Paravertebral Block versus Thoracic Epidural Analgesia for Postthoracotomy Pain Relief: A Meta-Analysis of Randomized Trials

2021 ◽  
Author(s):  
Mu Xu ◽  
Jiajia Hu ◽  
Jianqin Yan ◽  
Hong Yan ◽  
Chengliang Zhang
Keyword(s):  
Side Effects ◽  
Pain Relief ◽  
Epidural Analgesia ◽  
Meta Analysis ◽  
Thoracic Epidural Analgesia ◽  
Paravertebral Block ◽  
Cochrane Library ◽  
Thoracic Epidural ◽  
Analgesic Consumption ◽  
Postthoracotomy Pain

Abstract Objective Paravertebral block (PVB) and thoracic epidural analgesia (TEA) are commonly used for postthoracotomy pain management. The purpose of this research is to evaluate the effects of TEA versus PVB for postthoracotomy pain relief. Methods A systematic literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library (last performed on August 2020) to identify randomized controlled trials comparing PVB and TEA for thoracotomy. The rest and dynamic visual analog scale (VAS) scores, rescue analgesic consumption, the incidences of side effects were pooled. Results Sixteen trials involving 1,000 patients were included in this meta-analysis. The pooled results showed that the rest and dynamic VAS at 12, 24, and rest VAS at 48 hours were similar between PVB and TEA groups. The rescue analgesic consumption (weighted mean differences: 3.81; 95% confidence interval [CI]: 0.982–6.638, p < 0.01) and the incidence of rescue analgesia (relative risk [RR]: 1.963; 95% CI: 1.336–2.884, p < 0.01) were less in TEA group. However, the incidence of hypotension (RR: 0.228; 95% CI: 0.137–0.380, p < 0.001), urinary retention (RR: 0.392; 95% CI: 0.198–0.776, p < 0.01), and vomiting (RR: 0.665; 95% CI: 0.451–0.981, p < 0.05) was less in PVB group. Conclusion For thoracotomy, PVB may provide no superior analgesia compared with TEA but PVB can reduce side effects. Thus, individualized treatment is recommended. Further study is still necessary to determine which concentration of local anesthetics can be used for PVB and can provide equal analgesic efficiency to TEA.

A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy

2010 ◽  
Vol 1 (1) ◽  
pp. 12-23 ◽  
Author(s):  
Hilde M. Norum ◽  
Harald Breivik
Keyword(s):  
Spinal Cord ◽  
Pain Relief ◽  
Epidural Analgesia ◽  
Local Anaesthetic ◽  
Analgesic Efficacy ◽  
Thoracic Epidural Analgesia ◽  
Paravertebral Block ◽  
Nerve Blocks ◽  
Paravertebral Space ◽  
Thoracic Epidural

AbstractBackgroundThe “gold standard” for pain relief after thoracotomy has been thoracic epidural analgesia (TEA). The studies comparing TEA with paravertebral block (PVB) and recent reviews recommend PVB as a novel, safer method than TEA.MethodsA systematic search of the Cochrane and PubMed databases for prospective, randomized trials (RCTs) comparing TEA and PVB for post-thoracotomy analgesia was done. We assessed how TEA and PVB were performed, methods of randomization, assessment of pain relief, and complications. Abstracts only were excluded.ResultsTen studies were included, comprising 224 patients randomized to TEA, 243 to PVB. The studies were heterogeneous. Therefore, a systematic narrative review with our evaluations is presented.Only 3/10 trials reported the method of randomization. Pain during coughing was reported in only 5/10, pain assessment not specified in 5/10. Only 1/10 trials found PVB superior to TEA, but placed TEA catheters too low (<T7). TEA was superior to PVB in 1/10, during first 1.5 days. PVB and TEA were equally effective in 8/10. 5/10 trials found PVB had less hypotension or urinary retention. None of the studies used appropriate and optimal TEA: TEA was started after end of surgery in half, catheters placed too low (2/10), too high (1/10), not reported in (1/10). 7/10 infused local anaesthetic only, 2/10 added fentanyl, 1/10 added morphine, and none added adrenaline. PVB infusions had higher concentration of bupivacaine (5 mg/ml) in 2/10, 1/10 added fentanyl, 1/10 added ornipressin. Loading doses were higher in 5/10, and with more concentrated solutions in 5/10 of PVB than in the TEA group.Conclusions10 heterogeneous, mostly small, studies comparing TEA and PVB for post-thoracotomy analgesia do not allow conclusions on which method has superior analgesic efficacy and safety. The main methodological problem was that none of the studies use optimal thoracic epidural analgesia, with siting of catheters inappropriate in some and the epidural infusion containing too concentrated local anaesthetic because opioid and adrenaline were not added. Anatomical considerations (the paravertebral space comprises parts of the epidural space and contains spinal cord arteries) and personally experienced complications with PVB (paraplegia) convince us that PVB must have higher risk of, infrequent but serious, spinal cord complications than TEA. Percutaneous PVB may puncture pleura and lung.Some surgeons expressed satisfaction with PVB because the method omits costly acute pain services for monitoring on surgical wards and saves time in the operating room. They are, however, bound to experience serious complications from PVB, sooner or later.To our knowledge, optimally conducted epidural analgesia has not been compared with PVB. Current literature and our experience with both techniques for up to four decades, indicate that PVB may be an alternative for post-thoracotomy pain when TEA is infeasible for various patient-related reasons (Breivik et al., 2009). Severely disturbed haemostasis is a contraindication for PVB and TEA. Higher concentrations of local anaesthetics are needed to obtain intercostal nerve blocks and epidural analgesia with PVB, risking local anaesthetic intoxication. Robust monitoring regimen for effects and adverse effects is as important for PVB as for TEA.

