Search

Xiao-Long Liang, Ran An, Qi Chen, Hong-Liang Liu Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, 400030, People’s Republic of ChinaCorrespondence: Hong-Liang LiuChongqing University Cancer Hospital, School of Medicine, Chongqing University, No. 181, Hanyu Road, Shapingba District, Chongqing, 400030, People’s Republic of ChinaTel +86 13883686721Email liuhl75@163.comBackground: To date, there is no definitive evidence for the analgesic effects and side effects of thoracic epidural anesthesia (TEA) versus thoracic paravertebral block (TPVB) after thoracoscopic surgery. In this study, we conducted a meta-analysis of published randomized clinical trials (RCTs) to analyze the analgesic effects of TEA versus TPVB after thoracoscopic surgery.Methods: We systematically searched RCTs published by October 26, 2020, in PubMed, EMBASE, and Cochrane library and conducted a meta-analysis to analyze the analgesic effects of TEA versus TPVB after thoracoscopic surgery. The primary measure was postoperative pain score, and the secondary measures were postoperative 24-hour usage of opioids, hypotension, postoperative nausea, and vomiting.Results: A total of 458 patients from five RCTs were included in this study. After thoracoscopic surgery, the numerical rating scale (NRS) score for resting pain was higher in the TPVB group than in the TEA group at 1– 2 hours and 4– 6 hours after surgery (MD = 0.44, 95% CI = 0.24 to 0.64, P < 0.0001, I2 = 0%; MD = 0.47, 95% CI = 0.23 to 0.70, P < 0.0001, I2 = 0%). The postoperative 24-hour usage of morphine was higher in the TPVB group than in the TEA group (SMD = 0.67; 95% CI = 0.03 to 1.31; P = 0.04; I2 = 84%). The incidence of hypotension was significantly lower in the TPVB group than in the TEA group (OR = 4.52; 95% CI = 2.03 to 10.10; P = 0.0002; I2 = 0%). No significant between-group difference was observed in postoperative nausea and vomiting (PONV).Conclusion: Compared with TPVB, TEA provides statistically significant but clinically unimportant short-term benefits following thoracoscopic surgery.Keywords: thoracic paravertebral block, thoracic epidural anesthesia, thoracoscopic surgery, meta-analysis

Purpose Ultrasound-guided thoracic paravertebral block (US-TPVB) is considered a treatment option for the management of acute pain in various pain-related conditions. We conducted a prospective pilot study to evaluate the possibility of US-TPVB as a sympathetic blockade in patients with neuropathic pain disorders in the upper extremities. Patients and Methods A total of 12 patients underwent US-TPVB between the T2 and T3 paravertebral space with 10 mL of 1% mepivacaine. The temperature change (°C) before and after the procedure was compared between the ipsilateral and contralateral hands. We counted the proportion of patients showing a temperature increase ≥1.5°C and compared a change in the pain intensity before and after the procedure. Results The median increase in the temperature change between the ipsilateral and contralateral hands was 1.54°C (interquartile range, 1.28–2.20). There were seven patients (58.3%) who showed a temperature difference ≥1.5°C between both hands after the US-TPVB. Eleven patients (91.7%) reported a reduction in pain according to the score on the 11-point numerical rating scale. No serious complications relevant to the procedure were reported. Conclusion US-TPVB could be a useful technique for sympathetic blockade in patients with upper extremity pain.

Background Persistent or recurring radicular pain after lumbar surgery is a clinical condition of failed back surgery syndrome (FBSS) that seriously affects the life quality of patients. Conventional medication and physiotherapy do not fully relieve this pain. A simpler, safer, and less invasive option is lumbar selective nerve root block or paravertebral block. Here, we share our experience regarding lumbar paravertebral block for a patient with FBSS, which successfully alleviated radicular pain after lumbar surgery. Case presentation An 80-year-old man with left lower limb radicular pain diagnosed as L4-5, L5-S1 intervertebral disc protrusion, spinal canal stenosis, and degenerative scoliosis underwent lumbar surgery. Four months after surgery, he experienced left lower limb radicular pain. After designing the puncture route based on X-ray film, we performed a combined ultrasound-guided L4 and L5 paravertebral block. With his improved pain control, his functional status and ability to perform daily activities also markedly improved. Conclusion Real-time ultrasound-guided lumbar paravertebral block performed with a pre-designed route on X-ray film can provide a simple and safe way to relieve radicular pain in FBSS.

