Journal reading

Acta Anaesthesiol Scand 2010; 54: 246–251

Unilateral paravertebral block:

an alternative to conventional spinal anaesthesia
for inguinal hernia repair

P. BHATTACHARYA, M. C. MANDAL, S. MUKHOPADHYAY, S. DAS, P. P. PAL and S. R. BASU

Department Of Anaesthesiology, North Bengal Medical College, Darjeeling, West
Bengal, India
• INGUINAL herniorrhaphy is one of the most
frequently performed surgeries and can be
successfully performed using general,
regional or local anaesthesia.
• But nowadays, uncomplicated hernia repairs
in adult patients are mostly accomplished
under regional anaesthesia: central neuraxial
block (CNB) and peripheral nerve block (PNB)
• Paravertebral somatic nerve block produces ipsilateral
segmental analgesia through injection of local
anaesthetic onto the spinal nerve roots alongside the
vertebral column.

• It is advocated predominantly for unilateral procedures

such as thoracotomy, breast surgery, chest wall trauma,
hernia repair or renal surgery, although it can be used
for bilateral surgeries as well.
• The aim of this study was to evaluate the
efficacy of unilateral paravertebral somatic
nerve block in comparison with spinal
anaesthesia (SA) in inguinal hernia repair
regarding post-operative pain relief, early
ambulation and reduction of potential
complications.
 Methods
• After obtaining Institutional Ethics
Committee’s approval,
• 60 consenting male, ASA physical status I & II,
• aged 18–65 years,
• scheduled for a unilateral inguinal hernia
repair procedure
• Exclusion criteria included: known
cardiovascular, respiratory, renal, hepatic
ormetabolic disease, active gastrointestinal
reflux, mental dysfunction, morbid obesity,
history of substance abuse, chronic analgesic
use and history of allergy to local anaesthetics.
• Patients were randomly assigned to two
groups: P and S, according to a sealed
envelope method to receive one of the
following two anaesthetic techniques –
paravertebral block (PVB) or SA, respectively.
• Intra- and post-operative data were recorded
by residents not participating in the study.
 P
• The PVB was performed using a 18G Tuohy
needle unilaterally using the classic ‘loss of
resistance’ technique with the patient sitting.

• A point 2.5–3cm lateral to the superior aspect of

the spinous process of L1 vertebra was marked
as the point corresponding to the transverse
process. Local injection of lignocaine 10mg/ml
was used at the site of needle insertion.
• After waiting for 3–5 min, the Tuohy needle
was inserted perpendicularly to the skin to a
depth of about 3–5 cm untill the transverse
process was contacted.
• The needle was then withdrawn a bit and
walked off the transverse process and inserted
1–1.5cm deeper to the superior ridge of the
transverse process where a ‘loss of resistance’
was experienced using normal saline.
• After negative aspiration for blood, 20 ml of
plain bupivacaine 5mg/ml was injected after
eliciting paraesthesia.
 S
• The patients in group S were pre-loaded with
10 ml/kg of RL. Under the same sedation
protocol, they were administered SA using
midline approach with a 25-G Quincke needle
at the L3–4 or L2–3 intervertebral space in the
sitting position.
• The subarachnoid injection contained 12.5mg
of 5mg/ml hyperbaric bupivacaine.
 Result
• The study spanned from August 2007 to July
2008.
• Two patients (7%) in group P were administered
GA due to an inadequate block and were
excluded from the study.
• So, data from 58 patients were available for
analysis (n=28 in group P and n=30 in group S).
 Discussions
• The data of our study focuses on the fact that
PVB can be comparable with SA when used as
the sole anaesthetic for inguinal hernia repair
with respect to better haemodynamic stability,
as evident from better maintenance of MAP
nearer to the preoperative values and no
episodes of bradycardia and hypotension
(Table 3).
• PVB resulted in unilateral, segmental
anaesthesia and prolongation of analgesia
(4.5–7 hours).
• This was in sharp contrast to conventional SA,
which results in much shorter duration of
analgesia (3.5–4 h) and bilateral blockade,
thus precluding ambulation until its
anaesthetic effects completely wear off.
Thank you