British Journal of Anaesthesia 1998; 81: 230–238
REVIEW ARTICLE
Thoracic paravertebral block
J. RICHARDSON AND P. A. LÖNNQVIST
Paravertebral nerve block produces ipsilateral anal-
gesia through injection of local anaesthetic alongside
the vertebral column. It is advocated predominantly
for unilateral surgery, for example, thoracotomy,
chest wall trauma, breast surgery, cholecystectomy,
herniorrhaphy or renal surgery, although it can be
used as a bilateral technique. In chronic pain, it is
used for the treatment of benign or malignant neural-
gia. There is confusion over the indications for this
block and it is apparent that much ignorance sur-
rounds this subject. Its place alongside extradural,
intercostal and interpleural analgesia requires eluci-
dation. The aim of this review is to describe the
anatomy, techniques, analgesia, side effects and com-
plications of paravertebral nerve blocks so that a
more considered use of this form of analgesia can be
undertaken.
History of paravertebral blocks
A requirement for analgesia and abdominal muscle
relaxation during surgery led Hugo Sellheim of
Leipzig (1871–1936) in 1905 to perform the first
paravertebral block.7 51 His aim was to find a replace-
ment technique for spinal anaesthesia, devoid of its
feared hazards of cardiovascular and respiratory col-
lapse. A surgical resident in Leipzig, Arthur Läwen
(1876–1958), made a special study of this new tech-
nique. Through the painstaking injection of small
quantities of procaine at the emergence of each
spinal nerve in many hundreds of patients with
abdominal pain who subsequently underwent
laparotomy or postmortem examination, Läwen
(with others), mapped out the segmental innervation
of the intra-abdominal organs. He then developed
this knowledge into a powerful diagnostic tool.41 Not
only could a few millilitres of local anaesthetic at the
appropriate spinal levels indicate the organ from
which the abdominal pain was arising, but it also
aided palpation through relaxation of abdominal
muscle spasm. Its particular use was in the differenti-
ation of ureteric from gallbladder colic, but it was
also indicated in the differential diagnosis of stomach
compared with pancreatic, duodenal or gallbladder
pain.7 51 Injections were investigated at all vertebral
levels, from the cervical region where they are better
known as cervical plexus and stellate ganglion
blocks, to the sacral region where in effect they
become caudal extradural blocks.
(Br. J. Anaesth. 1998; 81: 230–238)
Keywords: anaesthetic techniques, regional, paravertebral;
anaesthetics, local, bupivacaine; pain, postoperative
Although originally the main therapeutic indica-
tion for paravertebral nerve blocks was the relief of
surgical pain, in the early years of this century its
applications flourished. These grew to include the
alleviation of angina pectoris, the intractable pain of
malignancy, pain from fractured neck of femur, and
ischaemic limb pain including causalgia and post-
traumatic sympathetic dystrophies. It was also used
for treating supraventricular tachycardias, bronchial
asthma, aiding the passage of renal and gallbladder
stones, and the management of pain from herpes
zoster.51
Its popularity reached a peak in the 1920s and
1930s following which, during the 1950s and 1960s,
publications about this technique almost completely
disappeared. In the late 1970s, at the same time as
negative views were being expressed in textbooks,
publications slowly started to reappear. The past
decade has seen an upturn of interest and study.
