Intercostally Placed Paravertebral Catheterization: An Alternative Approach to Continuous Paravertebral Blockade

Abstract

Continuous paravertebral nerve blocks can provide effective postoperative analgesia after abdominal and thoracic surgery. While offering a number of advantages compared with thoracic epidural analgesia, access to the paravertebral space using a classic approach is not always easily accomplished and/or possible. In this regard, continuous paravertebral blockade via a percutaneous intercostal approach may theoretically serve as an alternative approach to the paravertebral space. One hundred ten patients undergoing major abdominal, thoracic, or retroperitoneal procedures had preoperative placement of unilateral or bilateral paravertebral catheter(s) via an intercostal approach. At a point 8 cm lateral to the midline a 5 cm, 18 G Tuohy needle was advanced with the needle tip angled 45 degrees cephalad and 60 degrees medial to the sagittal plane to come in contact with the lower third of the rib. The needle was "walked-off" the inferior border of the rib while maintaining its orientation and advanced a further 5 to 6 mm under the rib to lie in the subcostal groove. After injection of 5 mL ropivacaine 0.5%, a catheter was advanced medially the estimated distance to the paravertebral space. Postoperatively 0.2% ropivacaine was continuously infused at 10 mL/h in each catheter with hourly boluses of 5 mL available for breakthrough pain. Median pain scores averaged 2 on a scale of 0-10 and patient-controlled analgesia hydromorphone consumption averaged only 1.69 mg for the first 24 h postoperatively. There were no clinically significant complications of the technique. The intercostally placed paravertebral catheter provides postoperative analgesia after major surgery of the chest, abdomen, or retroperitoneum.