Abstract
BackgroundThoracic paravertebral blockade is an accepted anesthetic and analgesic technique for breast surgery. However, real-time ultrasound visualization of landmarks in the paravertebral space remains challenging. We aimed to compare ultrasound-image quality, performance times, and clinical outcomes between the traditional parasagittal ultrasound-guided paravertebral block and a modified approach, the ultrasound-guided proximal intercostal block.MethodsWomen with breast cancer undergoing mastectomy (n = 20) were randomized to receive either paravertebral (n = 26) or proximal intercostal blocks (n = 32) under ultrasound-guidance with 2.5 mg/kg ropivacaine prior to surgery. Block ultrasound images before and after needle placement, and anesthetic injection videoclips were saved, and these images and vidoes independently rated by separate novice and expert reviewers for quality of visualization of bony elements, pleura, relevant ligament/membrane, needle, and injectate spread. Block performance times, postoperative pain scores, and opioid consumption were also recorded.ResultsComposite visualization scores were superior for proximal intercostal compared to paravertebral nerve block, as rated by both expert (p = 0.008) and novice (p = 0.01) reviewers. Notably, both expert and novice rated pleural visualization superior for proximal intercostal nerve block, and expert additionally rated bony landmark and injectate spread visualization as superior for proximal intercostal block. Block performance times, needle depth, opioid consumption and postoperative pain scores were similar between groups.ConclusionsProximal intercostal block yielded superior visualization of key anatomical landmarks, possibly offering technical advantages over traditional paravertebral nerve block.Trial registrationClinicalTrials.gov, NCT02911168. Registred on the 22nd of September 2016.
Highlights
Thoracic paravertebral blockade is an accepted anesthetic and analgesic technique for breast surgery
We investigated the ability of a more lateral approach, the US-guided proximal intercostal block (PICB), to provide consistent real-time visualization of the wider, more superficial proximal intercostal space (PICS) just lateral to the transverse process and medial to angulus costae, and compared that to the visualization obtained with the more traditional paravertebral block (PVB)
Written informed consent was obtained from all subjects, after which they were randomly assigned to one of two techniques (PVB or PICB), based on a previously determined computer-generated random list kept by one investigator, with all blocks performed on given patient following that type
Summary
Thoracic paravertebral blockade is an accepted anesthetic and analgesic technique for breast surgery. Real-time ultrasound visualization of landmarks in the paravertebral space remains challenging. Thoracic paravertebral blocks (PVBs) have been successfully used for analgesia in patients undergoing breast surgery, with considerable evidence that PVBs provide better postoperative pain control than systemic analgesia alone [1,2,3,4,5]. While complications are relatively rare [6], difficulties identifying the transverse process using the landmark-based technique may result in more frequent needle redirections, theoretically increasing the risk of pneumothorax (0.5%) [7]. Real-time US visualization of these blocks remains technically challenging [13]. Goals of an optimal technique include: (1) continuous and simultaneous visualization of target and needle, (2) excellent pleural visualization to protect against pneumothorax, (3) sufficient distance from neuraxis to minimize bleeding risk, and (4) ease of performance for teaching trainees and practitioners.
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