Paravertebral Block (PVB)
Ultrasound-Guided Paravertebral Block
The paravertebral block involves injecting local anesthetic into the paravertebral space, producing unilateral analgesia across multiple thoracic or lumbar dermatomes.
🧠 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 |