PARAVERTEBRAL BLOCK an underused block'

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PARAVERTEBRAL BLOCK- an underused block.

• Dr Mahesh Shah
• The General Infirmary at Leeds
• U.K.

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• Paravertebral block a simple block to achieve
  somatic and sympathetic neural blockade of
  multiple dermatomes.

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• Clinical applications
• Analgesia for- thoracic surgery
• - upper abdominal surgery
  e.g. cholecystectomy
• - breast surgery
• - fractured ribs or
  contusions of the thoracic wall
• - upper leg surgery
• -

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• Clinical applications- posthoracotomy and
  postmastectomy pain
• - acute herpes
  zoster
• - pain in the
  intercostal area e.g. causalgia or neuralgia.

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• Anatomy of the thoracic paravertebral space
• The paravertebral space is a wedge shaped
  compartment bounded by
• Above and below heads and necks of the
  adjoining ribs
• Posterior costo-tranverse ligaments
• Medially communicates with the extradural space
  through the intevertebral
• Laterally bound by the parietal pleura with the
  apex leading into the intercostals space
• The base formed by the posterolateral aspect of
  the body of the vertebra and the intervertebral
  foramen
• The upper aspect of the spinous process coincides
  with the transverse process of the lower vertebra

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• Technique of Thoracic paravertebral block.
• The patient can be sitting, lateral or prone. The
  sitting position is the easiest. The needle is
  inserted 3cm lateral to the most cephalad portion
  of the spinous process and advanced at right
  angle to all skin planes to contact the
  transverse process of the vertebra below ( 2-4cm
  depth).
• It is then redirected cephalad and advanced
  (1-1.5cm) till a loss of resistance is felt. A
  single injection of 15-20ml causes a blockade of
  4 to 5 dermatomes with a tendency to caudal
  spread.
• Multiple injections can be performed.

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• Anatomy of Lumbar paravertebrals
• Lumbar nerves exit the vertebral foramina
  inferior to the caudad edge of the transverse
  process. The anterior branches of L1 to L4 with a
  contribution from T12 form the lumbar plexus.
• The cephalad aspect of the spinous process
  coincides with the caudad aspect of the
  homologous transverse process.

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• Technique of Lumbar paravertebral block
• The patient is placed prone or lateral. At a
  point 3cm lateral to the cephalad edge of the
  spinous process the needle is inserted at right
  angles in all planes till it contacts the caudad
  aspect of the homologous transverse process.
• The needle is then redirected off the caudad edge
  till a loss of resistance is felt and an impulse
  obtained with a nerve stimulator or paraesthesia
  is felt.

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• Continuous catheter techniques can be used

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Complications

• Local anaesthetic toxicity
• Pneumothorax lt1
• Epidural diffusion 1
• Hypotension lt5
• Intravascular injection into the vena cava or
  aorta is possible.

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Conclusion

• The paravertebral block is an underused block
  with a low risk of complications.
• It is easy to learn and use in clinical practice.