mophine was given to patients in the first group 20 minutes before the end of operation and intravenous PCA morphine (40 mg morphine in 100 mL isotonic saline, PCA demand dose 0.02 mg kg, 20 min lockout time) was given after the operation. The patients in the second group were placed prone position after intubation, bilateral paravertebral somatic block was performed with 5 mL levobupivacaine 0,5% for each nerve to upper dermatome of laminectomy level. Intravenous PCA morphine was started after the end of operation. All patients were recieved 8 mg ondansetron for antiemesis. Postoperative systolic and diastolic blood pressures, heart rate, peripheral oxygen saturation values, pain [Visual Analog Scale (VAS)] scores, total morphine consumption and side effects were recorded. Demographic data, operation times and hemodynamic parameters of groups were similar. VAS scores were higher in group 1 than group 2 on postoperative 4, 6, and 12 hours (P

The posterior approach for placing continuous interscalene catheters has not been studied in a controlled investigation. In this randomized, triple-masked, placebo-controlled study, we tested the hypothesis that an ultrasound-guided continuous posterior interscalene block provides superior postoperative analgesia compared to a single-injection ropivacaine interscalene block after moderately painful shoulder surgery.Preoperatively, subjects received a stimulating interscalene catheter using an ultrasound-guided, in-plane posterior approach. All subjects received an initial bolus of ropivacaine. Postoperatively, subjects were discharged with oral analgesics and a portable infusion device containing either ropivacaine 0.2% or normal saline programmed to deliver a perineural infusion over 2 days. The primary outcome was average pain on postoperative day (POD) 1 (scale: 0-10). Secondary outcomes included least and worst pain scores, oral opioid requirements, sleep disturbances, patient satisfaction, and incidence of complications.Of the 32 subjects enrolled, 30 perineural catheters were placed per protocol. Continuous ropivacaine perineural infusion (n = 15) produced a statistically and clinically significant reduction in average pain (median [10th-90th percentile]) on POD 1 compared with saline infusion (n = 15) after initial ropivacaine bolus (0.0 [0.0-5.0] versus 3.0 [0.0-6.0], respectively; P0.001). Median oral opioid consumption (oxycodone) was lower in the ropivacaine group than in the placebo group on POD 1 (P = 0.002) and POD 2 (P = 0.002). Subjects who received a ropivacaine infusion suffered fewer sleep disturbances than those in the placebo group (P = 0.005 on POD 0 and 1 nights) and rated their satisfaction with analgesia higher than subjects who received normal saline (P0.001).Compared to a single-injection interscalene block, a 2-day continuous posterior interscalene block provides greater pain relief, minimizes supplemental opioid requirements, greatly improves sleep quality, and increases patient satisfaction after moderate-to-severe painful outpatient shoulder surgery.

To consider optimal analgesic strategies for thoracic surgical patients.Recent studies have consistently suggested analgesic equivalence between paravertebral and thoracic epidural analgesia. Complications appear to be significantly less common with paravertebral analgesia.There is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy. Important side-effects such as hypotension, urinary retention, nausea, and vomiting appear to be less frequent with paravertebral block than with thoracic epidural analgesia. Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia. Importantly, contraindications to thoracic epidural analgesia do not preclude paravertebral block, which can also be safely performed in anesthetized patients without an apparent increased risk of neurological injury. The place of paravertebral block in video-assisted thoracoscopic surgery is less clear.

BACKGROUND: The efficacy of continuous wound infiltration with local anesthetic has not been compared with that of thoracic paravertebral block (PVB) after breast surgery. In this study, we evaluated the analgesic efficacy and morphine consumption of the two techniques after mastectomy. METHODS: Forty-eight patients undergoing modified radical mastectomy with axillary dissection were randomly assigned to either a preoperative PVB with 20 mL of ropivacaine 0.5% (group PVB) or a continuous ropivacaine 0.5% infusion (CRI) at a 2 mL/h rate for each of two multilumen catheters placed subcutaneously at the end of the procedure (group CRI). The catheters were left in place for 24 h postoperatively. A standardized general anesthetic was administered to all patients. Postoperative morphine consumption, pain scores and painful restricted movement of the shoulder for 24 h postoperatively as well as incidence of adverse events, including postoperative nausea and vomiting, were recorded. RESULTS: Morphine consumption was similar between groups (PVB: 42.6 11 vs CRI: 38.7 11 mg in 24 h, P 0.225). Absolute pain scores were low in both groups. Four hours after surgery, group PVB showed a significant reduction in postoperative pain (PVB: 0 [0–10] vs CRI: 0 [0–30], P 0.002) and reduced painful restricted movement (P 0.004), whereas the CRI group had lower pain scores (PVB: 10 [0–30] vs CRI: 0 [0–20], P 0.034) and painful restricted movement (P 0.043) 16 and 24 h (PVB: 10 [0–30] vs CRI: 0 [0–30], P 0.012) after surgery. Postoperative nausea and vomiting was significantly more frequent in the CRI group (P 0.017). CONCLUSIONS: Continuous wound infiltration of local anesthetics is an effective alternative to paravertebral analgesia after mastectomy with axillary dissection. (Anesth Analg 2008;106:997‐1001)