Anatomy and mechanism of analgesia (figs. 1
and 2)
The paravertebral space is a wedge-shaped area sand-
wiched between the heads and necks of the ribs.50 The
posterior boundary is the superior costotransverse lig-
ament and laterally, the posterior intercostal mem-
brane. Anteriorly is the parietal pleura, and the base of
the triangle (medially) is the postero-lateral aspect of
the vertebra, the intervertebral disc and the interver-
tebral foramen.50 The nervous contents of each para-
vertebral space are: the spinal (intercostal) nerve; its
dorsal ramus; the rami communicantes; and, anteri-
orly, the sympathetic chain. The spinal nerve as it
emerges from the intervertebral foramen is devoid of
a fascial sheath and is often broken up into small
nerve rootlets which are therefore easily penetrated by
local anaesthetic.62 This area also contains some loose
extrapleural fascia. There is no lateral limit; it is con-
tiguous with the tissue plane between the intercostal
muscles, that is, the intercostal space. The distribu-
tion of solutions injected into the paravertebral space
have been observed in cadaver studies with resin17 or
coloured dye,47 61 62 radiologically with contrast
media18 20 24 29 42 46 55 66 and clinically with instillation of
methylene blue at thoracotomy.59 83 Solutions can: (1)
JONATHAN RICHARDSON, MD, FRCP, FRCA, Department of
Anaesthetics, Bradford Royal Infirmary, Bradford BD9 6RJ. PER
ARNE LÖNNQVIST, MD, DEAA, PHD, Department of Paediatric
Anaesthesia and Intensive Care, KS/St Görans Children’s
Hospital, PO Box 12500, S-112 81 Stockholm, Sweden. Accepted
for publication: January 5, 1998.
Correspondence to J. R.
This article is accompanied by Editorial I.
Thoracic paravertebral block
remain localized; (2) spread superiorly and inferiorly
across the heads and necks of the ribs to the spaces
above and below; (3) pass medially through an inter-
vertebral foramen; (4) spread laterally in the inter-
costal plane.
Gross anterior spread is not possible unless the
parietal pleura has been traumatized.
There is some disagreement over the inferior limit
of spread; the origin of the psoas muscle probably
preventing any spread below T12.47 A somatic block
of lumbar dermatomes has been seen to accompany
a thoracic paravertebral block, although this may
have occurred either by spread anteriorly into the
transverse fascia of the abdominal cavity through the
medial and lateral arcuate ligaments to effect a lum-
bar plexus block,90 or through extradural spread.
The mechanism of action of paravertebral analge-
sia is by direct penetration of local anaesthetic into
the intercostal nerve, including its dorsal ramus, the
rami communicantes and the sympathetic chain.24 101
Mass movement of drug across further tissue planes,
as required for example for intrapleural block, is
unnecessary for analgesia as the nervous structures
are adjacent to the needle point or within the same
tissue plane.
An accompaniment of the somatic block is a unilat-
eral sympathetic block. This is because of penetration
by local anaesthetic into the sympathetic chain and the
slender rami communicantes.24 101 In a study of chronic
pain patients undergoing paravertebral blocks with
0.5% bupivacaine 15 ml, a mean somatic block of 5
dermatomes was accompanied by a mean sympathetic
block of 8 dermatomes, as evidenced by ipsilateral skin
warming demonstrated by thermography.14
Indications
Thoracic paravertebral blocks are particularly advo-
cated for unilateral surgical procedures, for example,
thoracotomy,3 13 53 60 72 75 83 87 breast surgery,30 cholecys-
tectomy5 27 42 46 61 and renal or ureteric surgery.42 43 46 49 It
can also provide analgesia for rib trauma23 28 29 55 103 and
herniorrhaphy.19 89 90 It has been used as a bilateral
technique in thoracic surgery96 and major abdominal
vascular surgery.82 In chronic pain management, it is
used for the treatment of benign or malignant neural-
gia,7 10 14 23 38 40 66 94 in the management of complex
regional pain syndromes with a sympathetic compo-
nent, and in the therapeutic control of hyperhydrosis.