Patient with Postthoracotomy Pain

2017 ◽  
Author(s):  
Jianguo Cheng ◽  
Olivia T Cheng
Keyword(s):  
Spinal Cord ◽  
Epidural Analgesia ◽  
Spinal Cord Stimulation ◽  
Pain Syndrome ◽  
Intercostal Nerve ◽  
Thoracic Epidural Analgesia ◽  
Intercostal Nerve Block ◽  
Thoracic Epidural ◽  
Postthoracotomy Pain ◽  
Intravenous Analgesia

Pain due to thoracotomy is among the most severe pain experienced after surgery. It has both neuropathic and myofascial components. About 50% of patients suffer from chronic postthoracotomy pain 1 year after surgery. Thoracic paravertebral block or thoracic epidural analgesia is recommended as the first-choice therapy for thoracotomy analgesia.  Preoperatively initiated thoracic epidural analgesia is associated with better pain control and decreased incidence (and intensity) of chronic postthoracotomy pain compared with postoperative (epidural or intravenous) analgesia. Compared with inhalation anesthesia, total intravenous anesthesia significantly reduced the incidence of chronic postthoracotomy pain syndrome, which is notoriously challenging to treat. Gabapentinoids and antidepressants may be beneficial for the neuropathic component of chronic postthoracotomy pain syndrome. A pregabalin and methylcobalamin combination has been shown to be safe and effective in the treatment of chronic postthoracotomy pain, with minimal side effects. Interventional therapies such as intercostal nerve block or ablation, spinal cord stimulation, and targeted subcutaneous neuromodulation may be indicated in more refractory and debilitating cases. This review contains 1 table, and 57 references. Key words: chronic postthoracotomy pain, cryoneurolysis, intercostal nerve block, open thoracotomy surgery, paravertebral block, postthoracotomy pain, postthoracotomy pain syndrome, spinal cord stimulation, thoracic epidural analgesia, thoracotomy, total intravenous analgesia, video-assisted thoracoscopic surgery

Postoperative Analgesia after Radical Retropubic Prostatectomy

2006 ◽  
Vol 105 (4) ◽  
pp. 784-793 ◽  
Author(s):  
Anil Gupta ◽  
Federica Fant ◽  
Kjell Axelsson ◽  
Dag Sandblom ◽  
Jan Rykowski ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Relief ◽  
Epidural Analgesia ◽  
Short Form ◽  
Radical Retropubic Prostatectomy ◽  
Thoracic Epidural Analgesia ◽  
Short Form 36 ◽  
Thoracic Epidural ◽  
Retropubic Prostatectomy ◽  
Intravenous Analgesia

Background Postoperative pain after radical retropubic prostatectomy can be severe unless adequately treated. Low thoracic epidural analgesia and patient-controlled intravenous analgesia were compared in this double-blind, randomized study. Methods Sixty patients were randomly assigned to receive either low thoracic epidural analgesia (group E) or patient-controlled intravenous analgesia (group P) for postoperative pain relief. All patients had general anesthesia combined with thoracic epidural analgesia during the operation. Postoperatively, patients in group E received an infusion of 1 mg/ml ropivacaine, 2 microg/ml fentanyl, and 2 microg/ml adrenaline, 10 ml/h during 48 h epidurally, and a placebo patient-controlled intravenous analgesia pump intravenously. Patients in group P received a patient-controlled intravenous analgesia pump with morphine intravenously and 10 ml/h placebo epidurally. Pain, the primary outcome variable, was measured using the numeric rating scale at rest (incision pain and "deep" visceral pain) and on coughing. Secondary outcome variables included gastrointestinal function, respiratory function, mobilization, and full recovery. Health-related quality of life was measured using the Short Form-36 questionnaire, and plasma concentration of fentanyl was measured in five patients to exclude a systemic effect of fentanyl. Results Incisional pain and pain on coughing were lower in group E compared with group P at 2-24 h, as was deep pain between 3 and 24 h postoperatively (P &lt; 0.05). Maximum expiratory pressure was greater in group E at 4 and 24 h (P &lt; 0.05) compared with group P. No difference in time to home discharge was found between the groups. The mean plasma fentanyl concentration varied from 0.2 to 0.3 ng/ml during 0-48 h postoperatively. At 1 month, the scores on emotional role, physical functioning, and general health of the Short Form-36 were higher in group E compared with group P. However, no group x time interaction was found in the Short Form-36. Conclusions The authors found evidence for better pain relief and improved expiratory muscle function in patients receiving low thoracic epidural analgesia compared with patient-controlled analgesia for radical retropubic prostatectomy. Low thoracic epidural analgesia can be recommended as a good method for postoperative analgesia after abdominal surgery.

Continuous Thoracic Epidural Analgesia for Postoperative Pain Relief Following Thoracotomy

1987 ◽  
Vol 67 (5) ◽  
pp. 787-791 ◽  
Author(s):  
WILLIAM G. LOGAS ◽  
NABIL EL-BAZ ◽  
ABDEL EL-GANZOURI ◽  
MARC CULLEN ◽  
EDGAR STAREN ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Relief ◽  
Epidural Analgesia ◽  
Thoracic Epidural Analgesia ◽  
Postoperative Pain Relief ◽  
Thoracic Epidural
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