Paravertebral Nerve

Introduction

It was a popular technique in the early 20^th century
However, for some reasons, paravertebral nerve block lost popularity and was almost extinct until the late 1970’s, when there was a renewed interest in the technique.
It is essentially a unilateral block of the spinal nerves, including dorsal and ventral rami, as well as sympathetic chain ganglion
Commonly performed at thoracic level
CPT 64461, 64462 76942

Indications

Relevant anatomy

Posteriorly- the superior costotransverse ligament (a continuation of internal intercostal muscle);
Anterolaterally- parietal pleura
Medially- vertebral bodies, intervertebral foramina and intervertebral discs.

Thoracic paravertebral space is a triangular or wedge shaped space running the length of the thoracic vertebral column bilaterally

In contrast to cervical and lumber regions, the thoracic paravertebral regions is in continuity with the adjacent vertebral levels, allowing for the spread of local anesthetic.

Needle Placement

Procedure

Patient is placed sitting upright with neck and back flexed and shoulders relaxed forward
The spinous process of each level is planned for the block is palpated and marked at its superior aspect
In thoracic paravertebral block, the numbered spinous process corresponds to the next numbered nerve root caudally
In lumbar area, transverse process is usually at the same level as the spinous process

Positions

Prone
Sitting
Lateral Decubitus

Ultrasound-guided Paravertebral Block

“Ultrasound guided multilevel paravertebral block (PVB) with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia.”

Abdallah FW, et al. Ultrasound-guided Multilevel Paravertebral blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection. Anesthesiology. 2013 Sep 26.

“A transverse in-line ultrasound-guided technique improves the feasibility of placing paravertebral nerve block (PVNB) catheters using in a wide range of pediatric patients.”

Boretsky K, et al. Ultrasound-guided approach to the paravertebral space for catheter insertion in infants and chuildren. Paediatr Anaesth. 2013 Jul 27.

“Thoracic epidural, thoracic paravertebral, and intercostal blocks are the top choices for patients with multiple fracture ribs (MFR) and they are of equivalent efficacy. Each has unique advantages and disadvantages. Our preference tends to be the thoracic paravertebral approach.”

Ho AM, et al. Acute pain management of patients with multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care. 2011 Aug;17(4):323-7.

“30-year-old woman with chronic hip pain secondary to avascular necrosis. She received preoperative L1-L2 paravertebral block for postoperative pain control after arthroscopic hip surgery.”

Ilkhchoui Y, et al. Preoperative L1 and L2 paravertebral block is an effective postoperative anlgesia for hip arthroscopy in multimoda; analgesic regimen. BMJ Case Rep. 2013 Aug 8;2013.

“Epidural anesthesia and paravertebral block, respectively, may prevent persistent post operative pain (PPP) after thoracotomy and breast cancer surgery in about one out of every four to five patients treated.”

Andreae MH, Andreae DA. Regional anesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth 2013 Nov;111(5):711-20.

“Neurolytic paravertebral block can be a useful technique in patients with intractable cancer pain.”

Malik T. Ultrasound-Guided Paravertebral Neurolytic Block: A report of two cases. Pain Pract. 2013 May21

References

and Interesting Articles

Batra RK, Krishnan K, Agarwal A. Paravertebral block. J Anaesthesiol Clin Pharmacol. 2011 Jan;27(1):5-11. PMID: 21804697; PMCID: PMC3146159.
Eason MJ, Wyatt R. Paravertebral thoracic block-a reappraisal. Anaesthesia. 1979 Jul-Aug;34(7):638-42. doi: 10.1111/j.1365-2044.1979.tb06363.x. PMID: 517716.
Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001 Sep;95(3):771-80. doi: 10.1097/00000542-200109000-00033. PMID: 11575553.
Klein SM, Nielsen KC, Ahmed N, Buckenmaier CC, Steele SM. In situ images of the thoracic paravertebral space. Reg Anesth Pain Med. 2004 Nov-Dec;29(6):596-9. doi: 10.1016/j.rapm.2004.08.016. PMID: 15635519.

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