Background: Paravertebral Block (PVB) is an established regional anesthetic technique. It is technically easy to perform and is being used increasingly for intra-operative and post-operative analgesia. This popularity is mainly due to the ease of the technique and fewer complications.

Materials and Methods: This is quantitative systematic review of literature database with the aim to assess the efficacy and safety of Paravertebral block in thoracic, abdominal and breast surgery.

Results: Six randomised control trials that included 386 patients were
reviewed. Authors of reviewed articles reported 100% success in block effectivenes and low incidence of complications.

Conclusion: Paravertebral block is effectiv anesthetic/analgetic technique with very few complications

DIANA BUTKOVIĆ

JANA KOGLER

MAJA KARAMAN ILIĆ1

MARTINA MATOLIĆ

VIŠNJA NESEK ADAM1

English

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PERIODICUM BIOLOGORUM UDC 57:61 VOL. 117, No 2, 315–317, 2015 CODEN PDBIAD  ISSN 0031-5362 Paravertebral block: review of the literatureAbstract Background: Paravertebral Block (PVB) is an established regional an-esthetic technique. It is technically easy to perform and is being used increas-ingly for intra-operative and post-operative analgesia. This popularity is mainly due to the ease of the technique and fewer complications. Materials and Methods: This is quantitative systematic review of li-terature database with the aim to assess the efficacy and safety of Paraverte-bral block in thoracic, abdominal and breast surgery.Results: Six randomised control trials that included 386 patients were reviewed. Authors of reviewed articles reported 100% success in block effec-tivenes and low incidence of complications. Conclusion: Paravertebral block is effectiv anesthetic/analgetic tech-nique with very few complicationsIntroductIonParavertebral Block (PVB) is an established regional anesthetic tech-nique. The injection of local anesthetic in a space immediately lat-eral to where the spinal nerves emerge from the intervertebral foramina produces unilateral, segmental, somatic, and sympathetic nerve block-ade which is effective for anesthesia and in treating acute and chronic pain of unilateral origin from the chest and abdomen.PVBs are highly adaptable and, except for thoracotomy, may serve as the primary anesthetic for breast surgery, chest trauma, hernia repair, soft tissue mass excisions, and /or as a useful adjunct in laparoscopic surgery, cholecystectomy, nephrectomy, or other abdominal and tho-racic surgery (1).MAterIAl And MethodsThe aim of this quantitative systematic review of literature database was to assess the efficacy and safety of PVB in thoracic, abdominal and breast surgery. The systematic search was conducted in the Central re-gister of controlled trials of the Cochrane Library ,MEDLINE and EM-BASE according to the current recommendations of the CochraneCo-llaboration (2).The search strategy consisted of a combination of free text words and Medical Subject Headings (MeSH) terms: ‘paravertebral’, ’thoracic surgery’, ’abdomina surgery’ and ‘breast surgery’The authors scanned the avaliable articles by the initial search to exclude irrelevant studies. Study eligibility was determined by reading the title and abstracts and obviously irrelevant trials were excluded at this stage. The six studies that are included in review are in Table 1 (3, 4, 5, 6, 7, 8).MAJA KARAMAN ILIĆ1 VIŠNJA NESEK ADAM1 MARTINA MATOLIĆ1JANA KOGLER2 DIANA BUTKOVIĆ31  Sveti Duh Univesity Hospital, Department of Anesthesiology,  Reanimatology and Intensive Care2  University Hospital Centre Zagreb, Department of Anesthesiology,  Reanimatology and Intensive Care3  Childrens ś Hospital Zagreb, Department of Anesthesiology,  Reanimatology and Intensive CareCorrespondence: Maja Karaman Ili} Sveti Duh Univesity Hospital  Department of Anesthesiology,  Reanimatology and Intensive Care E-mail: majakilic1@gmail.comAbbreviations: PVB  – Paravertebral Block MeSH – Medical Subject Headings  LA – Local Anesthetic RCT – Randomised Control Trial GA – General Anesthesia      Received May 5, 2015.Maja Karaman Ilić et al. Paravertebral block316 