Different Approaches to Ultrasound-guided Thoracic Paravertebral Block

Abstract

Given the fast development and increasing clinical relevance of ultrasound guidance for thoracic paravertebral blockade, this review article strives (1) to provide comprehensive information on thoracic paravertebral space anatomy, tailored to the needs of a regional anesthesia practitioner, (2) to interpret ultrasound images of the thoracic paravertebral space using cross-sectional anatomical images that are matched in location and plane, and (3) to briefly describe and discuss different ultrasound-guided approaches to thoracic paravertebral blockade. To illustrate the pertinent anatomy, high-resolution photographs of anatomical cross-sections are used. By using voxel anatomy, it is possible to visualize the needle pathway of different approaches in the same human specimen. This offers a unique presentation of this complex anatomical region and is inherently more realistic than anatomical drawings.

Ultrasound-guided truncal blocks for perioperative analgesia

“…These can be categorized as approaches that use either transverse or parasagittal ultrasound images, needle entry in the lateralto-medial or medial-to-lateral trajectory, and in-plane or outof-plane techniques [16]. However, in all of these techniques, the most important landmark structures in the ultrasound image are the transverse process of the thoracic spine, rib, and pleura.…”

“…3). The intercostal block is normally performed slightly (2 to 3 cm) medial to the angle of rib, towards the posterior thorax [16,25]. The needle is inserted in-plane in a caudal to cephalad direction and is positioned between the internal intercostal muscle and the innermost intercostal muscle or the pleura at the inferior aspect of the cranial rib (Supplementary Image 2).…”

Analgesic Benefits of Ultrasound-Guided Thoraco-Abdominal Wall Peripheral Nerve Blocks

“…A recent article by Krediet et al described several approaches to perform paravertebral blocks with ultrasound guidance [3]. Ultrasound examinations performed in the transverse plane place the probe lateral to the spinous process to visualize the transverse process and rib.…”

“…The needle is visualized passing through the superior costotransverse ligament as it enters the paravertebral space. Local anesthetic is then injected or a catheter is placed [3]. Single shot blocks tend to be done at multiple levels in the thoracic area with 5-10 ml of local anesthetic at each level.…”

“…Continuous paravertebral blocks are generally initiated with a large bolus of local anesthetic at a single level that spreads through multiple levels before the infusion is started. For performance of the block in the sagittal plane, the probe is initially placed 5 cm lateral to the midline [3]. The needle is then directed to the space between the internal intercostal membrane and the pleura.…”