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Summary
The major drawback ?fparavertebral space location using the traditional method of’ loss of’ resistance to air or saline is a failure
rate of at least 10%. We inwstigated whether pressure measurement during needle advancement could improtre reliability.
Twenty-nine blocks in 14 awake adult patients undergoing treatment for chronically painful neuralgic conditions of the chest
or abdominal wall were studied. In erector spinae, the mean inspiratory pressure (29.5 mmHg, S D 14.2), e.uceeded the e.upiratory
pressure (19.4 mmHg, SD 9.7). Holcvrw, upon traversing the superior costo-transaerse ligament, there iiws a sudden lowering
of pressures and the mean espiratory pressure (7.6 mmHg, SD 3.7) exceeded the inspiratory pressure (3.3 mniHg, S D 2.9). No
negative pressures were recorded. Correct needle placement H ~ U Sconjrnied bv X ray screening and contrast injection. All blocks
were successful and uncomplicated. Location of the paravertebral space by this objective method ?f ‘pressure inversion’ improces
sensitiaity and specificity and should lead to an improcement in the success rate o f thoracic paraitertebral analgesia.
Key words
Anaesthetic techniques, regional; paravertebral block.
Paravertebral blockade provides effective, safe, unilateral process (2-3 cm lateral to the spinous process), at the
analgesia, and has been successfully employed in acute and appropriate dermatomal level for distribution of the pain.
chronic pain management [I+]. Its major drawback, A pressure transducer (Medex Medical Inc., Rossendale,
however, is a failure rate of at least 10% (Lonnqvist PA, UK), zeroed at the transverse process, was connected via a
personal communication), due to a somewhat indistinct loss saline-filled, non-compliant tube and a three-way tap to the
of resistance to air or saline, the traditional method of space end of the Tuohy needle. Pressure measurements were
location [I]. A substantial improvement in reliability is displayed (Datascope 22001, Datascope Corporation,
therefore needed and we investigated whether pressure Paramus, New Jersey, USA) as the needle was advanced
measurement during needle advancement could fulfil this over the top of the transverse process, through erector
requirement. spinae, through the superior costo-transverse ligament and
into the areolar tissue of the paravertebral space. The effects
of inspiration and expiration on pressures were recorded, as
Patients and methods were the needle depths from the skin. X ray screening and
With local institution ethics committee approval, 14 contrast injection of 2 ml of Isovist 300 (Schering,
consenting patients undergoing repeated percutaneous Germany) was used to confirm final needle tip position.
thoracic paravertebral nerve blocks for chronically painful After careful aspiration, 15 ml of 0.5% bupivacaine with
neuralgic conditions of the chest or abdominal wall were methylprednisolone acetate 80 mg was injected. Successful
studied. Local anaesthesia was used, full aseptic precautions placement was confirmed by pinprick testing of the
observed, and patients were placed in the lateral position dermatomal spread at least 20 min after injection, except in
with the side to be blocked uppermost. A 16 gauge Tuohy post-thoracotomy patients, in whom prior sensory loss
needle was advanced horizontally onto the transverse interfered with assessment.
J. Richardson, MD, MRCP, FRCA. Consultant Anaesthetist, S.P.S. Cheema, FRCA, Senior Registrar in Anaesthetics,
J. Hawkins, FRCA, Senior Registrar in Anaesthetics, S. Sabanathan, MD, FRCS, Cardiothoracic Surgeon, Department of
Anaesthetics and Thoracic Surgery, Bradford Royal Infirmary, Bradford BD9 6RJ.
Accepted 16 May 1995.
0003-2409/96/020137 + 03 $l2.00/0 @ 1996 The Association of Anaesthetists of Gt Britain and Ireland 137
138 J . Richardson et al.
Table 1. Summary of results. Assessment of spread of block excludes patients with post-thorectomy neuralgia.
paravertebral space, e.g. in post-thoracotomy neuralgia, We conclude that tactile or radiographic identification of
greatly interferes with the appreciation of a loss of the paravertebral space should be replaced or supplemented
resistance. Even with the aid of X ray screening with by pressure monitoring. Sensitivity and specificity is
contrast, injection may not always provide clear, readily improved and correct needle placement becomes objective
identifiable images [ 5 ] . This lack of specificity and sensitivity and reproducible. We hope this modification will encourage
contributes to a substantial failure rate. further study of this very useful, but relatively neglected,
We have demonstrated sudden lowering of pressures and method of unilateral afferent blockade.
pressure inversion as the superior costo-transverse ligament
is breached, providing an easy, objective and reproducible
method of correct space location. In muscle, the pressure is
References
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