Comparison of thoracic epidural and peripheral regional analgesia techniques for postoperative pain management in video-assisted thoracoscopic surgery (VATS) procedures: a retrospective study

Abstract

Aims: Effective postoperative analgesia is essential in thoracic surgery to preserve respiratory function, facilitate early mobilization, and reduce pulmonary complications. Thoracic epidural analgesia (TEA) has traditionally been regarded as the gold standard for pain control. However, the increasing use of minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) has prompted the adoption of ultrasound-guided peripheral regional anesthesia techniques, including the paravertebral block (PVB), erector spinae plane block (ESPB), and serratus anterior plane block (SAPB). This study aimed to compare TEA and peripheral regional blocks in terms of postoperative pain scores, opioid consumption, and recovery parameters in patients undergoing VATS procedures. Methods: This retrospective study included patients who underwent elective VATS between January 2023 and January 2025. Based on the analgesic technique received, patients were divided into two groups: TEA (n=82) and peripheral block group (PER, n=65). Pain was assessed using the Visual Analog Scale (VAS) at the post-anesthesia care unit (PACU) and at 24, 48, and 72 hours postoperatively. Opioid doses were standardized to morphine milligram equivalents (MME). Additional outcomes included intraoperative opioid use, postoperative rescue analgesia, length of hospital stay (LOS), complication rates, and 90-day mortality. Results: Patients in the TEA group had significantly lower VAS scores at all time points compared to the PER group (p<0.001). PACU opioid administration and total MME consumption were also significantly reduced in the TEA group (0 mg [IQR 0–2] vs. 2 mg [IQR 0–4], p<0.001). Although intraoperative opioid use was generally similar, TEA provided greater opioid-sparing effects. No significant differences were observed between groups in LOS, complication rates, or 90-day mortality. Conclusion: TEA demonstrated superior efficacy in postoperative pain control and opioid reduction compared to peripheral regional anesthesia techniques in patients undergoing VATS. While TEA remains the preferred option when feasible, ultrasound guided peripheral blocks offer a valuable alternative, particularly in patients with contraindications to neuraxial techniques.

Keywords

• Thoracic epidural analgesia
• video-assisted thoracoscopic surgery
• paravertebral block
• erector spinae plane block
• serratus anterior plane block
• postoperative pain

Video yardımlı torakoskopik cerrahi (VATS) girişimlerinde postoperatif ağrı yönetimi için torakal epidural ve periferik rejyonel analjezi tekniklerinin karşılaştırılması: tek merkezli retrospektif bir analiz

Abstract

Giriş/Amaç: Toraks cerrahisinde etkili postoperatif analjezi, solunum fonksiyonlarının korunması, erken mobilizasyonun sağlanması ve pulmoner komplikasyonların azaltılması açısından kritik öneme sahiptir. Torakal epidural analjezi (TEA), geleneksel olarak ağrı kontrolünde “altın standart” olarak kabul edilmiştir. Ancak, video yardımlı torakoskopik cerrahi (VATS) gibi minimal invaziv yaklaşımların giderek daha yaygın hale gelmesi, ultrason eşliğinde uygulanan paravertebral blok (PVB), erector spinae plane blok (ESPB) ve serratus anterior plane blok (SAPB) gibi periferik rejyonel anestezi tekniklerinin kullanımını artırmıştır. Bu çalışma, VATS uygulanan hastalarda TEA ve periferik rejyonel blokların postoperatif ağrı skorları, opioid tüketimi ve iyileşme parametreleri açısından karşılaştırılmasını amaçlamaktadır. Gereç ve Yöntem: Bu retrospektif kohort çalışmaya, Ocak 2023 ile Ocak 2025 tarihleri arasında elektif VATS geçiren hastalar dahil edilmiştir. Uygulanan analjezi tekniğine göre hastalar iki gruba ayrılmıştır: TEA (n=82) ve periferik blok (PER, n=65). Ağrı düzeyleri, anestezi sonrası bakım ünitesinde (PACU) ve postoperatif 24, 48 ve 72. saatlerde görsel analog skala (VAS) kullanılarak değerlendirilmiştir. Opioid dozları morfin miligram eşdeğeri (MME) olarak standartlaştırılmıştır. Ek olarak değerlendirilen sonuçlar arasında intraoperatif opioid kullanımı, postoperatif kurtarma analjezisi ihtiyacı, hastanede kalış süresi (LOS), komplikasyon oranları ve 90 günlük mortalite yer almıştır. Bulgular: TEA grubundaki hastalar, tüm zaman noktalarında PER grubuna kıyasla anlamlı olarak daha düşük VAS skorlarına sahipti (p<0.001). PACU’da uygulanan opioid miktarı ve toplam MME tüketimi de TEA grubunda belirgin şekilde daha düşüktü (0 mg [IQR 0–2] vs. 2 mg [IQR 0–4], p<0.001). İntraoperatif opioid kullanımı genel olarak benzer olmakla birlikte, TEA daha belirgin bir opioid koruyucu etki sağlamıştır. LOS, komplikasyon oranları ve 90 günlük mortalite açısından gruplar arasında anlamlı bir fark saptanmamıştır. Sonuç: TEA, VATS geçiren hastalarda postoperatif ağrı kontrolü ve opioid kullanımının azaltılması açısından periferik rejyonel anestezi tekniklerine kıyasla üstünlük göstermiştir. Uygulanabilir olduğu durumlarda TEA tercih edilmesi önerilirken, ultrason eşliğinde uygulanan periferik bloklar, özellikle santral bloklara kontrendikasyonu olan hastalarda değerli bir alternatif olarak öne çıkmaktadır.