Techniques
The standard technique of space location is by loss of
resistance to air or saline.23 71 The patient can be in the
prone, lateral (usually with the side to be blocked
uppermost) or sitting position. Two or three centi-
metres lateral to the spinous process, a short bevelled
8- or 10-cm spinal needle, or a Tuohy needle if a cath-
eter is required, is advanced perpendicular to all skin
planes. At approximately 2 to 5 cm in an adult, the
transverse process should be contacted. Upon bony
contact, the needle is re-angled superiorly and
advanced 1 or 1.5 cm over the top of the process until
loss of resistance to air or saline is appreciated. A
“click” may be appreciated as the superior costotrans-
verse ligament is penetrated. The depth from the skin
is variable but in the thoracic region the paravertebral
231
Figure 1 Schematic thoracic spinal nerve. AD:anterior division,
PD:posterior division, C:spinal cord, SG:spinal ganglion,
RM:recurrent meningeal, SC:sympathetic chain, RC:rami
communicantes, PC:posterior cutaneous, LC:lateral cutaneous
AC:anterior cutaneous, P:pleura.
space is usually 4–6 cm. Paraesthesiae may be experi-
enced by an awake patient in the distribution of the
anterior ramus, but if they occur in the distribution of
the posterior ramus (that is, over the skin of the back) it
does not necessarily mean that the needle point is cor-
rectly positioned, as posterior branches of the spinal
nerve may have been contacted in spinal muscle.
It should be noted that compared with extradural
space location where a very resistant ligamentum
flavum is traversed, followed by almost free injection,
thoracic paravertebral space location by this method
is somewhat indefinite. False positive losses of resis-
tance may occur when the needle tip is radiologically
embedded in muscle. With advancement, penetra-
tion of the superior costo-transverse ligament may
not be appreciated, following which false negative
losses of resistance may occur as paravertebral areo-
lar tissue provides more resistance to injection of air
or saline than extradural fat. There may therefore be
encouragement for further needle advancement and
hence pleural penetration. In patients who are either
tender, obese or very muscular, prior location of the
aiming point of the transverse process may be impos-
sible. Scar tissue in the paravertebral space, for exam-
ple, in previous thoracotomy patients, can interfere
with the appreciation of a loss of resistance.
There are two supplementary ways of improving
the reliability of space location. X-Ray screening with
contrast injection is helpful if the facilities are readily
available. The appearances have been described as
“linear streaming” where dye is seen, over the course
of a few seconds, to spread superiorly and inferiorly
over the heads and necks of the ribs, alongside the
vertebral column. Otherwise a “cloud-like” appear-
ance may be seen; here, contrast medium is more
localized and spreads along one or two intercostal
232
Figure 2 Optimal needle position in relation to the transverse
process of the vertebra (TP) and the nervous structures of the
thoracic paravertebral space (Adapted from Mandl51). R : rib,
AD:anterior division, SP:spinous process, SC:sympathetic
chain, DRG:dorsal root (spinal) ganglion, C:spinal cord.
spaces.46 Either appearance leads to an adequate
block.46
Pressure monitoring can be used as an alternative
or supplementary technique.70 A transducer is con-
nected to the end of a Tuohy needle via a three-way
tap and a pressure waveform is displayed during nee-
dle advancement. In muscle, the pressure is greater
on inspiration than expiration, either because the
posterior spinal muscles are active during inspira-
tion, or else that they are compressed by the expan-
sion of the chest cage against the elastic confines of
the skin. With advancement, there is a sudden lower-
ing and inversion of pressures when the paravertebral
space is reached, because of the transmission of sub-
atmospheric intrapleural pressure on inspiration.
Inadvertent puncture of the pleura is readily appreci-
ated as both inspiratory and expiratory pressures
become subatmospheric on quiet respiration.35 This
objective technique improves sensitivity and speci-
ficity.70 The lateral distance from the spinous process
to the paravertebral space and the depth of the skin
to the paravertebral space have been found to corre-
late well with age, height, weight and body surface
area in children and adolescents.45
Catheter techniques are straightforward but it
should be noted that some manipulation of needle
angulation may be necessary and greater force in
feeding the catheter is needed compared with
extradural catheterization. We do not recommend the
insertion of more that 4 cm of catheter in an adult or
2–3 cm in children, as inadvertent lateral projection
into an intercostal space may encourage just one der-
matome analgesia (see below) (fig. 3).
