Abstract
Thoracic paravertebral blocks (TPVBs) provide an effective pain relief modality in conditions where thoracic epidurals are contraindicated. Historically, TPVBs were placed relying solely on the landmark-based technique, but the availability of ultrasound imaging makes it a valuable and practical tool during the placement of these blocks. TPVBs also provide numerous advantages over thoracic epidurals, namely, minimal hypotension, absence of urinary retention, lack of motor weakness, and remote risk of an epidural hematoma. Utilization of both landmark-based and ultrasound-guided techniques may increase the successful placement of a TPVB. This article reviews relevant sonoanatomy as it pertains to TPVBs. However, certain patient-related issues, including pneumothoraces, surgical emphysema, body habitus, and transverse process fractures, all may make imaging with ultrasound challenging. The changes noted on ultrasound imaging as a result of these issues will be further described in this review.
Highlights
BackgroundThoracic paravertebral block (TPVB) is an effective technique for pain management in patients with rib fractures
TPVBs provide numerous advantages over thoracic epidurals, namely, minimal hypotension, absence of urinary retention, lack of motor weakness, and remote risk of an epidural hematoma. Utilization of both landmark-based and ultrasound-guided techniques may increase the successful placement of a TPVB
Even though thoracic epidurals are considered the gold standard for this patient population, the use of low-molecular-weight heparin (LMWH), spine, and other bony fractures preclude the utilization of thoracic epidurals in this group of trauma patients [1]
Summary
Thoracic paravertebral block (TPVB) is an effective technique for pain management in patients with rib fractures. Moving the ultrasound to the inferolateral chest wall looking for the “lung point” (which is a point where lung sliding or B-lines are visualized again) confirms the diagnosis of PNX [6] It is important for the operator performing the ultrasound-guided paravertebral block to recognize a PNX using the criteria above. The absence of a sliding sign can lead to confusion in identifying the pleura accurately, making it difficult to identify the paravertebral space In this situation, depending upon the amount of air, the probe can be moved to explore an intertransverse process window cephalad or caudad to place the block where pleura seems more identifiable. Multimodal pain management, including nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and short-acting opioids, should be strongly considered
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