Underutilization of paravertebral block in thoracic surgery.

a t i AIN AFTER thoracotomy and thoracoscopic surgery can cause patient distress, impair respiratory function, and deay recovery.1,2 Epidural analgesia is generally regarded as a tandard of care for patients undergoing thoracotomy,1,3 but pidural block is probably not warranted for less invasive horacic surgery. Sometimes, however, the extent of surgery is nclear until histopathology results are obtained during surgery r a thoracoscopic procedure is complicated by bleeding or nadequate surgical exposure, and so an open thoracotomy is erformed. In addition, epidural block is contraindicated in atients with coagulopathy or local sepsis,4 and some patients efuse neuraxial block because of concern regarding spinal cord njury and permanent paraplegia. Thoracic paravertebral block (PVB) is an alternative analgeic technique, particularly for unilateral surgical procedures of he chest and abdomen.5,6 It is relatively simple to perform and as a low incidence of side effects.5-8 Thoracic PVB was first escribed in 1905 to produce abdominal analgesia by injection f small volumes of procaine at different spinal levels.5,6 PVB as since been used in open thoracic surgery,4,9-11 thoracoabominal surgery,12 video-assisted thoracoscopic surgery,13 laprotomy,13 breast surgery,14 after traumatic rib fracture,15 and in ther chronic pain states. The block may be achieved by muliple small-volume (3-4 mL) injections5,6 or a single largerolume (15-20 mL) injection14 and can be maintained by infuion via a paravertebral catheter of a low-concentration local nesthetic solution.5,6 When compared with thoracic epidural block, PVB is more ikely to preserve bladder and lower-limb motor function, hereby assisting early mobilization after surgery. The hemoynamic instability following the cardiovascular effects of epiural block is avoided.16 Importantly, paravertebral injections nd catheter insertion can be performed in sedated and ventiated patients with less risk of neuraxial injury. The catheters an also be safely and accurately placed under direct vision uring thoracotomy.10,11,17,18