Analgesic efficacy and safety of epidural and paravertebral blocks in thoracotomy surgery

Abstract

Objectives: Epidural anesthesia, once considered a gold standard, has significant complications: hypotension, urinary retention, and catastrophic neurological damage in rare cases. While paravertebral analgesia can provide similar analgesic effectiveness to epidural analgesia, it is associated with fewer side effects. To compare the perioperative and postoperative effects of epidural (ED) and ultrasound-guided paravertebral block (PVB) applications in thoracotomy surgeries.

Methods: Fifty-two patients underwent elective thoracotomy; Group 1 (ED, n = 23) and Group 2 (PVB, n = 29) were evaluated. A comparison of hemodynamic parameters and complications preoperatively and postoperatively, postoperative analgesia requirements, visual analog scale (VAS) pain scores within 24 hours at specified times, the amount of analgesic used, the time to mobilize, the time to discharge, and the VAS values measured at three months was made.

Results: There was no difference between the study groups regarding demographic and ASA values, most comorbid chronic diseases, obesity, and smoking. The number of attempts, the postoperative 2nd hour VAS score, and the doses of paracetamol and tramadol used was significantly higher in Group 1 than in Group 2 (p = 0.002, p = 0.002, p = 0.012, and p = 0.022, respectively). There was no statistical difference between the groups in terms of postoperative 6, 12, 24 hours, and 3 months VAS scores, first mobilization and discharge, time to remove the thorax tube, intensive care (PACU) need, and perioperative and postoperative complications (p > 0.05).

Conclusions: Ultrasound-guided PVB can be considered a safe and effective alternative to ED in thoracotomy surgery.

Keywords

• Epidural block
• paravertebral block
• postoperative pain
• chronic pain

References

1. 1. Yeung JH, Gates S, Naidu BV, Wilson MJ, Smith FG. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016;2:CD009121.
2. 2. Arends S, Böhmer AB, Poels M, Schieren M, Koryllos A, Wappler F, et al. Post-thoracotomy pain syndrome: seldom severe, often neuropathic, treated unspecific, and insufficient. Pain Rep 2020;5:e810.
3. 3. Marshall K, McLaughlin K. Pain management in thoracic surgery. Thorac Surg Clin 2020; 30:339-46.
4. 4. Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? Interact Cardiovasc Thorac Surg 2010; 10:92-6.
5. 5. D’Ercole F, Arora H, Kumar PA. Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth 2018;32:915-27.
6. 6. Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M;PROSPECT Working Group *of the European Society of Regional Anaesthesia and Pain Therapy. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2022;77:311-25.
7. 7. Park SK, Yoon S, Kim BR, Choe SH, Bahk JH, Seo JH. Pre-emptive epidural analgesia for acute and chronic post-thoracotomy pain in adults: a systematic review and meta-analysis. Reg Anesth Pain Med 2020;45:1006-16.
8. 8. Davies RG, PS Myles, Graham J. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy -- a systematic review and meta-analysis of randomized trials. BJA: Br J Anaesth 2006;96:418-26.

9. 9. Mohta M, Ophrii EL, Sethi AK, Agarwal D, Jain BK. Continuous paravertebral infusion of ropivacaine with or without fentanyl for pain relief in unilateral multiple fractured ribs. Indian J Anaesth 2013;57:555-61.
10. 10. Grider JS, Mullet TW, Saha SP, Harned ME, Sloan PA. A randomized, double-blind trial comparing continuous thoracic epidural bupivacaine with and without opioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain. J Cardiothorac Vasc Anesth 2012;26:83-9.
11. 11. Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2014;18:626-35.
12. 12. Ng A Swanevelder J. Pain relief after thoracotomy: is epidural analgesia the optimal technique? Br J Anaesth 2007;98:159-62.
13. 13. Markham T, Wegner R, Hernandez N, Lee JW, Choi W, Eltzschig HK, et al. Assessment of a multimodal analgesia protocol to allow the implementation of enhanced recovery after cardiac surgery: retrospective analysis of patient outcomes. J Clin Anesth 2019;54:76-80.
14. 14. Batchelor TJ, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2019;55:91-115.
15. 15. Asban A, Xie R, Abraham P, Kirklin JK, Donahue J, Wei B. Reasons for extended length of stay following chest tube removal in general thoracic surgical patients. J Thorac Dis 2020; 12:5700-8.
16. 16. Cerfolio RJ, Bryant AS, Skylizard L and Minnich DJ. Optimal technique for the removal of chest tubes after pulmonary resection. J Thorac Cardiovasc Surg 2013;145:1535-9.
17. 17. Terkawi AS, Tsang S, Sessler DI, Terkawi RS, Nunemaker MS, Durieux ME, et al. Improving analgesic efficacy and safety of thoracic paravertebral block for breast surgery: a mixed-effects meta-analysis. Pain Physician 2015;18:E757-80.
18. 18. Scholz J, Finnerup NB, Attal N, Aziz Q, Baron R, Bennett MI, et al. The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain 2019;160:53-9.