Ultrasound-Guided Thoracic Paravertebral Block

1. Saeid Safari M.D.
Department of Anesthesiology, Tehran University of Medical Sciences

2. Introduction

3. Background
• 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.
• This produces unilateral, segmental, somatic, and sympathetic nerve
blockade, which is effective for anesthesia and in treating acute and chronic
pain of unilateral origin from the chest and abdomen.

4. Background
• Hugo Sellheim of Leipzig (1871-1936) is believed to have pioneered TPVB in
1905.
• 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.

5. Background
• 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,
• its application has been extended to children.

6. Background
• Thoracic paravertebral block is indicated for procedures on the thorax that
are lateral to the paravertebral muscles, such as breast surgery and
thoracotomy.
• When the pleura is entered surgically, intubation is required.
• Breast surgery can be done without intubation.
• Superficial surgery of the upper abdominal wall can be done with bilateral
thoracic paravertebral block.

7. Anatomy

8. Anatomy:
• The thoracic paravertebral space, in transverse cross section, is triangular.
• Its boundaries include:
• Posteriorly, the superior costotransverse ligament,
• Medially , vertebral body and vertebral foramen,
• Endothoracic fascia that forms the deep border of the space and
separates the nerve root from the sympathetic ganglia

9. Spinal Nerve Root in Paravertebral space
• The thoracic spinal nerve roots and sympathetic chain emerge from the
lateral vertebral foramina and course anterior to the transverse processes
close to the parietal pleura
• Medially, the nerve root is bounded by the vertebral body.
• As the nerve root travels laterally, it is bounded anteriorly by the
endothoracic fascia and superiorly by the inferior margin of the rib.
• Posteriorly, the nerve is bounded by the transverse process and the
costotransverse ligament.
• The nerve becomes the intercostal nerve as it enters the plane between the
innermost and inner intercostal muscles

10. The blue shaded area
represents the
paravertebral space.

13. Anatomy of the
paravertebral space.
ETF, endothoracic fascia;
SCL, superior costotransverse
ligament;
LCL, lateral costotransverse
ligament;
ITL, interspinous
costotransverse ligament.

14. Indication & Contraindication

15. • Anesthesia
• Breast surgery
• Herniorrhaphy (thoracolumbar
anesthesia)
• Chest wound exploration
• Chronic Pain Management
• Benign and malignant neuralgia
• Miscellaneous
• Postherpetic neuralgia
• Relief of pleuritic chest pain
• Multiple fractured ribs
• Treatment of hyperhydrosis
• Liver capsule pain after blunt
abdominal trauma
• Postoperative Analgesia (as part
of a balanced analgesic regimen)
• Thoracotomy
• Thoracoabdominal esophageal
surgery
• Video-assisted thoracoscopic
surgery
• Cholecystectomy
• Renal surgery
• Breast surgery
• Herniorrhaphy
• Liver resection
• Appendicectomy
• Minimally invasive cardiac surgery
• Conventional cardiac surgery
(bilateral TPVB)
Indication:

16. Contraindications
• There are very few absolute contraindications for TPVB.
• These include:
• Infection at the site of injection,
• Allergy to local anesthetic drug,
• Empyema,
• Neoplastic mass occupying the paravertebral space.
• Coagulopathy,
• Bleeding disorders, or patients receiving anticoagulant drugs are relative
contraindications for TPVB.

17. Classic Approach

18. Classic Approach
• The classic technique of paravertebral block uses a blind approach in which
the needle is inserted 2.5 to 4 em lateral to the posterior spinous process in
search of the transverse process.
• When the transverse process is contacted, the needle is withdrawn and
directed caudad to the transverse process and approximately 1 cm deep to
the transverse process.
• Once the costotransverse ligament is pierced, local anesthetic is injected.

24. 10:00 PM

25. Special relationship between the
spinous and transverse processes at
the thoracic level.
Due to the steep downward
angulation of the spinous processes
at the thoracic levels, the needle
inserted at the level of the spinous
process contacts the transverse
process that belongs to the vertebra
below it.

26. Technique of "walking off" the transverse
process:

27. • n this space, there is a fascial plane, so that local anesthetic can spread from
two to six dermatomes with a single injection.
• When this technique is used, there is occasional spread to the epidural space.

28. • One must exercise caution in patients with kyphoscoliosis or deformed
spines and those who have had previous thoracic surgery.
• The chest deformity in the former may predispose to inadvertent thecal
or pleural puncture, and the altered paravertebral anatomy due to
fibrotic obliteration of the paravertebral space or adhesions of the lung
to the chest wall in the latter may predispose to pulmonary puncture.

