Paravertebral Nerve Block

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  • Surgical anesthesia for thoracic and abdominal surgery
  • Extracorporeal shock wave lithotripsy—successful anesthesia and postoperative analgesia have been reported.
  • Postoperative analgesia
    • Breast surgery
    • Thoracic surgery
    • Analgesia for trauma
    • Rib fractures
  • Diagnosis and management of chronic pain disorders involving the thorax
  • Analgesia for liver mass radiofrequency ablation or other biliary manipulation
  • Post-herpetic neuralgia—successful treatment of pain refractory to other medical therapy has been reported using repeated paravertebral blockade via catheter injection.

Absolute Contraindications

  • Patient refusal
  • Infection at the injection site(s)
  • Allergy to local anesthetics

Relative Contraindications

  • Coagulopathy or bleeding diathesis
  • Therapeutic anticoagulation
  • Unstable spinal fracture
  • Hypotension
  • Uncorrected hypovolemia
  • Systemic infection
  • Increased intracranial pressure
  • Contralateral pneumothorax
  • Severe underlying respiratory disease
  • Sterile gloves and mask
  • Standard monitors: ECG, blood pressure cuff, pulse oximeter
  • Standard resuscitation equipment, including oxygen, suction, and appropriate resuscitation drugs
  • Sterile prep solution
  • Sterile towels or fenestrated drape
  • Local anesthetic (e.g., 1% lidocaine) for skin infiltration
  • Local anesthetic for paravertebral block (typically longer acting agents such as 0.1% to 0.25% bupivacaine or 0.2% ropivacaine are used)
  • 10-mL sterile syringe and small (25-gauge or 30-gauge) needle for skin infiltration
  • One 10-cm, 22-gauge Quincke or Tuohy tip spinal needle
  • One sterile “loss of resistance” syringe
  • Additional supplies, such as 18-gauge Tuohy needle, sterile saline, and an epidural-type catheter, if an indwelling catheter is to be placed

The thoracic paravertebral space is a wedge-shaped area that lies on either side of the vertebral column.Its walls are formed by the parietal pleura anterolaterally; vertebral body, the intervertebral disk, and intervertebral foramen medially; and the superior costo-transverse process posteriorly. The spinal nerves in the paravertebral space are organized in small bundles submerged in the fat of the area. At this location, a thick fascial sheath does not envelop the spinal nerves. Therefore, they are relatively easily anesthetized by injection of local anesthetic. The thoracic paravertebral space is continuous, with the intercostal space laterally, epidural space medially, and the contralateral paravertebral space via the prevertebral fascia. The mechanism of action of a paravertebral blockade includes direct penetration of the local anesthetic into the spinal nerve, extension laterally along with the intercostal nerve, and medial extension through the intervertebral foramina.

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The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Patients should be monitored for a minimum of 20-30 minutes after the procedure for:
    • Hypotension due to sympathetic blockade
    • Development of epidural block, which is characterized by bilateral, multi-level dermatomal distribution
    • Development of spinal block, which is characterized by rapid onset of a dense block of all dermatomes at and below the level of injection. Occasionally, a high spinal or “total” spinal can develop, compromising respiration, and causing paralysis of the extremities, and muscles of respiration.
    • Development of local anesthetic toxicity, both early (due to direct intravascular injection) and late (due to absorption of deposited local anesthetic), characterized by tachycardia, tinnitus, metallic taste, confusion, and, rarely, seizure
  • Observe for development of hematoma or infection at the injection sites.
  • Monitor for decreased oxygen saturation, development of cough or shortness of breath, or wheezing, all of which can indicate development of a pneumothorax.
  • Paravertebral muscle spasm
  • Infection
  • Hematoma
  • Local anesthetic toxicity; including tachycardia, mental status change, tinnitus, metallic taste, seizure
  • Nerve injury
  • Epidural block
  • Subarachnoid block or total spinal anesthesia
  • Pneumothorax
  • Hypotension, myocardial depression. This effect is generally transient and may be attenuated by the use of epinephrine-containing solutions.
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