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Pain relief with paravertebral blocks or epidural analgesia? Those who do not know the history of paravertebral blocks are condemned to rediscover the complications
Scandinavian Journal of Pain 1 (2010) 3–4
Contents lists available at ScienceDirect
Scandinavian Journal of Pain journal homepage: www.ScandinavianJournalPain.com
Editorial comment
Pain relief with paravertebral blocks or epidural analgesia? Those who do not know the history of paravertebral blocks are condemned to rediscover the complications Pain relief with paravertebral blocks (PVB) is more than 100 years old. The block is easy to learn: With the needle you touch the transverse process of the vertebral body at the level of pain location, or where an operation will take place, “walk” the needle below (or above) the transverse process, advance about 1 cm deeper and inject 10–30 ml of a concentrated local anaesthetic with adrenaline. With ultrasound you can see whether your injection enters the correct paravertebral space or, unintendedly, muscles of the back (Axel Sauter, personal communication), the interpleural space, or lung. Unilateral anaesthesia follows, lasting a few hours, depending on dose and whether a vasoconstrictor is added. In Norway, PVB was a routine procedure before thoracoplasty for tuberculous caverns of the apex of the lungs during the 1950s and early 1960s (Bjørn Lind, personal communications). PVB has been reintroduced several times since 1905, and is now being rediscovered again. One of us (HB) used PVB frequently until learning how to do thoracic epidural analgesia (TEA) well. A classic application of PVB, was to administer single bolus PVB and subsequently transtracheal saline to dissolve an endobronchial mucus-plug and provoke forceful, pain free coughing, in patients who developed atelectasis after thoracotomy or cholecystectomy (Breivik, 1974). If the patient is unable to expectorate due to pain on deep inspiration and coughing, a postoperative atelectasis can become infected, and progress to pneumonia, sepsis, and multiorgan failure. In this issue of the Scandinavian Journal of Pain a systematic review is published on all available randomized studies (RCTs) comparing PVB with TEA for post-thoracotomy analgesia (Norum and Breivik, 2010). One RCT concluded that PVB was better than TEA, another RCT concluded that TEA was superior to PVB, whereas 8/10, mostly with small numbers of patients, did not find any differences in effects on post-thoracotomy pain. The most surprising finding was that PVB was compared with less than optimal epidural analgesia in all the ten studies: The epidural catheters were sited too high or too low for a thoracotomy, not documented, or discontinued early. Rather concentrated local anaesthetic solutions without opioid or adrenaline were injected or infused epidurally. This is bound to cause sympathetic block, hypotension, and less pain relief than what a triple component, low dose epidural can do (Breivik et al., 1995). All ten RCTs reported to have randomized patients to two groups, however, only two reported satisfactory methods of randomization, two reported
This article refers to doi:10.1016/j.sjpain.2009.10.003.
blinded observers of outcomes. By monitoring hyposensitive cutaneous areas, which should always be done during TEA, unblinding of applied technique is bound to occur. The most sensitive outcome variable for post-thoracotomy pain relief is pain intensity on coughing (Niemi and Breivik, 2003; Niemi, 2004). Pain relief at rest with quiet, superficial breathing can be obtained even with systemic nonopioid and opioid analgesics. But once the patient needs to inspire deeply and cough forcefully to get rid of bronchial secretions, only neuraxial blocks (TEA or subarachnoid analgesia), paravertebral, or intercostal nerve blocks will do. Pain during coughing was reported in half the trials, the remaining half reported pain at rest or did not specify pain. Clearly a good study with sufficient numbers of patients, using appropriate design, expertly conducted TEA, and clinically relevant and sensitive outcome variables (Niemi, 2004) is needed before we can conclude which technique is most effective (Norum and Breivik, 2010). Rare, but serious, complications can occur with both techniques and cannot be studied with RCTs. Our clinical experience during two decades and our clinical research have convinced us that a mixture of bupivacaine 1 mg/ml, fentanyl 2 g/ml, and adrenaline 2 g/ml infused epidurally, at the appropriate segmental level for the operation, can secure sufficient epidural analgesia for coughing. Also, the mixture can reduce significantly many of the otherwise common dose-related adverse effects of epidural local anaesthetics (hypotension, motor block, weak legs, urinary retention) and of epidural opioids (respiratory depression, urinary retention, pruritus, sedation, nausea). The small dose of adrenaline causes vasoconstriction in the epidural space (not in subarachnoid vessels), delayed systemic absorption of bupivacaine and fentanyl, spinal cord ␣2 -agonist analgesia (dorsal horn), and reduced risk of bleeding by increasing stickiness of platelets (Breivik et al., 1995; Niemi and Breivik, 2003; Niemi, 