Purpose Thoracic paravertebral block (TPVB) is an established analgesic technique for breast surgery although it is technically challenging. Erector spinae plane block (ESPB) requires less technical expertise and may be an alternative to TPVB. However, whether ESPB has similar analgesic effects to TPVB for breast surgery is still inconclusive. Moreover, information on sensory blockade of ESPB is scarce. Accordingly, we conducted this retrospective propensity-matched study to see if ESPB could provide comparable analgesic effects to TPVB in patients undergoing breast surgery. We also compared cutaneous sensory block levels after the two techniques. Patients and methods In this retrospective cohort study, we analyzed data saved in our database and compared the two techniques using a propensity matching method. The data of patients who underwent unilateral breast surgery under general anesthesia with the addition of either TPVB or ESPB were identified. We considered that the analgesic efficacy of ESPB was noninferior to TPVB if both postoperative fentanyl consumption and area under the curve (AUC) for pain scores within 24 h were within 50 µg and 240 mm･h margins, respectively. Cutaneous sensory block levels, additional analgesic requirements, and complications were also compared between the two groups. Results Among 93 patients, 30 patients for each group were matched. Both postoperative fentanyl consumption and AUC for pain scores after ESPB were noninferior to those after TPVB. ESPB did not produce sensory blockade consistently, and the number of dermatomes was smaller after ESPB [1 (0-3)] [median (interquartile range)] than after TPVB [4 (2-5)] (P=0.002). No serious complications related to blocks were observed. Conclusion ESPB and TPVB provided comparable postoperative analgesia for 24 h in patients undergoing breast surgery. Dermatomal sensory blockade was, however, less apparent and narrower after ESPB than after TPVB.

Purpose Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1-T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS. Patients and methods Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1-0.5 µg.kg-1.h-1) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA. Results The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia. Conclusion USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.

Purpose Animal models of regional anaesthesia are useful for studying the effects of blocks and improve their efficacy. The aim of our experiments was to validate a multi-site paravertebral block in the rat. Material and methods Dissection and indigo carmine dye injection were performed in five rats (3 rats were dissected and 2 were dye injected). In other groups (n=7rats/group), after inflammation inductive carrageenan injection in the abdominal wall, bupivacaine or saline was injected laterally to the spinal column at the T5, T10, L1, L4 and S1 level. The efficacy of the block on mechanical nociception was measured using von Frey hairs. In addition, we measured c-Fos immunoreactive nuclei in the cord. Results The multi-site injection showed a perinervous distribution of the injected solution without intra-thoracic, intra-abdominal or epidural diffusion. Bilateral block with a relatively small volume of bupivacaine (0.5 mL) significantly increased the threshold to mechanical pain as compared to control (p=0.007) and significantly decreased the number of c-Fos immunoreactive nuclei in the posterior horn of the spinal cord (p

Liping Wang,* Yu Wang,* Xi Zhang, Xidong Zhu, Guonian WangDepartment of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, People’s Republic of China*These authors contributed equally to this workBackground: Reports of postoperative pain treatment after uniportal video-assisted thoracoscopic surgery are limited. Thoracic paravertebral block and serratus anterior plane block have been described recently in pain management after thoracic surgery. A comparison between these two blocks for postoperative analgesia after uniportal video-assisted thoracoscopic surgery has not been previously reported. The aim of this study was to compare the analgesic benefits of serratus plane block and thoracic paravertebral block after uniportal video-assisted thoracoscopic surgery and examined the two block types for noninferiority.Methods: From December 2015 to May 2018, a total of 636 relevant records of patients who underwent uniportal video-assisted thoracoscopic surgery under general anaesthesia alone or with the addition of serratus plane block or thoracic paravertebral block performed preoperatively were identified. A propensity-matched analysis incorporating preoperative variables was used to compare the efficacy of postoperative analgesia in three groups.Results: Overall, 123 patients were identified for analysis. Propensity score matching resulted in 41 patients in each group. The visual analogue scale scores were significantly lower in the serratus plane block group and the thoracic paravertebral block group than in the control group at the 1st, 2nd, 4th, and 6th postoperative hours. Cumulative opioid consumption was significantly lower in the serratus plane and thoracic paravertebral block groups than in the control group at 6hrs (18.3±3.1mg, 18.7±3.9mg vs 21.5±4.4mg; P=0.001) and 24hrs (43.4±7.3mg, 42.5±7.7mg vs 49.3±8.8mg; P