Keywords

• Torakal epidural analjezi
• video yardımlı torakoskopik cerrahi
• paravertebral blok
• erector spinae plan blok
• serratus anterior plan blok
• postoperatif ağrı

References

1. Makkad B, Heinke TL, Sheriffdeen R, et al. Practice advisory for postoperative pain management of thoracic surgical patients: a report from the society of cardiovascular anesthesiologists. J Cardiothorac Vasc Anesth. 2025;39(5):1306-1324. doi:10.1053/j.jvca.2024.12.004
2. Zhu J, Wei B, Wu L, et al. Effect of thoracic paravertebral block on postoperative pulmonary complications after video-assisted thoracoscopic surgery: a dual-center randomized clinical trial. Ther Clin Risk Manag. 2025;21:691-703. doi:10.2147/TCRM.S515093
3. Raft J, Richebé P. Anesthesia for thoracic ambulatory surgery. Curr Opin Anaesthesiol. 2019;32(6):735-742. doi:10.1097/ACO.0000000000000795
4. Hamilton C, Alfille P, Mountjoy J, Bao X. Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review. J Thorac Dis. 2022;14(6):2276-2296. doi:10.21037/jtd-21-1740
5. Mendes E, Semerkant T, Cok OY. Application of a conventional paravertebral block on the thorax with a novel intrathoracic approach during the intraoperative period: two case reports: paravertebral block with an intrathoracic approach. J Surg Med. 2023;7(3):249-251. doi:10. 28982/josam.1109449
6. Holm JH, Bak M, Brøchner AC. Epidural analgesia versus systemic opioids for postoperative pain management after VATS: protocol for a systematic review. Acta Anaesthesiol Scand. 2025;69(1):e14546. doi:10. 1111/aas.14546
7. Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2022;77(3):311-325. doi:10.1111/anae.15609
8. Demirci B, Akbudak İH, İlhan S, Mete Yıldız A. Comparison of erector spinae plane block and serratus anterior plane block for pain management in thoracoscopic surgery. J Health Sci Med. 2025;8(4):629-634. doi:10.32322/jhsm.1703176