29. Ultra-Sonography

30. Anatomy:
• Ultrasound has some benefit when performing thoracic paravertebral
block close to the midline.
• The transverse spinous process and rib can often be visualized, and
measuring their approximate depth from the skin can be helpful. This is
particularly true in obese patients where the posterior spinous process
may be difficult to palpate.

31. • Patient Position: Prone
• Transducer: 11cm curved array oscillating at 5 to 8 MHz or 25-mm linear
array oscillating at 10 to 13 MHz.
• Transducer Orientation: Initially sagittal to identify the rib and pleura. The
transducer is then rotated 90 degrees to an oblique axial position. Here, the
rib, intercostal muscles, and pleura are identified.
• Needle: 5- to 10-cm, 22-gauge blunt needle or I8-gauge Tuohy needle.
• Local Anesthetic: 10 to 15 mL of 0.5% ropivacaine

32. • Once this plane has been identified, an additional 10 to 15mL of local
anesthetic can be injected in aliquots of 5 mL. At the conclusion of this
injection, a catheter may be inserted 5 to 10 cm beyond the end of the needle
if a continuous block is desired.
• If radio-opaque dye is injected through the catheter, and a chest x-ray is
obtained, then the dye usually spreads in a spindle-like pattern in the
paravertebral space.

33. Clinical Pearls

34. Clinical Pearls
• Perform TPVB with the patient in the sitting position.
• Surface landmarks should always be identified and marked with a skin
marker.
• Since TPVB produces unilateral anesthesia/analgesia, one must ensure that
the surface markings for the injections are made on the indicated (correct)
side.
• Use needles with depth markings to facilitate estimation of the depth of
insertion.
• It is imperative to search and make contact with the transverse process
before advancing the needle any further.

35. Clinical Pearls
• The depth at which the transverse process is contacted varies in the same
patient at different thoracic levels. It is deepest in the cervical, upper and
lower thoracic, and shallowest in the mid thoracic region.
• The loss of resistance is subtle and best appreciated using a 5-mL glass
syringe.
• The needle should not be advanced more than 1.5 cm beyond the contact
with the transverse process.
• Avoid directing the needle medially to prevent inadvertent epidural or
intrathecal injection

36. Clinical Pearls
• Injecting saline or the bolus dose of the local anesthetic before catheter
insertion makes it easier to insert a catheter.
• Very easy passage of catheter (>6 cm) suggests intrapleural placement.
• Consider using lidocaine or chloroprocaine for skin and subcutaneous
infiltration during a multiple-injection TPVB to reduce the total dose of the
more toxic long-acting local anesthetic.
• Use an epinephrine-containing (eg, :200 000 or :400000) long-acting local
anesthetic for the initial bolus injection because it reduces systemic
absorption and therefore the potential for systemic toxicity.

37. Clinical Pearls
• Local anesthetic dosage must be adjusted in the elderly and those with
impairment of hepatic and renal function as they are more prone for systemic
accumulation and local anesthetic toxicity.
• Increasing the dose of the local anesthetic infused during a continuous
thoracic paravertebral block may not always improve pain management.
Adjunct analgesics leg, a nonsteroidal antiinflammatory drug (NSAID), as
part of a multimodal analgesic regimen] may be more effective.

38. Clinical Pearls
• Catheter dislodgement is not uncommon and must be excluded
whenever patients complain of breakthrough pain that is not easily
controlled.
• Exclude local anesthetic toxicity whenever a patient becomes confused
while on a continuous thoracic paravertebral infusion.

39. Clinical Pearls
1. The block usually takes 20 to 30 minutes to set up.
2. Sympathetic block is common. When bilateral block IS performed,
hypotension IS possible.
3. Pneumothorax can occur.
4. If the space between the pleura is entered by mistake, a catheter may be
inserted into the intrapleural space, and local anesthetic can be infused to
provide analgesia if a chest tube is not present.

40. Clinical Pearls
• In most cases, the endothoracic fascia cannot be visualized on ultrasound,
and the pleura, which lies immediately deep to the endothoracic fascia, is
used as a landmark to prevent the needle from being inserted too far.
• In thin patients, the epidural space, the transverse process, the
costotransverse ligament, and the pleura can be imaged in longitudinal view
by placing the transducer lateral to the posterior spinous process and
toggling from medial to lateral.

41. Educational Clips for US guided TPVB

43. Thanks for your attention!

44. Lumbar Paravertebral Block