Background Animal and volunteer studies indicate that ropivacaine is associated with less neurologic and cardiac toxicity than bupivacaine. Ropivacaine may offer advantages when used for thoracic paravertebral block. This study was designed to describe the pharmacokinetics of ropivacaine after thoracic paravertebral block. Methods Twenty female patients undergoing elective unilateral breast surgery were randomly assigned to receive a single bolus thoracic paravertebral injection of 2 mg/kg ropivacaine, with or without 5 mug/ml epinephrine. Simultaneous arterial and venous blood samples were obtained for plasma ropivacaine assay. Data were analyzed with NONMEM, using two possible absorption models: conventional first-order absorption and absorption following the inverse gaussian density function. Results Epinephrine reduced the peak plasma concentrations and delayed the time of peak concentration of ropivacaine in both the arterial and venous blood. The time course of drug input into the systemic circulation was best described by two inverse gaussian density functions. The median bioavailability of the rapid component was approximately 20% higher when epinephrine was not used. The mean absorption times were 7.8 min for the rapid absorption phase and 697 min for the slow absorption phase, with wide dispersion of the absorption function for the acute phase. The half-time of arterial-venous equilibration was 1.5 min. Conclusion The absorption of ropivacaine after thoracic paravertebral block is described by rapid and slow absorption phases. The rapid phase approximates the speed of intravenous administration and accounts for nearly half of ropivacaine absorption. The addition of 5 mug/ml epinephrine to ropivacaine significantly delays its systemic absorption and reduces the peak plasma concentration.

A 61-year-old man with multiple unilateral rib fractures (T3-T8) gained the ability to breathe deeply and to ambulate after ultrasound-guided continuous thoracic paravertebral block and was discharged home after being observed for 15 hours after the block. The ultrasound guidance was helpful in determining the site of rib fractures and the optimal level for catheter placement. This report also discusses the management of analgesia using continuous paravertebral block in an outpatient with trauma.

Background Pectoral nerve (PecS) block is a recently introduced technique for providing surgical anaesthesia and postoperative analgesia during breast surgery. The present study was planned to compare the efficacy and safety of ultrasound-guided PecS II block with thoracic paravertebral block (TPVB) for postoperative analgesia after modified radical mastectomy. Methods Forty adult female patients undergoing radical mastectomy were randomly allocated into two groups. Group 1 patients received a TPVB with ropivacaine 0.5%, 25 ml, whereas Group 2 patents received a PecS II block using same volume of ropivacaine 0.5% before induction of anaesthesia. Patient-controlled morphine analgesia was used for postoperative pain relief. Results The duration of analgesia was significantly prolonged in patients receiving the PecS II block compared with TPVB [mean (sd), 294.5 (52.76) vs 197.5 (31.35) min in the PecS II and TPVB group, respectively; P Conclusions We found that the PecS II block provided superior postoperative analgesia than the TPVB in patients undergoing modified radical mastectomy without causing any adverse effect. Clinical trial registration CTRI/2014/06/004692.

Thoracic paravertebral blocks can be used to provide analgesia for unilateral trunk surgeries. Ultrasound-guided approaches for needle tip placement and injection monitoring are described. Anterior displacement of the pleura occurs with injection of local anesthetic in the paravertebral space.

Cosmetic and reconstructive breast augmentation is a frequently performed surgical procedure. Despite advances in medical treatment, surgical intervention is often associated with postoperative pain, nausea, and vomiting. Paravertebral nerve block (PVB) has the potential to offer long-lasting pain relief and fewer postoperative side effects when used for breast surgery. We compared thoracic PVB with general anesthesia for cosmetic breast surgery in a single-blinded, prospective, randomized study of 60 women scheduled for unilateral or bilateral breast augmentation or reconstruction. Patients were assigned (n = 30 per group) to receive a standardized general anesthetic (GA) or thoracic PVB (levels T1-7). Procedural data were collected, as well as verbal and visual analog pain and nausea scores. Verbal postoperative pain scores were significantly lower in the PVB group at 30 min (P = 0.0005), 1 h (P = 0.0001), and 24 h (P = 0.04) when compared with GA. Nausea was less severe in the PVB group at 24 h (P = 0.04), but not at 30 min or 1 h. We conclude that PVB is an alternative technique for cosmetic breast surgery that may offer superior pain relief and decreased nausea to GA alone.Paravertebral nerve block has the potential to offer long-lasting pain relief and few postoperative side effects when used for breast surgery. We demonstrated that paravertebral nerve block, when compared with general anesthesia, is an alternative technique for breast surgery that may offer pain relief superior to general anesthesia alone.