Sabanathan described a method of catheterization
for use in chest surgery.83 Before thoracotomy clo-
sure, the parietal pleura is stripped up to the verte-
bral bodies and a blunt dissection of the extrapleural
fascia, two dermatomes above and two below the
incision, is carried out. An externally introduced
Tuohy needle is advanced into the paravertebral
space and an extradural-type catheter is advanced
British Journal of Anaesthesia
Figure 3 Optimal position of a paravertebral catheter
under direct vision into position alongside the verte-
bral column. The parietal pleura is then replaced and
held in position by two sutures. Through the combi-
nation of direct vision and the preparation of a
pocket for local anaesthetic, these modifications
make for a very highly reliable technique, even in
infants of a median age of 1.5 weeks (fig.4).3 15 34 86 87
In thoracic surgery, these methods can be com-
bined.86 87 A percutaneous bolus of bupivacaine given
by the anaesthetist through the loss of resistance or
pressure monitoring technique, provides analgesia
for the intraoperative period. A catheter can be
placed at the same time and methylene blue can be
injected before chest closure to confirm or refute its
successful position. If spread of dye is optimal, that
is, over the heads and necks of the ribs above and
below the injection for at least 4 dermatomes, it is left
in situ. If spread is suboptimal it can be replaced
by the surgeon before chest closure. The positioning
of a catheter under direct vision has been described
during thoracoscopy.96
Nursing surveillance
No additional nursing skills or observations are nec-
essary other than those required for the care of post-
operative patients.73 An aseptic technique is required
in changing an infusion syringe and an in-line bacter-
ial filter is advocated.
Drugs used
Drugs used include bupivacaine, bupivacaine with
epinephrine, bupivacaine with corticosteroid (per-
sonal experience) and lidocaine with epinephrine.
The dose of local anaesthetic required involves a con-
sideration of the number of dermatomes which it is
Thoracic paravertebral block
Figure 4 Radiographic appearances after contrast medium
infusion through a correctly placed paravertebral catheter.
Contrast is confined to, but well distributed within, the adjacent
paravertebral spaces showing a longitudinal streaming effect.
desired to block. No reliable formula has as yet been
developed, but it can be assumed in an adult that
a volume of 15 ml will spread over and block at least
3 dermatomes,5 14 20 23 28 29 66 70 71 78 83 87 96 and in children
a bolus dose of 0.5 ml kg91 will reliably cover at least
4 dermatomes.46
In adult thoracotomy pain management, we use
bupivacaine with a concentration ranging from 0.25
to 0.5%, starting with a bolus dose of 15–20 ml, at
least 10 min before skin incision. A further bolus of
0.5% bupivacaine 10 ml is given during chest closure
and this is followed by an infusion of 0.5% bupiva-
caine at a rate of 0.1 ml kg–1 h91 for 2 days, after which
the concentration is lowered to 0.25% for a further 3
days.86 Other authors agree that continuous infusion
provides better analgesia than intermittent bolus
doses.12
Pharmacokinetics
The two local anaesthetic agents which have been
studied are bupivacaine and lidocaine, both with and
without epinephrine. The mean (SEM) maximum
plasma concentration (Cpmax) obtained with a bolus
of 0.5% buplvacaine 20 ml is 1.45 (0.32) ␮g ml91 with
a median (range) time to Cpmax (tCp max) of 25
(10–60) min. After the initial peak with the bolus
injection, there is a gradual increase to a mean (SEM)
peak concentration of 4.92 (0.7) ␮g ml91 at 48 h
(5–96).4 There were no symptoms or signs of toxicity
in this study. Similar levels were found in a previous
study using these methods, but additionally it was
found that of the total bupivacaine levels, there was a
higher concentration of the S-enantiomer, of which
there is evidence for less toxicity compared with the
R-enantiomer.16
Patients with a median age range of 5.3 weeks
given a bolus followed by infusion of 0.25% bupiva-
caine for post-thoracotomy pain relief had satisfac-
tory peak loading dose and infusion levels.34 In a
subsequent study of even smaller infants, given
0.125% bupivacaine, satisfactory levels were again
shown.15
The preliminary results of a comparison of 0.25%
bupivacaine compared with 0.25% bupivacaine with
233
epinephrine 20 ml 1:200 000 given as a bolus dose
of 1 mg kg91 to thoracotomy patients, was reported
by Snowden and colleagues.95 The Cpmax ranged
from 0.48–1.08 ␮g ml91 (median 0.705) in the bupi-
vacaine with epinephrine group, compared with
0.27–2.39 ␮g ml91 (median 0.918) in the bupivacaine
group. Although this difference was not statistically
significant, the lowering of maximal plasma bupiva-
caine concentrations with epinephrine containing
solutions has also been shown with intercostal nerve
blocks32 and would seem logical. The median (range)
tCp max was 5 min (5–20) for both groups.
