The document discusses various techniques for performing thoracic and lumbar paravertebral blocks, emphasizing the importance of anatomical landmarks, needle insertion techniques, and considerations for patient positioning. It details indications, contraindications, potential complications, and the use of local anesthetics for effective pain management in surgical and chronic pain settings. Additionally, it covers the technique of erector spinae plane blocks, primarily for postoperative pain relief in thoracoabdominal surgeries.

1. Erector spinae plane block
paravertebral block
Moderator : Dr Shikha Sharma
Presenter : Dr Tanvi sharma

2. Thoracic paravertebral block (TPVB)
• Technique of injecting local anesthetic alongside the thoracic
vertebra close to where the spinal nerves emerge from the
intervertebral foramen.
• Produces unilateral, segmental, somatic, and sympathetic nerve
blockade, effective for anesthesia and in treating acute and chronic
pain of unilateral origin from the chest and abdomen

4. Thoracic Paravertebral Space Anatomy
• It is bound posteriorly by the superior costotransverse ligament
anterolaterally by the pleura, medially by the vertebrae and
intervertebral foramina, and superiorly and inferiorly by the ribs.
• Communicates with the epidural space medially and with the
intercostal space laterally. The TPVSs on either side of the thoracic
vertebra also communicate with each other through the epidural and
prevertebral space.

7. Mechanism of Block & Distribution of
Anesthesia
• Produces ipsilateral somatic and sympathetic nerve blockade
• Multiple injection technique is preferable over single, large-volume
injection.
• Segmental contralateral anesthesia :10%

8. TECHNIQUE
• Sitting position (preferred) ,lateral, or prone
position.
• Surface landmarks are identified and skin markings
are made 2.5 cm lateral to the midline ( transverse
process )of the vertebra.
• Strict asepsis should be maintained
• a 22-gauge tuohy needle is recommended with
depth markings or depth guard

10. Loss-of-Resistance Technique
• The skin and underlying tissue is infiltrated with lidocaine 1%, and the block
needle is inserted perpendicular to the skin in all planes to contact the transverse
process of the vertebra
• The depth at which the transverse process is contacted varies (3–4 cm) . the
depth is deeper at the cervical and lumbar spine level and shallower at the
thoracic levels.
• During needle insertion it is possible to miss the transverse process and puncture
the pleura. therefore, search and make contact with the transverse process
before advancing the needle too deep .
• Maximum depth :4 cm thoracic and 5 cm cervical / lumbar levels
• The needle is then walked above or bellow (safer) the transverse process and
gradually advanced until a loss of resistance is elicited as the needle traverses the
superior costotransverse ligament .

11. Predetermined Distance Technique :
• TPVB can also be performed by advancing the needle by a fixed
predetermined distance (1 cm) once the needle is walked off the
transverse process, without eliciting loss of resistance.
• Advantage: low risk of pneumothorax

13. CONTRAINDICATIONS
• Infection at the site of injection
• Allergy to local anesthetic drug
• Neoplastic mass occupying the paravertebral space
• Coagulopathy, or patients on anticoagulant ( relative contraindication)
• Kyphoscoliosis ,deformed spines , previous thoracic surgery.(Caution)

14. Local anesthetic
• Long-acting local anesthetic drug
• Bupivacaine or levobupivacaine 0.5% and ropivacaine 0.5%. For single-
injection :20–25 ml
• Multiple-injection 4–5 ml of local anesthetic is injected at each level planned
• TPVS : well vascularized space leading to rapid absorption . epinephrine (2.5–
5.0 mcg/ml) can be used to reduce systemic toxicity.
• The duration of anesthesia 3–4 h, analgesia : (8–18 h).
• For continuous pain relief : infusion of bupivacaine or levobupivacaine 0.25%
or ropivacaine 0.2% at 0.1–0.2 ml/kg/h is started after the initial bolus
injection and continued for 3–4 days or as indicated.