Purpose of review Paravertebral blocks are becoming increasingly popular, especially as an anesthetic adjunct for breast procedures. New reports suggest additional reasons for adding this block to the anesthetic armamentarium. Recent findings Recent studies demonstrate a benefit from preoperative placement of a paravertebral block, not only in reducing acute postoperative pain, but also statistically significant reductions in the percentage of patients that develop chronic postsurgical pain 1 year after surgery. Another study found that the breast-cancer recurrence rate at 36 months after surgery was lower in the paravertebral group compared with the general anesthesia-only group of patients. Summary Paravertebral blocks are a well established option to provide anesthesia and postoperative analgesia during breast surgery. Recent studies suggest additional benefits to this procedure. Not only is acute pain better controlled, but the development of chronic mastectomy pain syndrome and recurrence of cancer may be reduced by preoperative placement of paravertebral block. These studies provide additional reasons why this block should be considered as part of the anesthetic for breast surgery.

The benefits of thoracic paravertebral block (TPVB) have been demonstrated for patients undergoing surgery for breast cancer. However, pleural puncture resulting in pneumothorax is a serious complication associated with traditional approaches using guidance from anatomic landmarks and nerve stimulation and may contribute to the low utilization of this block. An ultrasound-guided technique has the potential to reduce complications by providing direct visualization of the paravertebral space during needle manipulation. We evaluated the complications using a single-injection, transverse, in-plane ultrasound-guided technique for paravertebral blockade in patients undergoing mastectomy with immediate reconstruction for breast cancer treatment or prophylaxis.Data from all patients who underwent TPVB between January 1, 2010, and December 3, 2013, at Massachusetts General Hospital was prospectively recorded in a computerized database. All blocks were placed for postoperative analgesia after unilateral or bilateral mastectomy with immediate breast reconstruction. Medical records were retrospectively reviewed for any patient who developed complications including accidental pleural puncture, symptomatic pneumothorax, hypotension, or bradycardia, as well as signs and symptoms of toxicity or effects of local anesthetic outside of the paravertebral space.Eight hundred fifty-six patients underwent a total of 1427 thoracic paravertebral injections (285 unilateral and 571 bilateral TPVB). There were 6 complications (0.70%; 99.2% confidence interval, 0.17%-1.86%) including symptomatic bradycardia and hypotension (n = 3), vasovagal episode (n = 1), and evidence of possible local anesthetic toxicity (n = 2). There was no incidence of suspected accidental pleural puncture or symptomatic pneumothorax identified in our study population.The routine use of a single-injection, transverse, in-plane ultrasound-guided technique for TPVB in patients undergoing mastectomy with immediate breast reconstruction is associated with very few complications.

Paravertebral block (PVB) is a safe and effective anesthetic technique for thoracotomy and mastectomy. However, no systematic review or meta-analysis has focused on PVB for inguinal herniorrhaphy. Our study compares PVB with general anesthesia/systemic analgesia, neuraxial blocks, and other peripheral nerve blocks.We analyzed 14 randomized controlled trials from PubMed, MEDLINE, CENTRAL, EMBASE, and CINAHL up to February 2015, without language restriction, comparing PVB under sedation with general anesthesia/systematic analgesia (135 vs 133 patients), neuraxial blocks (191 vs 186 patients), and other peripheral nerve blocks (119 vs 117 patients). We investigated pain scores, consumption of postoperative analgesia, incidence of postoperative nausea and vomiting (PONV), length of hospital stay, postanesthesia care unit bypassing rate, time to perform blocks, intraoperative hemodynamics, and incidence of urinary retention. Joint hypothesis testing was adopted for pain and analgesics, PONV, and hemodynamic variables. All analyses were performed with RevMan 5.2.11 (Cochrane Collaboration, Copenhagen). Hartung-Knapp-Sidik-Jonkman method was used for post hoc testing.PVB reduced PONV (nausea: risk ratio [RR] = 0.22; 95% confidence interval [CI], 0.05-0.93; numbers needed to treat [NNT] = 4.5; I = 15% and vomiting: RR = 0.15; 95% CI, 0.03-0.76; NNT = 8.3; I = 0%) compared with general anesthesia/systematic analgesia (quality of evidence [QoE]: high). Compared with neuraxial blocks, PVB resulted in less postoperative nausea (RR = 0.34 [95% CI, 0.13-0.91], NNT = 8.3, I = 0%) and urinary retention (RR = 0.14 [95% CI, 0.05-0.42], NNT = 7.4, I = 0%) than neuraxial blocks (QoE: high). More time was needed to perform PVB than neuraxial blocks (standardized mean difference = 1.90 [95% CI, 0.02-3.77], I = 92%; mean difference = 5.33 minutes; QoE: moderate). However, the available data could not reject the null hypothesis of noninferiority on all pain scores and analgesic requirements for both PVB versus general anesthesia/systematic analgesia and PVB versus neuraxial blocks (QoE: low), as well as on hemodynamic outcomes for PVB versus neuraxial blocks (QoE: moderate). Our systematic review showed that PVB decreased postoperative pain scores and analgesic requirement as compared with ilioinguinal block and transversus abdominis plane block.This meta-analysis shows that PVB provides an anesthesia with fewer undesirable effects for inguinal herniorrhaphy. The choice between general anesthesia/systematic analgesia, neuraxial blocks, PVB, and other peripheral nerve blocks should be based on time available to perform the block and a complete coverage over the relevant structures by the blocks.