2004). The only study of the ten reviewed (Richardson et al., 1999), in which the conclusions were clearly in favour of PVB (with bupivacaine 5 mg/ml in the PVB compared with 2.5 mg/ml at same rate of infusion in the TEA group), the TEA-catheters were below thoracic segment T7 (too caudad), whereas the PVB-catheters always were at an appropriate segmental level. In another study the epidural catheters were above T1 (too cephalad for thoracotomy). However, one study confirmed superior pain relieving effect of TEA compared with PVB during the first 1.5 days after thoracotomy, at the time when pain is most intense (Bimston et al., 1999). Paravertebral blocks now receive a lot of enthusiastic press, and a renaissance, a rediscovering of this old, previously much used technique is happening—again (Davies et al., 2006; Joshi et al., 2008). It is even described as the new pain relieving technique
1877-8860/$ – see front matter © 2009 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.sjpain.2009.11.002
4
Editorial comment / Scandinavian Journal of Pain 1 (2010) 3–4
that will make thoracic epidurals obsolete, and it is hoped that the infrequent but serious complications from TEA (bleeding or infection in the epidural space) will disappear. It is mandatory that we remind everybody that also paravertebral blocks are not without risks of serious complications. A paravertebral injection at thoracic and lumbar levels reached the epidural space in 70% of cases, exclusively epidural location in 31%, and only 17% were confined to the paravertebral space (Purcell-Jones et al., 1989). By using high concentrations and large volumes of local anaesthetic, posterior intercostal nerve blocks are achieved in addition to a one-sided or bilateral epidural block. It can therefore be expected that all complications known to occur related to TEA, also may occur with PVB. In addition, paravertebral blocks are close to the intervertebral foramina and may result in the same complications as with the intraforaminal epidural injectiontherapy for radicular pain. Intraforaminal epidural injections are documented to damage, or inject into radicular arteries supplying the anterior artery of the spinal cord. This has caused interruption of circulation to the spinal cord, spinal cord infarct and permanent paraplegia (Glaser and Falco, 2005). Personally we (HB) know one case where a thoracic PVB resulted in immediate and permanent paraplegia. Most likely this was from a direct intraarterial injection into a critical radicular spinal supply artery. Unfortunately that case was never published. The focus during the last decade on rare, but serious complications after epidural analgesia (Moen et al., 2004) has increased the interest in PVB as a possibly safer technique than TEA (Davies et al., 2006). However, the risk of serious, but infrequent complications cannot be less with PVB than with optimally performed and monitored TEA. Time will show: We predict that when some 50 000 PVBs have been performed, serious complications will have occurred. It would therefore be a pity if PVB is being “sold” as safer than TEA, needing less vigilant monitoring than what we recommend for safe TEA practice (Breivik et al., 1995; Breivik, 1995; Breivik, 2008; Breivik et al., 2009). For example, total spinal anaesthesia, a complete surprise to surgeons, is a rapidly lethal complication of PVB if a competent anaesthesiologist is not at hand to help resuscitate the patient (Lekhak et al., 2001; Chaudri et al., 2009; Gay and Evans, 1971). We are convinced that an optimally effective and safe TEA can be practiced with a paramedian approach to the epidural space at the appropriate segmental spinal cord level, inducing spinal cord analgesia with low dose bupivacaine, fentanyl, and the ␣2 -agonist adrenaline (Breivik, 2008). Each of these three drugs act via different mechanisms for analgesia in the spinal cord and spinal nerve roots, potentiating each other so that the doses needed and therefore the dose-related side effects of the drugs markedly decrease. A robust monitoring and documenting regimen by well-trained ward nurses and daily consultations by the Acute Pain Service insure safety. Thus, TEA can be prolonged and practiced safely on the surgical wards (Niemi, 2004; Breivik, 2008; Breivik et al., 2009). A curious aspect of the current enthusiastic publications on PVB for post-thoracotomy pain in surgical journals is the pleasure the authors find in saving about US$ 500 as the Acute Pain Service is not involved in monitoring PVB on surgical wards (Luketich et al., 2005). Another curious aspect is that some practice bilateral thoracic PVBs for midline incisions: This clearly must at least double the risk of complications. The risk of pneumothorax is reported to be increased eight times (Naja et al., 2001; Lönnqvist et al., 1995). This must be the most clumsy, and risky, approach to the epidural space for pain relief that we can imagine! 1. Conclusions Paravertebral block is a valuable technique for relieving dynamic pain after thoracotomy and upper abdominal surgery on one side, but we must be as vigilant in performing and monitoring
PVBs as most hospitals now are when practicing epidural analgesia on surgical wards (Breivik et al., 2009).
