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PARAVERTEBRAL BLOCKSIndicationUnilateral procedures involving the trunk or pelvisAnatomyCopyright 2004, Icon Learning Systems, LLC. A subsidiary of MediMedia, USA, Inc. All rights reserved.Copyright 2004, Icon Learning Systems, LLC. A subsidiary of MediMedia, USA, Inc. All rights reserved.The thoracic paravertebral space is defined anterolaterally by the parietal pleura, posteriorly by the superior costotransverse ligament, medially by the vertebra and superiorly and inferiorly by the heads and necks of adjoining ribs.The lumbar paravertebral space is defined anterolaterally by the psoas muscle and medially by the vertebra.Needle22G 100mm Tuohy needle attached with sterile tubing to the syringe containing local anestheticPositionPatient sitting, leaning slightly forward with the chin on the chest to flex the cervical and thoracic spine.ProcedureFind the C7 vertebra. This is the most prominent cervical vertebra in the neck. Mark the superior aspect of C7Working caudally count and mark the vertebrae below.From the mid-point of the superior aspect of each spinous process, measure 2.5cm laterally and mark these points. This will generally overly the caudad portion of the transverse process of the vertebra below.Because of the extreme angulation of the spinous process a line lateral will overly the transverse process of the vertebra below. (i.e. a line lateral to the T3 spinous process overlies the transverse process of T4). This is true till T8 or T9. After prepping the skin, inject the needle insertion site with lidocaine containing epinephrine using a 27G needle. Attempt to contact the transverse process with the 27G needle. This will help judge the depth and position of the transverse process.Insert the Tuohy needle perpendicular to the skin a distance of 2-4cm (more in the obese) to contact the transverse process. If the transverse process is not contacted at an appropriate depth do not go deeper. The needle is likely between two transverse processes. Withdraw the needle and redirect either cephalad or caudad until the transverse process is contacted.Once contact with the transverse process at an appropriate depth is made is made, measure and mark the distance. The depth of the subsequent transverse processes will be approximately the same.If bone is contacted at a point which seems too deep the needle is likely on the rib anterior to the transverse process.The transverse processes of T1 and T2 are slightly deeper due to overlying neck muscles and ligaments.Once the transverse process is contacted the needle is then withdrawn to the skin, and re-inserted to "walk off" the inferior aspect of the transverse process.Once the needle is successfully advanced past the transverse process it should be advanced 1cm in the thoracic spine and 0.5cm in the lumbar spine.After negative aspiration, 5ml of local anesthetic is injected at each level.Local AnestheticRopivacaine 0.5% or 0.75% with 1:400,000 epi, 5-8ml per levelSuggested level of blockade by procedureNeedle localized breast biopsyT2-T4Simple MastectomyT2-T6Radical MastectomyT1-T6Iliac Crest GraftT11, T12, ?L1Inguinal HerniaT11, ?T12, ?L1, L2? = Inject above and below the transverse processCommentsResistance on injection is likely due the needle tip being in the superior costotransverse ligament. The needle should be advanced 1-2mm.The syringe should never be disconnected from the tubing while performing the block. The needle tip can inadvertently be in the pleural cavity, which can cause a pneumothorax if the tubing is opened to air.With adequate subcutaneous injection of lidocaine, this block is not associated with significant discomfort. ................
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