Purpose: Combined regional and general anesthesia are often used for the management of breast cancer surgery. Thoracic spinal block, thoracic epidural block, thoracic paravertebral block, and multiple intercostal nerve blocks are the regional anesthesia techniques which have been used in breast surgery, but some anesthesiologists are not comfortable because of the complication and side effects. In 2012, Blanco et al introduced pectoralis nerve (Pecs) II block or modified Pecs block as a novel approach to breast surgery. This study aims to determine the effectiveness of combined ultrasound-guided Pecs II block and general anesthesia for reducing intra- and postoperative pain from modified radical mastectomy. Patients and methods: Fifty patients undergoing modified radical mastectomy with general anesthesia were divided into two groups randomly (n=25), to either Pecs (P) group or control (C) group. Ultrasound-guided Pecs II block was done with 0.25% bupivacaine (P group) or 0.9% NaCl (C group). Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid consumption, postoperative visual analog scale (VAS) score, and postoperative opioid consumption were measured. Results: Intraoperative opioid consumption was significantly lower in P group (P≤0.05). VAS score at 3, 6, 12, and 24 hrs postoperative were significantly lower in P group (P≤0.05). Twenty-four hours postoperative opioid consumption was significantly lower in P group (P≤0.05). There are no complications following Pecs block in both groups, including pneumothorax, vascular puncture, and hematoma. Conclusion: Combined ultrasound-guided Pecs II block and general anesthesia are effective in reducing pain both intra- and postoperatively in patients undergoing modified radical mastectomy. Ultrasound-guided Pecs II block is a relatively safe peripheral nerve block.

Andrea Saporito,1 José Aguirre,2 Alain Borgeat,2 Andreas Perren,3 Luciano Anselmi,1 Roberto Poggi,4 Bruno Minotti,5 Stefano Cafarotti,6 Davide La Regina,7 Samuele Ceruti81Service of Anesthesiology, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 2Department of Anesthesiology, Balgrist University Hospital, Zürich, Switzerland; 3Department of Intensive Care, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 4Service of Anesthesiology, Ospedale Regionale di Lugano, Lugano, Switzerland; 5Department of Emergency Medicine, St Gallen General Hospital, St Gallen, Switzerland; 6Service of Thoracic Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 7Service of Visceral Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland; 8Department of Intensive Care, Geneva University Hospital (HUG), Geneva, SwitzerlandIntroduction: Breast surgery is associated with persistent postsurgical pain; usually related to poorly treated acute pain. Paravertebral block has been successfully employed in analgesic protocols for breast surgery; its impact on postdischarge pain (PDP) has not been investigated. The aim of this study was to assess characteristics of PDP after breast surgery, the development of chronic postoperative pain (CPP) and its impact on health care costs.Methods: We conducted a retrospective, observational study on a continuous cohort of adult female patients undergoing local breast cancer surgery under combined anesthesia. All patients were interviewed 6 months after hospital discharge. The survey was specifically conceived to assess incidence, features and duration of PDP. The overall cost of additional healthcare resources consumed with a specific relationship to persistent PDP was estimated.Results: A database of 244 patients was preliminarily analyzed. Of these, 188 were included in the following statistical analysis; 123 patients (65.2%) reported significant PDP, with a median intensity on NRS of 6 (IQR=2), more frequently described as burning and associated with paresthesia and/or hyperalgesia (87 patients, 46%). One hundred and six patients (56.5%) reported this pain as interfering with their normal daily activities, work and sleep. In 26.8% of cases (50 patients) symptoms lasted more than 1 month and in 28 patients (15.0%) pain became chronic. The majority of patients self-treated their pain with non-steroideal anti-inflammatory drugs, but in 50 patients (26.8%) this therapy was reported as ineffective. This additional consumption of healthcare resources led to a significant economical impact.Conclusion: PDP and CPP seem to be common complications after breast cancer surgery, even if a combined anesthesia technique with a thoracic paravertebral block is performed, leading to severe consequences on patients’ quality of life and increasing consumption of healthcare resources after discharge.Trial number: NCT03618459 (www.clinicaltrials.gov).Keywords: breast surgery, paravertebral block, regional anesthesia, postoperative pain