We have measured plasma concentrations of lido-
caine in children undergoing renal surgery.43 Patients
were given a bolus of lidocaine 0.5 ml kg91 (10 mg ml91)
with epinephrine (5 ␮g ml91), followed by an infusion
of 0.25 ml kg91 h91 of the same solution which was
started 2 h after the initial bolus injection and contin-
ued for 10 h. Peak concentrations ranged between
1.7 and 3.0 ␮g ml91 after the bolus with a tCp max of
15–30 min. Steady state levels of lidocaine were
reached 8–10 h after the start of the infusion and
ranged from 2.1–3.2 ␮g ml91. These moderate levels
were not associated with symptoms or signs of toxi-
city. We have been unable to find any clinical reports of
severe central nervous system or cardiovascular sys-
tem toxicity either because of excessive systemic local
anaesthetic levels or profound sympathetic block.
Efficacy
Particularly when used as a method of providing unilat-
eral analgesia for unilateral surgery, paravertebral
blocks can provide high quality pain relief, as shown by
low pain scores and an opioid sparing effect.3 11 60 72 75 83 85
Sufficient analgesia in some situations, particularly
breast surgery, has obviated the need for general anaes-
thesia.30 78
Pre-emptive paravertebral blocks before thoraco-
tomy combined with continuous postoperative para-
vertebral blocks as part of a balanced perioperative
technique has led to pain scores of less than 0.5 cm
on a scale of 0–10 cm, with almost complete preser-
vation of pulmonary function and with stress inhibi-
tion (as shown by glucose and cortisol estimation).75 80
Stress inhibition has also been shown after cholecys-
tectomy,27 effects which cannot be demonstrated for
these types of surgery with more central forms of
afferent block.37 79 92 Post-thoracotomy pulmonary
function has been studied and found to be better pre-
served with paravertebral blocks than with systemic
opioids,3 83 85 intrapleural bupivacaine76 or extradural
bupivacaine.79 The ability to perform pulmonary
function tests in the presence of a large chest wound
is an objective measure of pain control. Postoperative
pulmonary complications and hospital stays are
reduced,3 75 83 86–88 as is the generation of chronic pain
(post-thoracotomy neuralgia).77
Comparative studies
EXTRADURAL ANALGESIA
In comparing the analgesia which can be obtained
with extradural compared with paravertebral blocks,
Matthews and Govenden found that pain scores at rest
after thoracotomy were similar with both techniques
234
but the side effects of postural hypotension and uri-
nary retention were significant problems only with
extradural analgesia.53 We have compared extradural
morphine and paravertebral bupivacaine after thora-
cotomy and found similar results; pain relief was simi-
lar but troublesome side effects, especially urinary
retention, accompanied extradural analgesia.72 We
have also studied extradural bupivacaine compared
with paravertebral bupivacaine for perioperative thora-
cotomy pain management.80 Pain relief was the same,
but opioid requirements were less in the paravertebral
group, with consequently less opioid related side
effects. Pulmonary function was significantly better in
the paravertebral group and stress responses, as mea-
sured by cortisol and glucose assay, were suppressed in
the paravertebral group, but not in the extradural
group.