References Breivik H. Behandling av atelektaser med transtracheal injeksjon av saltvann{nl}[Treatment of atelectasis by transtracheal injection of saline]. Tidsskr Nor Laegeforen 1974;94:1443–4. Norum HM, Breivik H. A systematic review of comparative studies indicates that paravertebral block is not superior nor safer than epidural analgesia for pain after thoracotomy. Scand J Pain 2010;1:12–23. Breivik H, Niemi G, Haugtomt H, Högström H. Optimal epidural analgesia: importance of drug combinations and correct segmental site of injection. In: Breivik H, editor. Post-operative pain management. Baillier’s clinical anaesthesiology international practice and research, vol. 9; 1995. p. 493–512. Niemi G, Breivik H. Minimally effective concentration of adrenaline in a lowconcentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. Acta Anaesthesiol Scand 2003;47:439–50. Niemi G. Optimizing postoperative epidural analgesia. Doctoral thesis submitted to Faculty of Medicine University of Oslo, Oslo, Series of dissertations submitted to the Faculty of Medicine, University of Oslo No. 219, Unipub AS, Oslo 2004. Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Merans AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth 1999;83:387–92. Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral extrapleural infusion for post-thoracotmoy pain management. Surgery 1999;126:650–6. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and sideeffects of paravertebral vs epidural blockade for thoracotomy-a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96:418–26. Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107(3):1026–40. Purcell-Jones G, Pither CE, Justins DM. Paravertebral somatic nerve block: a clinical, radiographic, and computed tomographic study in chronic pain patients. Anesth Analg 1989;68:32–9. Glaser SE, Falco F. Paraplegia following thoracolumbar transforaminal steroid injection. Pain Physician 2005;8:309–14. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–99. Anesthesiology 2004;101:950–9. Breivik H. Safe perioperative spinal and epidural analgesia: importance of drug combinations, segmental site of injection, training and monitoring. Acta Anaesthesiol Scand 1995;39:869–71. Breivik H. Epidural analgesia for acute pain after surgery and during labor including patient-controlled epidural analgesia. In: Breivik H, Campbell WI, Nicholas MK, editors. Clinical Pain Management. Practice and Procedures. 2nd ed. London: Hodder-Arnold; 2008. p. 311–21. Breivik H, Bang U, Jalonen J, Vigfússon G, Alahuhta S, Lagerkranser, M. Nordic guidelines for neuraxial blockade in patients with disturbed haemostasis proposed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine taskforce. Acta Anaesthesiol Scand; 2009 Oct 19. [E-pub ahead of print]. Lekhak B, Bartely C, Concacher ID, Nouraei SM. Total spinal anaesthesia in association with insertion of a paravertebral catheter. Br J Anaesth 2001;86:280–2. Chaudri BB, Macfie A, Kirk AJ. Inadvertent total spinal anesthesia after intercostal nerve block placement during lung resection. Ann Thorac Surg 2009;88:283–4. Luketich JD, Land SR, Sullivan EA, Alvelo-Rivera M, Ward J, Buenaventura PO, et al. Thoracic epidural versus intercostal nerve catheter plus patient controlled analgesia: a randomized study. Ann Thorac Surg 2005;79:1845–9. Naja Z, Lönnqvist PA. Somatic paravertebral nerve blockade. Incidence of failed block and complications. Anaesthesia 2001;56:1184–8. Gay GR, Evans JA. Total spinal anestesia following lumbar paravertebral block: a potentially lethal complication. Anesth Analg 1971;50:344–8. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia 1995;50:813–5.