9. Lin J, Liao Y, Gong C, et al. Regional analgesia in video-assisted thoracic surgery: a bayesian network meta-analysis. Front Med (Lausanne). 2022; 9:842332. doi:10.3389/fmed.2022.842332
10. Sandeep B, Huang X, Li Y, Xiong D, Zhu B, Xiao Z. A comparison of regional anesthesia techniques in patients undergoing video-assisted thoracic surgery: a network meta-analysis. Int J Surg. 2022;105:106840. doi:10.1016/j.ijsu.2022.106840
11. Piccioni F, Segat M, Falini S, et al. Enhanced recovery pathways in thoracic surgery from Italian VATS group: perioperative analgesia protocols. J Thorac Dis. 2018;10(Suppl 4):s555-s563. doi:10.21037/jtd. 2017.12.86
12. Adıyeke Ö, Sarban O, Mendeş E, Abdullah T, Gümüş Özcan F. Comparison of the efficacy between thoracic epidural analgesia and paravertebral block in patients undergoing pneumonectomy: a retrospective cohort study. GKD Anest Yoğ Bak Dern Derg. 2024;30(1):29-34. doi:10.14744/GKDAD.2024.91668
13. Xiang Y, Chen L, Jia J, Yili F, Changwei W. The association of regional block with intraoperative opioid consumption in patients undergoing video-assisted thoracoscopic surgery: a single-center, retrospective study. J Cardiothorac Surg. 2024;19(1):124. doi:10.1186/s13019-024-02611-3
14. Dossi R, Patella M, Barozzi B, et al. Comparing erector spinae plane (ESP) and thoracic paravertebral (TPV) block analgesic effect after elective video-assisted thoracic surgery: a randomized, multiple-blinded, non-inferiority trial. J Thorac Dis. 2025;17(3):1531-1540. doi:10. 21037/jtd-24-1548
15. Zeng J, Tang ZH, Liang JQ, et al. Comparison of various regional analgesia methods for postoperative analgesic effects in video-assisted thoracoscopic surgery: a systematic review and network meta-analysis. Pain Physician. 2022;25(7):E917-e30.
16. Jo Y, Park S, Oh C, et al. Regional analgesia techniques for video-assisted thoracic surgery: a frequentist network meta-analysis. Korean J Anesthesiol. 2022;75(3):231-244. doi:10.4097/kja.21330
17. Scorsese G, Jin Z, Greenspan S, et al. Effectiveness of thoracic wall blocks in video-assisted thoracoscopic surgery, a network meta-analysis. J Pain Res. 2023;16:707-724. doi:10.2147/JPR.S396530
18. Luo G, Tao J, Zhu J, Xie K, Ni C. Comparison of analgesic effects of different regional blocks in video-assisted thoracic and breast surgeries: a network meta-analysis and systematic review. Pain Physician. 2022; 25(5):339-354.
19. Zhang S, Han X, Zhou D, et al. The effects of erector spinae plane block on perioperative opioid consumption and rehabilitation in video assisted thoracic surgery. BMC Anesthesiol. 2021;21(1):313. doi:10.1186/s12871-021-01536-x
20. Yilmaz M, Uzun N, Oral Ahiskalioglu E, Ulas A. Retrospective evaluation of analgesia approaches in patients undergoing thoracic surgery over the last one year: a single-center study. Challenge J Perioperative Med. 2025;3(1):1-7. doi:10.20528/cjpm.2025.01.001
21. Hong JM, Kim E, Jeon S, et al. A prospective double-blinded randomized control trial comparing erector spinae plane block to thoracic epidural analgesia for postoperative pain in video-assisted thoracic surgery. Saudi Med J. 2023;44(2):155-163. doi:10.15537/smj.2023.44.2.20220644
22. Ökmen K, Köprücüoğlu M. Rhomboid intercostal and serratus anterior interfascial plane blocks for the treatment of post-operative pain after video-assisted thoracoscopic surgery: a retrospective propensity-matched study. Turk J Anaesthesiol Reanim. 2021;49(3):211-217. doi:10. 5152/TJAR.2020.471
23. Tulgar S, Ciftci B, Ahiskalioglu A, et al. Serratus posterior superior intercostal plane block: a technical report on the description of a novel periparavertebral block for thoracic pain. Cureus. 2023;15(2):e34582. doi:10.7759/cureus.34582
24. Manici M, Kalyoncu İ, Sincer Y, Gürkan Y. Enhancing minimally invasive thoracic surgery: efficacy of serratus posterior superior intercostal plane block in VATS procedures. GKDA Derg. 2024;30(2):87-88. doi:10.14744/GKDAD.2024.22448
25. Zhang L, Hu Y, Liu H, et al. Analgesic efficacy of combined thoracic paravertebral block and erector spinae plane block for video-assisted thoracic surgery: a prospective randomized clinical trial. Med Sci Monit. 2023;29:e940247. doi:10.12659/MSM.940247
26. Zengin M, Alagöz A, Sazak H, Ülger G, Baldemir R, Şentürk M. Comparison of efficacy of erector spinae plane block, thoracic paravertebral block, and erector spinae plane block and thoracic paravertebral block combination for acute pain after video-assisted thoracoscopic surgery: a randomized controlled study. Minerva Anestesiol. 2023;89(3):138-148. doi:10.23736/S0375-9393.22.16639-3
27. Zengin M, Baldemir R, Ülger G, Sazak H, Alagöz A. Comparison of deep and combined serratus anterior plane block after video-assisted thoracoscopic surgery; a prospective randomized trial. J Health Sci Med. 2023;6(1):18-24. doi:10.32322/jhsm.1185437
28. Tulgar S, Ciftci B, Ahiskalioglu A, et al. Recto-intercostal fascial plane block: another novel fascial plane block. J Clin Anesth. 2023;89:111163. doi:10.1016/j.jclinane.2023.111163