Thoracic paravertebral nerve block
Editor—We read with interest the study by Vogt and colleagues,1 and the accompanying editorial,2 highlighting long lasting analgesia from a single preoperative injection of bupivacaine and epinephrine for patients undergoing thoracoscopic surgery. We agree that pain following video assisted thoracic surgery (VATS) can be severe but we also believe that, in many thoracic units, it is not taken sufficiently seriously.Following strenuous efforts studying how to avoid the severe pain which follows open thoracic surgery,3 with the take up in our unit of VATS—a supposedly minimally invasive alternative—we were appalled at the severity of acute pain and the generation of chronic pain, the latter of which, we measured at 38% at 2 months4 compared with our chronic pain generation rate following open thoracotomy managed with various analgesic modalities of 22.3% altogether and approximately 10% if managed with paravertebral analgesia.5 Although the overall figure of 38% sounds high, the second biggest published study looking into chronic pain after thoracotomy reported a 44% incidence at a mean of 30.3 months (15–48) after operation.6 A second study by the same group found a 61% chronic pain rate at 1 yr.7
We wish to share with others our experience which we believe has helped patients. We tackled the problem in three ways. Firstly, we provided patients with single shot paravertebral nerve blocks before operation, using similar methods to Vogt and colleagues.1 Secondly, the advice of the surgical literature to orbit the instruments about the surgical focus8 was abandoned. VATS can involve the use of up to five instruments followed by chest drains. Up to five intercostal nerves are therefore at risk of trauma and as far as chronic pain generation is concerned partial nerve damage is as bad as complete section.9 A skilful surgeon, for most VATS, can align the instruments along a single intercostal space thus minimizing neurological and rib trauma.
Thirdly, after careful measurements of the rib to rib (intercostal) distance in many patients, our suspicions were confirmed that the instruments and ports can actually be of larger diameter than many of the spaces through which they must be inserted. We invented a rib punch to take out an ellipse of the upper part of the inferior rib. This minimized the trauma needed for insertion, a modification which we hoped would reduce neurovascular trauma and rib fractures (having previously found that rib removal rather than rib distraction reduced chronic pain following thoracotomy3).
In VATS, if longer postoperative analgesia than described by Vogt and colleagues is required, the positioning of a percutaneous catheter under direct vision has been described.10
Lönnqvist's editorial and the report in the same issue of coexisting harlequin and Horner syndromes after high thoracic paravertebral anaesthesia suggest there is much yet to be learnt about this fascinating technique. The keys to its full understanding will indeed lie within sympathetic afferents and efferents.
Bradford, UK
*E-mail: docjohnnyr{at}hotmail.com
References
1 Vogt A, Stieger DS, Theurillat C, Curatolo M. Single-injection thoracic paravertebral nerve block for postoperative pain after thoracoscopic surgery. Br J Anaesth 2005; 95:816–21
2 Lönnqvist PA. Pre-emptive analgesia with thoracic paravertebral blockade. Br J Anaesth 2005; 95:727–8
3 Sabanathan S, Richardson J, Mearns AJ. Management of pain in thoracic surgery. Br J Hosp Med 1993; 50:114–12[Medline]
4 Richardson J and Sabanathan S. Pain management in video assisted thoracic surgery: evaluation of localised partial rib resection. A new technique. J Cardiovasc Surg 1995; 36:505–9[Medline]
5 Richardson J, Sabanathan S, Mearns AJ, Sides CS, Goulden C. Post-thoracotomy neuralgia. Pain Clinic 1994; 7:87–97
6 Kalso E, Perttunen K, Kaasinen S. Pain after thoracic surgery. Acta Anaesthesiol Scand 1992; 36:96–100[ISI][Medline]
7 Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgery: a follow-up study. Acta Anaesthesiol Scand 1999; 43:563–7[CrossRef][ISI][Medline]
8 Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Video assisted thoracic surgery: basic technical concepts and intercostals approach strategies. Ann Thorac Surg 1992; 54:800–7[Abstract]
9 Devor M. Neuropathic pain and the injured nerve: peripheral mechanisms. Br Med Bull 1991; 47:619–30
10 Soni AK, Conacher ID, Waller DA, Hilton CJ. Video-assisted thoracoscopic placement of paravertebral catheters: a technique for post-operative analgesia for bilateral thoracoscopic surgery. Br J Anaesth 1994; 72:462–4
11 Burlacu CL and Buggy DJ. Coexisting harlequin and Horner syndromes after high thoracic paravertebral anaesthesia. Br J Anaesth 2005; 95:822–4
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