Geir Niemi Department of Anaesthesia and Intensive Care Medicine, Rikshospitalet, Oslo University Hospital, 0027 Oslo, Norway Harald Breivik a,b,∗ Department of Anaesthesia and Intensive Care Medicine, Rikshospitalet, Oslo University Hospital, 0027 Oslo, Norway and b University of Oslo, Medical Faculty, Oslo, Norway a
∗ Corresponding author at: University of Oslo, Medical Faculty, Oslo, Norway. Tel.: +47 23070000; fax: +47 23073690. E-mail address:[email protected] (H. Breivik)
Contents lists available at ScienceDirect
Scandinavian Journal of Pain journal homepage: www.ScandinavianJournalPain.com
Editorial comment
Pain relief with paravertebral blocks or epidural analgesia? Those who do not know the history of paravertebral blocks are condemned to rediscover the complications Pain relief with paravertebral blocks (PVB) is more than 100 years old. The block is easy to learn: With the needle you touch the transverse process of the vertebral body at the level of pain location, or where an operation will take place, “walk” the needle below (or above) the transverse process, advance about 1 cm deeper and inject 10–30 ml of a concentrated local anaesthetic with adrenaline. With ultrasound you can see whether your injection enters the correct paravertebral space or, unintendedly, muscles of the back (Axel Sauter, personal communication), the interpleural space, or lung. Unilateral anaesthesia follows, lasting a few hours, depending on dose and whether a vasoconstrictor is added. In Norway, PVB was a routine procedure before thoracoplasty for tuberculous caverns of the apex of the lungs during the 1950s and early 1960s (Bjørn Lind, personal communications). PVB has been reintroduced several times since 1905, and is now being rediscovered again. One of us (HB) used PVB frequently until learning how to do thoracic epidural analgesia (TEA) well. A classic application of PVB, was to administer single bolus PVB and subsequently transtracheal saline to dissolve an endobronchial mucus-plug and provoke forceful, pain free coughing, in patients who developed atelectasis after thoracotomy or cholecystectomy (Breivik, 1974). If the patient is unable to expectorate due to pain on deep inspiration and coughing, a postoperative atelectasis can become infected, and progress to pneumonia, sepsis, and multiorgan failure. In this issue of the Scandinavian Journal of Pain a systematic review is published on all available randomized studies (RCTs) comparing PVB with TEA for post-thoracotomy analgesia (Norum and Breivik, 2010). One RCT concluded that PVB was better than TEA, another RCT concluded that TEA was superior to PVB, whereas 8/10, mostly with small numbers of patients, did not find any differences in effects on post-thoracotomy pain. The most surprising finding was that PVB was compared with less than optimal epidural analgesia in all the ten studies: The epidural catheters were sited too high or too low for a thoracotomy, not documented, or discontinued early. Rather concentrated local anaesthetic solutions without opioid or adrenaline were injected or infused epidurally. This is bound to cause sympathetic block, hypotension, and less pain relief than what a triple component, low dose epidural can do (Breivik et al., 1995). All ten RCTs reported to have randomized patients to two groups, however, only two reported satisfactory methods of randomization, two reported
This article refers to doi:10.1016/j.sjpain.2009.10.003.
blinded observers of outcomes. By monitoring hyposensitive cutaneous areas, which should always be done during TEA, unblinding of applied technique is bound to occur. The most sensitive outcome variable for post-thoracotomy pain relief is pain intensity on coughing (Niemi and Breivik, 2003; Niemi, 2004). Pain relief at rest with quiet, superficial breathing can be obtained even with systemic nonopioid and opioid analgesics. But once the patient needs to inspire deeply and cough forcefully to get rid of bronchial secretions, only neuraxial blocks (TEA or subarachnoid analgesia), paravertebral, or intercostal nerve blocks will do. Pain during coughing was reported in half the trials, the remaining half reported pain at rest or did not specify pain. Clearly a good study with sufficient numbers of patients, using appropriate design, expertly conducted TEA, and clinically relevant and sensitive outcome variables (Niemi, 2004) is needed before we can conclude which technique is most effective (Norum and Breivik, 2010). Rare, but serious, complications can occur with both techniques and cannot be studied with RCTs. Our clinical experience during two decades and our clinical research have convinced us that a mixture of bupivacaine 1 mg/ml, fentanyl 2 g/ml, and adrenaline 2 g/ml infused epidurally, at the appropriate segmental level for the operation, can secure sufficient epidural analgesia for coughing. Also, the mixture can reduce significantly many of the otherwise common dose-related adverse effects of epidural local anaesthetics (hypotension, motor block, weak legs, urinary retention) and of epidural opioids (respiratory depression, urinary retention, pruritus, sedation, nausea). The small dose of adrenaline causes vasoconstriction in the epidural space (not in subarachnoid vessels), delayed systemic absorption of bupivacaine and fentanyl, spinal cord ␣2 -agonist analgesia (dorsal horn), and reduced