We present a patient who required perioperative analgesia with continuous nerve block for shoulder disarticulation, for whom the only approach possible to the brachial plexus was from posterior. A 51-yr-old woman was suffering from intractable upper extremity pain and dysfunction as a result of severe lymphedema after metastatic spread of breast cancer to the axilla. Her pain was poorly controlled despite aggressive treatment with oral, systemic, and intrathecal opiates. She presented for amputation of her arm as a last resort for management of pain. In order to provide optimal postoperative analgesia, continuous peripheral nerve block was selected in consultation with the patient, and due to anatomic disfigurement and tumor invasion, a continuous cervical paravertebral block was placed preoperatively and shoulder disarticulation was performed using a combined regional/general anesthesia technique. The patient had an uneventful recovery without pain for the 6 postoperative days that the catheter was in place and 0.25% bupivacaine was infused at 5 mL/h. Because of anatomic considerations, which precluded the use of all other approaches to the brachial plexus, the posterior cervical paravertebral approach provided an effective means of pain control in this difficult clinical situation.

Objective: To test the hypothesis that there is relative sympathetic hyperactivity in the affected limb in patients with sympathetically maintained pain syndromes by measuring serum norepinephrine and epinephrine in the affected versus the unaffected sides. Design: Venous pool samples were drawn just proximal to the affected area and from an identical site on the unaffected side. Serum norepinephrine and epinephrine were measured by high-pressure liquid chromatography with electrochemical detection. Subjects: Sixteen women and seven men with a mean age of 44.4 years diagnosed as having sympathetically maintained pain on the basis of a positive response to paravertebral block and a criteria-based diagnostic scheme. Results: The serum norepinephrine level was significantly lower in the affected limbs than the unaffected limbs (p = 0.024). The serum epinephrine level was not significantly different. Conclusions: These results are not consistent with the hypothesis of segmental sympathetic hyperactivity in the affected limb in sympathetically maintained pain and support a hypothesis of peripheral receptor upregulation with pathologic response to circulating catecholamines. Other possible explanations are discussed.

A reliable, safe approach to achieving unilateral anesthesia in multiple contiguous thoracic dermatomes would be of great benefit to anesthesiologists in the acute and chronic pain setting. The multidermatomal intercostal technique is one such approach, although the anatomical mechanism of this nerve block is a matter of debate. At our pain clinic, we have used another technique, a modification of the paravertebral block, to achieve multiple segments of unilateral sensory blockade. We have used this technique, which we call the paravertebral-peridural block, for over 20 years in the treatment of various pain problems. In retrospective analysis of the 384 blocks performed from 1982 to 1986, there was one pneumothorax (0.26%), one thecal puncture (0.26%), and two accidental intrathecal injections (0.52%). Eighteen blocks (4.6%) resulted in transient hypotension. There were no permanent sequelae. Ninety-three percent of blocks were evaluated as "good" or "excellent" in quality. Bilateral sensory blockade was documented in five patients (1.3%). In order to clarify the mechanism of bilateral blockade resulting from a unilateral technique, we injected four fresh cadavers with colored latex solution using the paravertebral-peridural approach. This revealed spread of the latex across the midline prevertebrally to the contralateral paravertebral space. We conclude that the paravertebral-peridural thoracic block is a reliable, safe technique for achieving unilateral anesthesia over multiple dermatomes with a single injection.