In a retrospective comparison of the analgesia
obtained by extradural blocks compared with para-
vertebral blocks in children undergoing renal
surgery, we found the need for supplemental mor-
phine administration was significantly lower in the
paravertebral group and the number of patients
requiring no supplemental morphine was signifi-
cantly higher in the paravertebral group.49
In contrast with these studies that have favoured
paravertebral techniques, must be set two other inves-
tigations that have shown equivocal results. Pertunen
and colleagues carried out a comparison of
extradural, paravertebral and intercostal blocks for
post-thoracotomy pain. Similar levels of pain, opioid
requirements, pulmonary function and adverse
effects were found in all groups.64 Bigler and
colleagues compared extradural bupivacaine and
morphine with paravertebral bupivacaine in post-
cholecystectomy patients. Both groups were given
boluses preoperatively followed by the same drugs by
infusion postoperatively.5 Pain scores were signifi-
cantly better in the extradural group compared with
the paravertebral group. There was no difference in
their effects on pulmonary function.
In conclusion, both techniques lead to high quality
pain relief which can be associated with good preserva-
tion of postoperative pulmonary function. Stress modi-
fication has been shown with paravertebral blocks. The
choice of an optimal regional technique probably
comes down to other factors such as contraindications,
side effects and possible complications (see below).
INTERCOSTAL BLOCKS
These blocks are done by injecting local anaesthetic
into the same tissue plane as for a paravertebral injec-
tion, but usually approximately 8 cm from the midline.
This single difference makes for very dissimilar effects:
(1) Multiple level spread is discouraged. Johansson,
carefully studying healthy volunteers found that
0.5% bupivacaine 20 ml deposited 8 cm from
the midline (that is, intercostally) blocked just
one level.31
(2) Catheter techniques are cumbersome and unre-
liable: the use of up to 4 catheters at any one
time has been described.63 Repeated intercostal
nerve blocks are therefore required which are
painful, time consuming and compound the
risks of a pneumothorax.6 39
British Journal of Anaesthesia
(3) In this relatively distal position along the length
of the intercostal nerve, it could not be expected
that the sympathetic chain, the rami communi-
cantes or the dorsal ramus are reliably blocked.
Studies on the use of intercostal nerve blocks for
pain after postero-lateral thoracotomy have
reported unrelieved back pain (caused by dam-
aged costotransverse and costovertebral struc-
tures), or unrelieved shoulder pain probably
because of failure to block these structures.104
(4) The complications of pleural or pulmonary
damage would be expected to be greater than
with paravertebral blocks, because of the relative
shallowness of the intercostal space distally com-
pared with its triangular shape alongside the ver-
tebral column (paravertebrally). Comparisons
are difficult but the incidence of pneumothorax
after intercostal block has been reported to range
from 0.073% to 19%,58 compared with approxi-
mately 0.5% with paravertebral blockade.48 71
Having made these observations, we are aware of
only one direct comparison, that of Pertunen and
colleagues.64 They compared extradural, paraverte-
bral and intercostal blocks for post-thoracotomy pain
in 45 patients divided into three groups and found
similar levels of pain, opioid requirements, pul-
monary function and adverse effects.
