Paravertebral nerve blocks (PVBs) are regional anesthetic techniques that target the paravertebral space (PVS), where spinal nerves emerge from the intervertebral foramina. They allow for segmental, unilateral anesthesia without the sympathectomy and motor blockade seen in neuraxial techniques. To facilitate extubation in the OR and a shorter overall hospital course, I’ll perform these pre-operatively as part of our robotic cardiac surgery procedures.
The paravertebral space (PVS) is bordered by the parietal pleura (anteriorly), superior costotransverse ligament (SCTL, posteriorly), the intercostal space/ribs (laterally), and the vertebral body/intervertebral foramen (medially). Additionally, the erector spinae muscle (ESM) is easily visualized.
There are so many combinations to consider when performing the PVB:
- Positioning: prone, lateral, sitting upright
- Probe: linear or curvilinear
- Probe placement: parasagittal (2-3 cm lateral to midline) or transverse
- Technique: in-plane or out-of-plane
I prefer an in-plane approach to visualize my needle at all times (risk of pneumothorax) using either the transverse or parasagittal approaches (depending on which one provides better sonoanatomy). After confirming correct needle placement with hydrodissection, I’ll inject 15-20 mL of local anesthetic into the PVS looking for depression of the pleura – a telltale sign that I’m indeed in the PVS.
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