Period biol, Vol 117, No 2, 2015.resultsThe studies included in the reviw were randomised, control trials(RCT).Hadžić, Naja,Pusch and Klein repor-ted 100% success in block effectivenes. The failure rate associated with PVB is not > 9%.Inadvertent vascular pun-cture (5,2%), hypotension (6%), epidural spread of Local Anesthetic (LA) (1,8%), inadvent pleural punction (1.8%) and pneumothorax (0.5%) were the recorded complicati-ons. Complicatins were  higher in bilateral compared to unilateral block. Postoperative nausea and vomiting are significantly lower in patients given PVB compared to GA.dIscussIonFirst PVB was performed in 1905 as an alternative to neuraxial block for obstetric procedures and became a popular technique for the provision of analgesia in the early part of the twentieth century (9,10). The technique however remained neglected till the late 1970s. Renaissance for PVB began 1979 due to efforts from Eason and Wyatt who presented a reappraisal on Thoracic Paravertebral Block (TPVB) (11). PVB is technically easy to learn with a high success rate, and is being used increasingly for not only intra-operative and post-operative analgesia but also as a sole anesthetic technique for carrying out various procedures. This popularity is mainly due to the ease of the technique and fewer complications. Post-operative pain control is one of the major concerns in the post-operative care of patients undergoing thoracic surgery, especially when thoracotomy is required. In thora-cic surgery PVB is placed at the level of the surgical thoracic incision,in most of the cases it is a unilateral block (12).The injection of LA in the paravertebral space produces analgesia because of direct contact of LA with the spinal nerve roots before they emerge from the intervertebral foramina. The pain associated with thoracotomy surgery can be severe (13).Pain stimuli arising from skin and muscles incision as well as from ribs are spread and conducted by intercostal nerves that are also important for the transition from acute to chronic pain from nociceptive to neurogenic and neurophatic pain. The paravertebral block has also been used extensively for anaesthesia and analgesia for abdominal surgery, es-pecially for ambulatory inguinal hernia repair (4, 14). The injection of LA into the paravertebral space avoids the severe autonomic dysfunction seen with neuraxial techniques and allows the patient to mobilise earlier.The paravertebral approach to analgesia after inguinal herniorrhaphy can provide analgesia that is superior to oral analgesia or  local field blocks.Breast surgery under the PVB showed satisfactory pain control with no need for supplementation of analgetics. Postoperative pain is effectively controlled and patients rated the experience as very satisfactory (15).From the retrived papers,with eception of reviwed ar-ticles, additinal posibility for PVB application is observed.Paravertebral blocks have been used less frequently for other abdominal procedures. A series of ten patients un-dergoing abdominal vascular surgical procedures was reported. Cardiovascular stability was noted upon inci-sion, clamping of the aorta and throughout surgery in all patients (16).No further intra-operative opioids or neuromuscular blocking drugs were required and postoperative analgesia was excellent. The paravertebral block has also been used success-fully as rescue analgesia for visceral pain after failure of TAble 1Studies included in review.Trial No of patients Type of surgery Type Details Naja and colleagues  (3) 60 Breast surgery MPVB Lidocaine 1%, bupivacaine 0.5%, fentanyl, clonidine, epinephrineWassef et al.(4) 30 Heniorraphy MPVB 2%lidocain,epinephrinKlein and colleagues (5) 60 Breast surgery MPVB Bupivacaine 0.5%, epinephrineRichardson et al.(6) 100 Thoracic surgery SPVB 0,5% bupivacainHadžić et al (7) 50 heniorraphy SPVB 0,75% ropivacainPusch and colleagues(8) 86 Breast surgery SPVB Bupivacaine 0.5%MPVB – multiple paravertebral block SPVB – single paravertebral blockParavertebral block  Maja Karaman Ilić et al.Period biol, Vol 117, No 2, 2015. 