Randomized Prospective Study Evaluating Single-Injection Paravertebral Block, Paravertebral Catheter, and Thoracic Epidural Catheter for Postoperative Regional Analgesia After Video-Assisted Thoracoscopic Surgery

Abstract

Objective: Video-assisted thoracoscopic surgery (VATS) has improved patient outcomes; however, postoperative pain remains potentially severe. The objective of this study was to compare adjunct analgesic modalities for VATS, including paravertebral nerve blockade (PVB) and thoracic epidural anesthesia (TEA). Design: Prospective, randomized trial. Setting: Large academic hospital, single institution. Participants: Adult patients undergoing VATS. Interventions: Ultrasound-guided PVB catheter, ultrasound-guided single-injection PVB, or TEA. Measurements and Main Results: Postoperative visual analog scale pain scores (at rest and with knee flexion) and opioid usage were recorded. Pain scores (with movement) for the TEA group were lower than those for either PVB group at 24 hours (p 0.008) and for the PVB catheter group at 48 hours (p = 0.002). Opioid use in TEA group was lower than that for either PVB group at 24 and 48 hours (p < 0.001) and 72 hours (p < 0.05). Single-injection PVB was faster compared with PVB catheter placement (6 min v 12 min; p < 0.001) but similar to TEA (5 min). Patient satisfaction, nausea, sedation, and 6-month postsurgical pain did not differ between groups. Conclusions: TEA led to lower pain scores and opioid requirement for VATS procedures compared with PVB techniques. Single-injection PVB was faster and equally as effective as PVB catheter, and it led to similar patient satisfaction as TEA; therefore, it should be considered in patients who are not ideal candidates for TEA.

The Analgesic Effects of Thoracic Paravertebral Block versus Thoracic Epidural Anesthesia After Thoracoscopic Surgery: A Meta-Analysis

“…Finally, five eligible RCTs were included in the meta-analysis. [14][15][16][17][18] The five eligible articles were carefully reviewed; their characteristics are provided in Table 1. The RCTs enrolled a total of 458 patients, and the results were published between 2015 and 2020.…”

Postoperative analgesia in patients undergoing robot-assisted thoracic surgery: a comparison between thoracic epidural analgesia and intercostal nerve block combined with intravenous patient-controlled analgesia

“…TEA and para-vertebral block (PVB) have been recognized to be two major methods of postoperative analgesia not only for open thoracotomy but also for VATS (18,21,22). Although the incidence of minor side effects such as perioperative hypotension is less with PVB than with TEA, analgesic efficiencies, incidence of major side effects such as hematoma, and patients' outcomes are considered comparable between TEA and PVB (21)(22)(23).…”

Choosing the Best Method for Postoperative Regional Analgesia After Video-Assisted Thoracoscopic Surgery

“…In addition, hypotension and urinary retention were less frequent in the PVB group. In contrast, Yeap et al 12 reported lower pain scores and lower opioid consumption for TEA compared with PVB. Reconciling the study by Yeap et al 12 with the existing evidence presents a challenge because of some heterogeneity in PVB techniques and pain score assessment methods used.…”

“…In this issue of the journal, Yeap et al 12 report on the findings of an interesting study comparing the effectiveness of TEA and PVB for postoperative pain control after VATS. With 3 interventional arms; 2 primary outcomes; and multiple secondary outcomes, including assessment of long-term chronic pain, this study undertook ambitious aims.…”

“…Another interesting point that deserves discussion relates to the PVB technique used in the VATS studies. Yeap et al 12 and Okajima et al 13 used the ultrasound guidance method for PVB, whereas others 7 used only anatomic landmarks. Furthermore, it is possible that placement of the PVB may have not been consistent among studies.…”