Paravertebral Block (PVB) [Neurosurgery Wiki]

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====== Paravertebral Block (PVB) ======

**Ultrasound-Guided Paravertebral Block**

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The paravertebral block involves injecting local anesthetic into the paravertebral space, producing unilateral analgesia across multiple thoracic or lumbar dermatomes.
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🧠 Anatomy

  * **Paravertebral space**:
    * Lateral to the vertebral body and intervertebral foramen
    * Boundaries:
      * Anterior: Parietal pleura
      * Posterior: Superior costotransverse ligament
      * Medial: Vertebral body
      * Lateral: Rib

  * Contents:
    * Spinal nerve (dorsal and ventral roots)
    * Sympathetic chain
    * Fat and connective tissue

🔧 Technique

  * **Patient position**: Sitting or lateral decubitus
  * **Ultrasound**:
    * Linear probe (thoracic), curvilinear for deeper/lumbar levels
    * Parasagittal view, lateral to spinous processes
  * **Landmarks**:
    * Transverse process (hyperechoic line with shadow)
    * Pleura (mobile with respiration)
    * Superior costotransverse ligament (target for needle entry)
  * **Needle**:
    * In-plane, cranial-to-caudal approach
    * Advance through the ligament into the space
  * **Inject**:
    * 10–20 mL of local anesthetic
    * Observe pleural displacement (anterior) or hydrodissection

💉 Indications

  * Thoracic surgery (e.g., VATS, mastectomy)
  * Rib fractures
  * Chronic thoracic pain (e.g., post-herpetic neuralgia)
  * Abdominal or lumbar surgery (for lumbar PVB)

✅ Advantages

  * Strong unilateral analgesia
  * Less risk of hypotension than epidural
  * No significant motor block
  * Suitable for high-risk surgical patients

⚠️ Complications

  * Pneumothorax
  * Vascular puncture
  * Epidural or intrathecal spread
  * Local anesthetic systemic toxicity (LAST)
  * Incomplete block if spread is limited

📊 Comparison</tab>

^ Feature                    ^ PVB                      ^ ESP Block                 ^ Intertransverse Block      ^
| Target                    | Paravertebral space      | Erector spinae plane      | Between transverse processes |
| Nerve coverage            | Dorsal + ventral rami    | Mainly dorsal ± ventral   | Dorsal + ventral (variable) |
| Complexity                | Intermediate             | Easy                      | Moderate                    |
| Pleural puncture risk     | Moderate                 | Low                       | Low                         |
| Spread to sympathetic chain| Yes                     | Rare                      | Possible                    |