risk of bleeding by increasing stickiness of platelets (Breivik et al., 1995; Niemi and Breivik, 2003; Niemi, 2004). The only study of the ten reviewed (Richardson et al., 1999), in which the conclusions were clearly in favour of PVB (with bupivacaine 5 mg/ml in the PVB compared with 2.5 mg/ml at same rate of infusion in the TEA group), the TEA-catheters were below thoracic segment T7 (too caudad), whereas the PVB-catheters always were at an appropriate segmental level. In another study the epidural catheters were above T1 (too cephalad for thoracotomy). However, one study confirmed superior pain relieving effect of TEA compared with PVB during the first 1.5 days after thoracotomy, at the time when pain is most intense (Bimston et al., 1999). Paravertebral blocks now receive a lot of enthusiastic press, and a renaissance, a rediscovering of this old, previously much used technique is happening—again (Davies et al., 2006; Joshi et al., 2008). It is even described as the new pain relieving technique
1877-8860/$ – see front matter © 2009 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.sjpain.2009.11.002
4
Editorial comment / Scandinavian Journal of Pain 1 (2010) 3–4
that will make thoracic epidurals obsolete, and it is hoped that the infrequent but serious complications from TEA (bleeding or infection in the epidural space) will disappear. It is mandatory that we remind everybody that also paravertebral blocks are not without risks of serious complications. A paravertebral injection at thoracic and lumbar levels reached the epidural space in 70% of cases, exclusively epidural location in 31%, and only 17% were confined to the paravertebral space (Purcell-Jones et al., 1989). By using high concentrations and large volumes of local anaesthetic, posterior intercostal nerve blocks are achieved in addition to a one-sided or bilateral epidural block. It can therefore be expected that all complications known to occur related to TEA, also may occur with PVB. In addition, paravertebral blocks are close to the intervertebral foramina and may result in the same complications as with the intraforaminal epidural injectiontherapy for radicular pain. Intraforaminal epidural injections are documented to damage, or inject into radicular arteries supplying the anterior artery of the spinal cord. This has caused interruption of circulation to the spinal cord, spinal cord infarct and permanent paraplegia (Glaser and Falco, 2005). Personally we (HB) know one case where a thoracic PVB resulted in immediate and permanent paraplegia. Most likely this was from a direct intraarterial injection into a critical radicular spinal supply artery. Unfortunately that case was never published. The focus during the last decade on rare, but serious complications after epidural analgesia (Moen et al., 2004) has increased the interest in PVB as a possibly safer technique than TEA (Davies et al., 2006). However, the risk of serious, but infrequent complications cannot be less with PVB than with optimally performed and monitored TEA. Time will show: We predict that when some 50 000 PVBs have been performed, serious complications will have occurred. It would therefore be a pity if PVB is being “sold” as safer than TEA, needing less vigilant monitoring than what we recommend for safe TEA practice (Breivik et al., 1995; Breivik, 1995; Breivik, 2008; Breivik et al., 2009). For example, total spinal anaesthesia, a complete surprise to surgeons, is a rapidly lethal complication of PVB if a competent anaesthesiologist is not at hand to help resuscitate the patient (Lekhak et al., 2001; Chaudri et al., 2009; Gay and Evans, 1971). We are convinced that an optimally effective and safe TEA can be practiced with a paramedian approach to the epidural space at the appropriate segmental spinal cord level, inducing spinal cord analgesia with low dose bupivacaine, fentanyl, and the ␣2 -agonist adrenaline (Breivik, 2008). Each of these three drugs act via different mechanisms for analgesia in the spinal cord and spinal nerve roots, potentiating each other so that the doses needed and therefore the dose-related side effects of the drugs markedly decrease. A robust monitoring and documenting regimen by well-trained ward nurses and daily consultations by the Acute Pain Service insure safety. Thus, TEA can be prolonged and practiced safely on the surgical wards (Niemi, 2004; Breivik, 2008; Breivik et al., 2009). A curious aspect of the current enthusiastic publications on PVB for post-thoracotomy pain in surgical journals is the pleasure the authors find in saving about US$ 500 as the Acute Pain Service is not involved in monitoring PVB on surgical wards (Luketich et al., 2005). Another curious aspect is that some practice bilateral thoracic PVBs for midline incisions: This clearly must at least double the risk of complications. The risk of pneumothorax is reported to be increased eight times (Naja et al., 2001; Lönnqvist et al., 1995). This must be the most clumsy, and risky, approach to the epidural space for pain relief that we can imagine! 1. Conclusions Paravertebral block is a valuable technique for relieving dynamic pain after thoracotomy and upper abdominal surgery on one side, but we must be as vigilant in performing and monitoring
PVBs as most hospitals now are when practicing epidural analgesia on surgical wards (Breivik et al., 2009).