Ahmed H Bakeer,1 Nasr M Abdallah,2 Mahmoud A Kamel,1 Dina N Abbas,1 Ahmed S Ragab1 1Department of Anesthesia and Pain Management, National Cancer Institute, Cairo University, Giza, Egypt; 2Department of Anesthesia, Faculty of Medicine, Cairo University, Giza, Egypt Purpose: The study aimed at the evaluation of the impact of intravenous (IV) dexamethasone on efficacy and duration of analgesia of paravertebral block (PVB) in patients undergoing modified radical mastectomy (MRM).Patients and methods: This randomized, double-blind controlled trial included 50 patients with breast cancer scheduled for unilateral MRM. Ultrasound-guided PVB was performed in out-of-plane technique. The technique was repeated at each segment from C7 to T6. The participants were randomly allocated to one of two groups. Group BD (n=25) received IV 8 mg dexamethasone diluted with 8 mL of normal saline to reach 10 mL solution, while Group B received IV 10 mL normal saline. Top-up local infiltration analgesia into the surgical field was performed by the surgeon if needed using lidocaine 1% intraoperatively. Propofol infusion of 50–100 µg/kg/min was maintained throughout the surgery. The time to administration of the first postoperative analgesic dose, pain intensity as visual analog scale (VAS) score, number of patients who required rescue morphine analgesia, total morphine consumption, postoperative nausea and vomiting (PONV) impact scale, and the overall satisfaction of patients with pain management were measured.Results: Fifty patients were randomized and analyzed. The time to first rescue analgesic dose was significantly longer in Group DB (P

Purpose Ultrasound-guided thoracic paravertebral block (US-TPVB) is considered a treatment option for the management of acute pain in various pain-related conditions. We conducted a prospective pilot study to evaluate the possibility of US-TPVB as a sympathetic blockade in patients with neuropathic pain disorders in the upper extremities. Patients and Methods A total of 12 patients underwent US-TPVB between the T2 and T3 paravertebral space with 10 mL of 1% mepivacaine. The temperature change (°C) before and after the procedure was compared between the ipsilateral and contralateral hands. We counted the proportion of patients showing a temperature increase ≥1.5°C and compared a change in the pain intensity before and after the procedure. Results The median increase in the temperature change between the ipsilateral and contralateral hands was 1.54°C (interquartile range, 1.28–2.20). There were seven patients (58.3%) who showed a temperature difference ≥1.5°C between both hands after the US-TPVB. Eleven patients (91.7%) reported a reduction in pain according to the score on the 11-point numerical rating scale. No serious complications relevant to the procedure were reported. Conclusion US-TPVB could be a useful technique for sympathetic blockade in patients with upper extremity pain.

Background Although video-assisted thoracoscopic surgery (VATS) is increasingly used, the optimal analgesia strategy is still unknown. We explore the efficacy and safety of preemptive ultrasound-guided paravertebral block (PVB) combined with parecoxib during VATS. Methods Seventy-four patients were divided into two groups. PVBs were performed before anesthesia induction under real-time ultrasound guidance. Visual analog scale (VAS) score with coughing at 48 h after surgery, postoperative sufentanil consumption and level of sedation (LOS) at 1, 4, 8, 12, 24, and 48 h postoperatively, intraoperative hemodynamics, satisfaction scores of patients and surgeons, remedial measures, time to chest tube removed and mobilization, adverse effects and hospital stay length were recorded. We also recorded inflammatory markers, respiratory function and the prevalence of chronic pain after surgery. Results VAS scores at rest and with coughing during the first 24 h after surgery were significantly lower in the P group (P

Yu Mao,1,2,* Youmei Zuo,2,* Bin Mei,2 Lijian Chen,2 Xuesheng Liu,2 Zhi Zhang,1 Erwei Gu2 1Key Laboratory of Brain Function and Disease of Chinese Academy of Science, Department of Biophysics and Neurobiology, University of Science and Technology of China, Hefei City, Anhui 230027, People’s Republic of China; 2Department of Anaesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui 230031, People’s Republic of China *These authors equally contributed to this work Purpose: The purpose of this study was to assess the efficacy of perineural dexamethasone with ropivacaine in multimodal analgesia for thoracic paravertebral block (TPVB) in patients undergoing elective thoracotomy. Patients and methods: Ninety-six patients undergoing thoracotomy were enrolled in this trial and randomized to adjuvant therapy for TPVB: group S (saline), group R (0.5% ropivacaine), or group RD (5mg dexamethasone and 0.5% ropivacaine). Postoperative analgesia, recovery duration, and chronic pain were recorded. Results: Groups R and RD spent less time in the postanaesthesia care unit, had earlier out-of-bed activity, and had shorter postoperative hospital stays compared with group S. The RD group regained consciousness faster and had lower acute pain scores and used less patient-controlled analgesia during the first 72h after surgery compared with group S. Postthoracotomy pain was decreased in group RD (19.0%) compared with group S (47.6%) 3months postoperatively, p= 0.050. Conclusion: Perineural dexamethasone with ropivacaine for TPVB improves postoperative analgesia quality, reduces recovery time, and may decrease the incidence of chronic pain after thoracotomy with an opioid-based anesthetic regimen. Keywords: chronic pain, dexamethasone, nerve block, thoracotomy