317systemic analgesics for renal colic in an obstetric patient.Described experiences with liver surgery-pain control fol-lowing radiofrequency ablation of liver mass (17) as well for percutaneous transhepatic biliary drainage were satis-factory(18). The effect of PVB examined on the pain-relief and perioperative stress response in patients scheduled for open cholecystectomy showed less pain scores and less requirements on supplemental analgesics for three days postoperatively.A significant reduction in circulatory and hormonal response to stress was also seen (19).In conclusion, based on the current evidence, PVBs for surgical anesthesia at the level of the thoracic and lumbar vertebrae are associated with less pain during the immedi-ate postoperative period, as well as less postoperative nau-sea and vomiting, and greater patient satisfaction com-pared with GA. A modern approach to pain control should consider that reduction or elimination of pain, reduction of  morbidity, length of stay and hospital costs.references 1.  VILA H J R, LIU J, KAVASMANECK D 2007 Paravertebral block: new benefits from an old procedure. Curr Opin Anaesthesiol 20: 316–8. 2.  LEFEBVRE C, MANHEIMER E, GLANVILLE J 2011Search-ing for studies. In: Higgins J P T, Green S (ed). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 The Cochrane Collaboration. Available from www.cochrane-handbook.org. 3.  NAJA M Z, ZIADE M F, LÖ NNQVIST P A 2003 Nerve-stimu-lator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. Eur J Anaesthesiol 20: 897–903 4.  WASSEF M R, RANDAZZO T, WARD W 1998 The paraverte-bral nerve root block for inguinal herniorrhaphy--a comparison with the field block approach. Reg Anesth Pain Med 23(5): 451-6 5.  KLEIN S M, BERGH A, STEELE S M, GEORGIADE G S, GREENGRASS R A  2000 Thoracic paravertebral block for breast surgery. Anesth Analg 90: 1402–5. 6.  RICHARDSON J, SABANATHAN S, MEARNS A J, SHAH R D, GOULDEN C A 1995 Prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery. Br J Anaesth 75: 405–8 7.  HADZIC A,  KERIMOGLU B,  LOREIO D,  KARACA P E, CLAUDIO R E, YUFA M, WEDDERBURN R, SANTOS A C, THYS D M 2006Paravertebral blocks provide superior same-day recovery over general anesthesia for patients undergoing ingui-nal hernia repair. Anesth Analg 102(4): 1076-81 8.  PUSCH F, FREITAG H, WEINSTABL C, OBWEGESER R, HUBER E, WILDLING E 1999 Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta An-aesthesiol Scand 43: 770–4 9.  RICHARDSON J, LONNQVIST P A 1988 Thoracic paraverte-bral block (review article) Br J Anaesth 81: 230–810.  KARMAKAR M K  2001Thoracic paravertebral block (review article)  Anesthesiology 95: 771–8011.  EASON M J, WYATT R 1979 Paravertebral thoracic block—a reappraisal  Anaesthesia 34: 638–4212.  MATTHEWS P J, GOVENDEN V 1989 Comparison of conti-nuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy. Br J Anaesth 62(2): 204-5 . 13.  RICHARDSON J ,  SABANATHAN S,  JONES J,  SHAH R D, CHEEMA S, MEARNS A J1999 A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth   83(3): 387-9214.  KLEIN S M,  PIETROBON R,  NIELSEN K C,  STEELE S M, WARNER D S, MOYLAN J A, EUBANKS W S, GREEN-GRASS R A 2002 Paravertebral somatic nerve block compared with peripheral nerve blocks for outpatient inguinal herniorrhaphy. Reg Anesth Pain Med 27(5): 476-8015.  WELTZ C R, GREENGRASS R A, LYERLY H K 1995 Ambula-tory surgical management of breast carcinoma using paravertebral block. Ann Surg 222(1): 19-2616.  FALKENSAMMER J, HAKAIM A G, KLOCKER J, BIEBL M, LAU L L, NEUHAUSER B, MORDECAI M, CRAWFORD C, GREENGRASS R 2006 Paravertebral blockade with propofol sedation versus general anesthesia for elective endovascular ab-dominal aortic aneurysm repair. Vascular 14(1): 17-2217.  CULP W C , PAYNE M N, MONTGOMERY M L 2008. Tho-racic paravertebral block for analgesia following liver mass radio-frequency ablation. Br J Radiol  81(961): e23-5 18.  CULP WC J R, CULP W C 2005 Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radi-ol16(10): 1397-40019.  GIESECKE K, HAMBERGER B, JÄRNBERG P O, KLINGST-EDT C 1988 Paravertebral block during cholecystectomy: effects on circulatory and hormonal responses. Br J Anaesth 61(6): 652-6

Paravertebral block: review of the literature

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