References Breivik H. Behandling av atelektaser med transtracheal injeksjon av saltvann{nl}[Treatment of atelectasis by transtracheal injection of saline]. Tidsskr Nor Laegeforen 1974;94:1443–4. Norum HM, Breivik H. A systematic review of comparative studies indicates that paravertebral block is not superior nor safer than epidural analgesia for pain after thoracotomy. Scand J Pain 2010;1:12–23. Breivik H, Niemi G, Haugtomt H, Högström H. Optimal epidural analgesia: importance of drug combinations and correct segmental site of injection. In: Breivik H, editor. Post-operative pain management. Baillier’s clinical anaesthesiology international practice and research, vol. 9; 1995. p. 493–512. Niemi G, Breivik H. Minimally effective concentration of adrenaline in a lowconcentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. Acta Anaesthesiol Scand 2003;47:439–50. Niemi G. Optimizing postoperative epidural analgesia. Doctoral thesis submitted to Faculty of Medicine University of Oslo, Oslo, Series of dissertations submitted to the Faculty of Medicine, University of Oslo No. 219, Unipub AS, Oslo 2004. Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Merans AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth 1999;83:387–92. Bimston DN, McGee JP, Liptay MJ, Fry WA. Continuous paravertebral extrapleural infusion for post-thoracotmoy pain management. Surgery 1999;126:650–6. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and sideeffects of paravertebral vs epidural blockade for thoracotomy-a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96:418–26. Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107(3):1026–40. Purcell-Jones G, Pither CE, Justins DM. Paravertebral somatic nerve block: a clinical, radiographic, and computed tomographic study in chronic pain patients. Anesth Analg 1989;68:32–9. Glaser SE, Falco F. Paraplegia following thoracolumbar transforaminal steroid injection. Pain Physician 2005;8:309–14. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–99. Anesthesiology 2004;101:950–9. Breivik H. Safe perioperative spinal and epidural analgesia: importance of drug combinations, segmental site of injection, training and monitoring. Acta Anaesthesiol Scand 1995;39:869–71. Breivik H. Epidural analgesia for acute pain after surgery and during labor including patient-controlled epidural analgesia. In: Breivik H, Campbell WI, Nicholas MK, editors. Clinical Pain Management. Practice and Procedures. 2nd ed. London: Hodder-Arnold; 2008. p. 311–21. Breivik H, Bang U, Jalonen J, Vigfússon G, Alahuhta S, Lagerkranser, M. Nordic guidelines for neuraxial blockade in patients with disturbed haemostasis proposed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine taskforce. Acta Anaesthesiol Scand; 2009 Oct 19. [E-pub ahead of print]. Lekhak B, Bartely C, Concacher ID, Nouraei SM. Total spinal anaesthesia in association with insertion of a paravertebral catheter. Br J Anaesth 2001;86:280–2. Chaudri BB, Macfie A, Kirk AJ. Inadvertent total spinal anesthesia after intercostal nerve block placement during lung resection. Ann Thorac Surg 2009;88:283–4. Luketich JD, Land SR, Sullivan EA, Alvelo-Rivera M, Ward J, Buenaventura PO, et al. Thoracic epidural versus intercostal nerve catheter plus patient controlled analgesia: a randomized study. Ann Thorac Surg 2005;79:1845–9. Naja Z, Lönnqvist PA. Somatic paravertebral nerve blockade. Incidence of failed block and complications. Anaesthesia 2001;56:1184–8. Gay GR, Evans JA. Total spinal anestesia following lumbar paravertebral block: a potentially lethal complication. Anesth Analg 1971;50:344–8. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia 1995;50:813–5.
Geir Niemi Department of Anaesthesia and Intensive Care Medicine, Rikshospitalet, Oslo University Hospital, 0027 Oslo, Norway Harald Breivik a,b,∗ Department of Anaesthesia and Intensive Care Medicine, Rikshospitalet, Oslo University Hospital, 0027 Oslo, Norway and b University of Oslo, Medical Faculty, Oslo, Norway a
∗ Corresponding author at: University of Oslo, Medical Faculty, Oslo, Norway. Tel.: +47 23070000; fax: +47 23073690. E-mail address:[email protected] (H. Breivik)