INTRAPLEURAL ANALGESIA
Intrapleural analgesia arises as a result of injection of
local anaesthetic between the pleurae (compared with
outside the parietal pleura with paravertebral analge-
sia). Almost all studies have shown a lowering of pain
scores and opioid requirements. More objective mea-
sures such as the study of postoperative pulmonary
function have not conclusively shown any improve-
ment with intrapleural blocks.52 56 67 In a prospective
randomized comparison of post-thoracotomy pain
managed with paravertebral or intrapleural analgesia
involving 53 patients, we found that pain scores were
the same but pulmonary function was significantly
worse with intrapleural blocks.76 We questioned
whether respiratory muscle function was being
actively impaired by gravity-dependent pooling of
local anaesthetic on the diaphragm as we routinely
nurse our postoperative patients in the sitting posi-
tion.97 Bupivacaine after intrapleural administration is
known to be avidly taken up by the diaphragm.98
Dependent chest drain losses of local anaesthetic,
which can be approximately 30% to 40% with
intrapleural blocks,25 are much less with paravertebral
infusion.81 For this reason we have questioned the
continued use of intrapleural analgesia for post-
thoracotomy pain relief.74 76
Intrapleural analgesia is known to be positional
and it is generally recommended that patients are
nursed supine,33 52 54 56 67 temporarily after bolusing, or
continuously in the case of infusions. We challenge
the wisdom of this approach to postoperative care as
it would mitigate against maintenance of functional
residual capacity and accelerated mobilisation regi-
mens.36 84 86 Paravertebral administration does not
radiologically or clinically respond as if it is gravity
dependent.24 74 76 81 Qualitative differences also sepa-
rate these techniques. Lack of block of the posterior
Thoracic paravertebral block
ramus of the intercostal nerve with intrapleural anal-
gesia means that after thoracotomy, patients can suf-
fer from pain from the proximal wound edge and
from damaged vertebral muscles and ligaments.25 In
clinical settings other than after thoracotomy, it does
not appear that these two techniques have been
directly compared.
The risk of pleural or pulmonary damage with
intrapleural blocks99 is greater than with paraverte-
bral techniques as pleural penetration is necessary for
intrapleural catheterization. An accurate incidence of
pneumothorax is difficult to determine as it depends
upon efficient reporting of this complication. In ret-
rospective literature reviews, there was a 2% inci-
dence of pneumothorax with intrapleural blocks99
compared with a 0.5% incidence with paravertebral
blocks.71 A prospective, multiple-centre study agreed
with the latter figure.48
Contraindications
Paravertebral blocks have a low potential for neuro-
logical damage. Except in the case of inadvertent
extradural or intrathecal entry, or the use of neu-
rolytic agents, damage to nervous structures other
than peripheral (spinal or intercostal) nerves has not
(to our knowledge) occurred. Paravertebral blocks
can be safely performed in anaesthetized patients.
Because of the low potential for neurological dam-
age, the presence of a coagulation disorder or the use
of anticoagulants are relative rather than absolute
contraindications: the neurological consequences of
a paravertebral haematoma are probably small, espe-
cially if compared with an extradural haematoma. In
a number of patients undergoing major lung or
oesophageal resection who have been fully anticoag-
ulated we have successfully used paravertebral anal-
gesia. Venous puncture has been recorded in one
patient which required no specific treatment.44
Local sepsis at the proposed site is a contraindica-
tion, as is sepsis in the chest cavity, for example, an
empyema. Pus between the pleurae should not theo-
retically be disturbed by paravertebral cannulation
but the accompanying acidosis would be expected to
adversely effect local anaesthetic ionization (and
hence nerve penetration) and any accompanying
hyperaemia would encourage its systemic absorp-
tion. Occupation of the paravertebral space by
tumour is also a contraindication although a chest
wall tumour lateral to the paravertebral space is not.
Care is needed in the case of severe chest deformity
or scoliosis to avoid injection into the meninges or
pleura.
A planned pleurectomy is not a contraindication.