15. COMPLICATIONS
• Vascular puncture (3.8%)
• Hypotension (4.6%) : rare because sympathetic blockage is UL, may unmask
hypotension, caution in hypovolemic or hemodynamically labile.
• Pleural puncture (1.1%), managed conservatively. Clues ( loss of resistance
as the needle enters chest cavity, cough, onset of sharp chest or shoulder
pain, or sudden hyperventilation)
• Pneumothorax (0.5%)
• local anesthetic toxicity
• Inadvertent epidural, subdural, or intrathecal injection and spinal anesthesia
• Ipsilateral or bilateral horner syndrome

16. Key points
• Perform TPVB with the patient in the sitting position.
• Surface landmarks should always be identified and marked with a skin marker.
• 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 farther.
• 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 midthoracic region.
• 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
needle misadventure

17. Lumbar paravertebral block
• lumbar paravertebral space (LPVS)
anterolaterally : psoas major muscle;
medially :vertebral bodies, the intervertebral
discs, and intervertebral foramen with its
contents; and posteriorly : transverse process
and the ligaments . LPVS is occupied primarily
by the psoas major muscle.
• local anesthetic is injected anterior to the
transverse process into a triangular space
between the two parts of the psoas major
muscle containing the lumbar spinal nerve root.

18. TECHNIQUE
•
• Sitting, lateral, or prone position. Surface landmarks identified
• Iliac crest :L3-L4 interspace. Skin markings are made 2.5 cm lateral to the midline
• advance the needle by a fixed predetermined distance (1.5–2.0 cm) beyond the transverse
process, perpendicular to the skin until the transverse process is contacted. The depth : (4–6
cm) once the transverse process is identified, the marking noted and the depth marker is
adjusted so that it is 1.5–2.0 cm beyond the skin–transverse process depth
• The needle is withdrawn to the subcutaneous tissue and reinserted at a 10- to 15-degree
superior or inferior angle so that it slides off the superior or inferior edge
• The needle is advanced by a further 1.5–2.0 cm beyond the contact with the transverse
process or until the depth marker is reached.
• After negative aspiration the local anesthetic is injected

20. INDICATIONS
• LPVB is commonly used in combination with TPVB (T10 through L2) for surgical
anesthesia during inguinal herniorrhaphy. It can be also effective for rescue in
patients with severe pain after total hip replacement.
• diagnostic purpose evaluation of groin or genital pain
• Contraindications for LPVB are similar to TPVB
• Complications:
• intravascular, epidural, or intrathecal space injection medial angulation should be
avoided.
• Intraperitoneal injection or visceral injury
• Motor weakness involving the ipsilateral quadriceps muscle may result if the L2
spinal nerve is blocked (femoral nerve L2–L4).

21. USG GUIDED
• a low-frequency ultrasound transducer (2–5 MHz) with a
divergent beam and a wide field of vision.
• . The transverse process is seen as a hyperechoic structure,
anterior to which there is a dark acoustic shadow which
completely obscures the TPVS

22. • Transverse scan
• Place the transducer lateral to the spinous process with the
orientation marker directed to the patient’s right side

23. Transverse scan short axis needle insetion
• Teqnique is similar to that when surface anatomy landmarks are used
Transverse scan with inplane needle insertion/intercostal approach
• Block needle is inserted in plane of usg beam from lat to medial direction

24. Sagittal scan in plane approach
Block needle inserted along plane of usg
Following injection there is anterior displacement of pleura , widening of space

26. ERECTOR SPINAE PLANE BLOCK
• The “erector spinae” comprises a group of muscles including the
iliocostalis, longissimus, and spinalis muscles.
• They run bilaterally from the skull to the pelvis and sacral region, and
from the spinous to the transverse processes, extending to the ribs.
• Block is not useful as sole anesthesia , mainly used for postoperative
pain relief for thoracoabdominal surgeries and chronic pain
• Drug is deposited underneath ESM And overlying transverse process.
• INDICATIONS
• BREAST SURGERY, thoracic procedures , abdominal and pelvic
procedures
• Rib fractures ,thoracoabdomen neuralgia , cancer pain , CRPS

28. Anterior or ventral ramus of T2 to T5: Motor (Intercostal muscles) and sensory (anterior
and lateral chest wall, and parietal pleura)
Anterior or ventral ramus of T6 to T12: Motor (abdominal muscles) and sensory (anterior
and lateral abdominal wall,and parietal peritoneum)
Posterior or dorsal ramus of T2 to T12: Somatic motor and sensory information to and from
skin and deep muscles
Procedure Using Ultrasound Guidance
• Position : sitting, lateral decubitus, or prone .
• Teqnique: high-frequency linear USG probe 10 to 15 mhz is placed in the paramedian
sagittal plane , 2.5 to 3 cm lateral to the spinous process of thoracic vertebrae at the
level of block .
• LA in the fascial plane between the ESM above and the transverse process below. Is
injected 22-gauge, 50-mm needle used
• Dose : diluted local anesthetic (20 to 30 mL of 0.2% ropivacaine or 0.25% bupivacaine)
elevation of ESM can be seen by USG

29. Thank you