Single Thoracic Paravertebral Block

Patient Position: Sitting up across the bed with a stool placed under the feet for stability.

Indications: Anesthesia and immediate postoperative analgesia for inguinal hernia, prostatectomy, and hysterectomy.

Needle size: 22-gauge, 79-mm Tuohy needle.

Volume: 5 mL 0.5% ropivacaine per segment.

Anatomic Landmarks:
The paravertebral space is a wedge-shaped space on either side of the
vertebral column. Boundaries: anteriorly—parietal pleura;
medially—vertebral body, intervertebral discs, and intervertebral
foramen; posteriorly—superior costotransverse ligament. The spinous
process is the main bony landmark for this block.

Approach and Technique:
The spinous processes are palpated and marked with the skin marker. The
insertion points are marked 2.5 cm lateral to the superior border of
the spinal process and infiltrated with local anesthetic. Then the
Tuohy needle is placed perpendicular to the skin with bevel up and
advanced up to 3 to 5 cm (Fig. 22-1).
When the transverse process is found, the needle is pulled back to the
skin and redirected caudally to walk off the inferior aspect or the
transverse process, and is then advanced 1.0 cm past the premeasured
skin-to-bone distance until a “pop” through the superior
costotransverse ligament is appreciated. After the stylet is removed
from the needle, the syringe with 0.5% ropivacaine is connected to the
needle by extension tubing.

After negative aspiration, 5 ml of local anesthetic is injected at each level to be blocked.

Patient Position: The patient is sitting and is asked to assume the exaggerated kyphotic position.

Indications: Inguinal hernia surgery.

Needle Size: 22-gauge, 100-mm, b-beveled insulated needle.

Volume: 10 ml per level for inguinal hernia surgery, 5 ml per level for bilateral inguinal hernia surgery.

Anatomic Landmarks:
The paravertebral space is triangular in shape and bound medially by
the contiguous epidural space via the intervertebral foramen. The
posterior wall of the paravertebral space is made up of the anterior
costotransverse ligament. The anterior costotransverse ligament extends
between the rib and transverse process in the thoracic region. The
intercostal nerves and vessels are located in front of the ligament.
The anterior and lateral borders of the paravertebral space are defined
by the parietal pleura.

Approach and Technique:
The superior aspect of the iliac crest is identified and a line is
drawn to identify the spinous process of L4. Counting in a cephalad
direction from L4, T11 and L2 are identified. The site of introduction
of the needle is marked 2.5 cm lateral to the superior aspect of their
respective spinous processes. Next, the skin is cleaned with
chlorhexidine. This is followed by a local anesthesia with 5 ml
lidocaine 1% at T11 and L2. A 22-gauge insulated needle attached to a
nerve stimulator (3 to 5 mA, 2 Hz, 1.0 ms) is advanced in a
posterior-anterior direction approximately 10° to 20° lateral until it
touches the transverse process, or a stimulation of the external and
internal oblique muscles, the transverse abdominal muscles, and the
rectus abdominis is elicited. If the transverse process is contacted,
the needle is “walked off” caudad at T11 and cephalad at L2 and
advanced until the proper stimulation is elicited. After correct
positioning of the needle the local anesthetic solution is slowly
injected after negative aspiration for blood.