As long as the parietal pleura covering the vertebral
bodies and a few centimetres distally is left intact,
catheterization and a satisfactory block can be
achieved.60
Side effects and complications
Paravertebral blocks generally have a low incidence
of adverse effects. In retrospectively reviewing this
subject, we estimated that the overall incidence of
side effects or complications was less than 5%.71 In a
multiple-centred, prospective study of 367 paediatric
and adult patients, we found an overall failure rate of
235
10.1%. The frequency of complications was:
hypotension 4.6%; vascular puncture 3.8%; pleural
puncture 1.1%; and pneumothorax 0.5%.48
Neurological or haemodynamic complications
from accidental extradural or intrathecal entry have
not been associated with any long-term morbidity or
mortality, even after total spinal anaesthesia.26 93
Three patients (out of 206 injections) in one of these
studies developed postural headaches indicating that
meningeal trauma had probably occurred.93 The
most serious complication ever reported was a
Brown Séquard paralysis which followed the use of
paravertebral alcohol for the treatment of angina
pectoris in 1931.57 At that time, this frequently used
destructive treatment would not have involved radio-
logical screening.102
Accidental extradural injection is a rare event51 71
which indicates a faulty technique. Extradural spread
of local anaesthetic can occur but it is not known
whether or not this event contributes to the block.
Occasionally a 1 or 2 dermatome contralateral block
occurs but only rarely is a fully bilateral block
observed. It is possible that injection inferior to the
transverse process, directly adjacent to an interverte-
bral foramen, encourages this phenomenon.66
A unilateral Horner’s syndrome means spread up
to the cervical region has occurred. It is not itself a
cause for concern, although the patient will need
reassurance. The unique case of a bilateral Horner’s
syndrome is disconcerting.66 The actual spinal level
of injection was not stated. Anterior vertebral spread
of solution may have occurred,46 or else, there may
have been some cross-over of sympathetic fibres. A
bilateral block, if it is associated with a bilateral
phrenic nerve or recurrent laryngeal nerve block,
would be dangerous. However, there are no data as to
whether a posterior approach to the stellate ganglion
(via a paravertebral injection) is more or less haz-
ardous in this respect than the more frequently used
anterior approach.
Segmental thoracic pain has been observed in one
patient after cholecystectomy and caused chronic
pain for three months,5 the likely cause being inter-
costal nerve trauma. This event is probably quite
common, but a surgical incision within the same or
an adjacent dermatome with its associated acute and
possibly chronic pain makes the diagnosis of needle
or catheter intercostal nerve damage difficult.
Urinary retention is not a problem, either from our
experience or from published studies.
The haemodynamic consequences of a correctly
placed bolus of local anaesthetic in a normally
hydrated patient are minimal.14 71 A study of thoracic
paravertebral blocks using 0.5% bupivacaine 15 ml
produced a mean unilateral sympathetic block of
8 dermatomes but without any significant change
between supine and sitting arterial pressures.14 The
occurrence of hypotension in 4.6% of (mainly) peri-
operative blocks (see above) may be multifactorial,
with unmasking of relative hypovolaemia by unilateral
vasodilatation.
Discussion
We believe that paravertebral blocks are effective and
safe, although this may not be the commonly
accepted view in the anaesthetic literature. We are
236
unable to explain this difference of interpretation,
but counsel that descriptions of paravertebral blocks
as “ineffective and hazardous”,2 22 or lack of descrip-
tions of the technique in textbooks100 should no
longer be allowed to suppress interest and research in
this technique. At the beginning of this century, it
was thought that more central forms of afferent block
were not completely effective and had life-threaten-
ing complications. This situation may not Have sub-
stantially, changed.1 8 9 21 65 68 91 No ideal regional
anaesthetic block exists; all must be carefully com-
pared. Paravertebral blocks are relatively easy to
learn, they have few contraindications and require no
additional nursing surveillance. They are applicable
to large numbers of patients and, because of their low
side-effect profile (especially hypotension), they
contribute to accelerated postoperative mobilization
regimens. “Is it (yet) time for revivification of
paravertebral blocks?”.69
Acknowledgement
We dedicate this review to the memory of the surgeon, Emeritus
Hunterian Professor Sabaratnam Sabanathan. A great proponent
of paravertebral nerve blocks, a great scientist and a great friend.
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