Anaesrhesia, 1996, Volume 5 1, pages 137-1 39

Thoracic paravertebral space location

A new method using pressure measurement

J . RICHARDSON, S . P. S. CHEEMA, J . HAWKINS AND S. S A B A N A T H A N

Summary
The major drawback ?fparavertebral space location using the traditional method of’ loss of’ resistance to air or saline is a failure
rate of at least 10%. We inwstigated whether pressure measurement during needle advancement could improtre reliability.
Twenty-nine blocks in 14 awake adult patients undergoing treatment for chronically painful neuralgic conditions of the chest
or abdominal wall were studied. In erector spinae, the mean inspiratory pressure (29.5 mmHg, S D 14.2), e.uceeded the e.upiratory
pressure (19.4 mmHg, SD 9.7). Holcvrw, upon traversing the superior costo-transaerse ligament, there iiws a sudden lowering
of pressures and the mean espiratory pressure (7.6 mmHg, SD 3.7) exceeded the inspiratory pressure (3.3 mniHg, S D 2.9). No
negative pressures were recorded. Correct needle placement H ~ U Sconjrnied bv X ray screening and contrast injection. All blocks
were successful and uncomplicated. Location of the paravertebral space by this objective method ?f ‘pressure inversion’ improces
sensitiaity and specificity and should lead to an improcement in the success rate o f thoracic paraitertebral analgesia.

Key words
Anaesthetic techniques, regional; paravertebral block.

Paravertebral blockade provides effective, safe, unilateral
analgesia, and has been successfully employed in acute and
chronic pain management [I+]. Its major drawback,
however, is a failure rate of at least 10% (Lonnqvist PA,
personal communication), due to a somewhat indistinct loss
of resistance to air or saline, the traditional method of space
location [I]. A substantial improvement in reliability is
therefore needed and we investigated whether pressure
measurement during needle advancement could fulfil this
requirement.
Patients and methods
With local institution ethics committee approval, 14
consenting patients undergoing repeated percutaneous
thoracic paravertebral nerve blocks for chronically painful
neuralgic conditions of the chest or abdominal wall were
studied. Local anaesthesia was used, full aseptic precautions
observed, and patients were placed in the lateral position
with the side to be blocked uppermost. A 16 gauge Tuohy
needle was advanced horizontally onto the transverse
process (2-3 cm lateral to the spinous process), at the
appropriate dermatomal level for distribution of the pain.
A pressure transducer (Medex Medical Inc., Rossendale,
UK), zeroed at the transverse process, was connected via a
saline-filled, non-compliant tube and a three-way tap to the
end of the Tuohy needle. Pressure measurements were
displayed (Datascope 22001, Datascope Corporation,
Paramus, New Jersey, USA) as the needle was advanced
over the top of the transverse process, through erector
spinae, through the superior costo-transverse ligament and
into the areolar tissue of the paravertebral space. The effects
of inspiration and expiration on pressures were recorded, as
were the needle depths from the skin. X ray screening and
contrast injection of 2 ml of Isovist 300 (Schering,
Germany) was used to confirm final needle tip position.
After careful aspiration, 15 ml of 0.5% bupivacaine with
methylprednisolone acetate 80 mg was injected. Successful
placement was confirmed by pinprick testing of the
dermatomal spread at least 20 min after injection, except in
post-thoracotomy patients, in whom prior sensory loss
interfered with assessment.

J. Richardson, MD, MRCP, FRCA. Consultant Anaesthetist, S.P.S. Cheema, FRCA, Senior Registrar in Anaesthetics,
J. Hawkins, FRCA, Senior Registrar in Anaesthetics, S. Sabanathan, MD, FRCS, Cardiothoracic Surgeon, Department of
Anaesthetics and Thoracic Surgery, Bradford Royal Infirmary, Bradford BD9 6RJ.
Accepted 16 May 1995.

0003-2409/96/020137 + 03 $l2.00/0 @ 1996 The Association of Anaesthetists of Gt Britain and Ireland 137
138 J . Richardson et al.
Table 1. Summary of results. Assessment of spread of block excludes patients with post-thorectomy neuralgia.

Intramuscular pressures (mmHg) Paravertebral pressures (mmHg)

mean (range) mean (range)
Injection Dermatomal analgesia
site n Inspiration Expiration Inspiration Expiration Median (range)
T5 2 37.5 (1G65) 31.0 (6-56) 4.0 (2-6) 9.0 ( 6 1 2 ) I
Td 4 31.3 ( 1 4 5 5 ) 21.8 ( 1 s 3 1 ) 6.0 (&16) 9.5 ( 4 2 0 ) I(1-4)
Ti 4 25.3 (9-56) 12.8 (7-26) 1.0 (G2) 6.0 (2-12) 9
T" 3 49.7 (14-70) 27.3 (845) 1.0 (G3) 9.3 (3-19) 5 (1-8)
Tu 5 32.2 (12-73) 25.0 (8-55) 4.8 (&14) 7.8 (3-17) 7.5 (5-1 1)
Tin 10 22.3 (IMO) 14.6 (8-33) 4.2 (C11) 7.0 (3-17) 6 (2-10)
TII 1 8.0 6.0 1.o 3.0 4

Results sensation was six dermatomes (range 1-11). No patient

A total of 29 blocks were performed in seven male and seven
female patients. The mean age and weight were 56 years
(range 3 4 7 7 ) and 75 kg (range 53-110). The aetiology of
the neuralgias for which treatment was administered were:
idiopathic-seven, post-thoracotomy-three, post-nephrec-
tomy-two, post-cholecystectomy-one, malignant infiltra-
tion of the chest wall-one. The segmental level of the
injections ranged from Tsto T I , .In erector spinae, the mean
(SD) inspiratory pressure (29.6 (14.2) mmHg) (Table 1)
exceeded the expiratory pressure (19.4 (9.7) mmHg).
However, upon traversing the superior costo-transverse
ligament. there was a sudden lowering of pressures and
mean (SD) expiratory pressure (7.6 (3.7) mmHg) exceeded
inspiratory pressure (3.3 (2.9) mmHG (Fig. 1)). No negative
pressures were recorded. The mean (SD) depth of the
paravertebral space from the skin was 5 (0.7)cm. X ray
screening confirmed correct needle tip placement in all
patients by demonstrating a cloud-like or longitudinal
streaming of contrast [5]. All blocks produced subjective
pain relief and the median unilateral loss of pinprick
demonstrated haemodynamic instability.
Discussion
Location of the paravertebral space has hitherto relied upon
a loss of resistance technique using either air or saline [I].
Compared to epidural cannulation, where a firm ligamen-
tum flavum is traversed following which there is a sudden
loss of resistance, thoracic paravertebral space location by
this method is subjective and imprecise. False-positive loss
of resistance occurs when the needle tip is radiologically
imbedded in muscle. With needle advancement, penetration
of the thin superior costo-transverse ligament may not be
appreciated, following which false-negative loss of resist-
ance can occur as paravertebral areolar tissue provides
more resistance to air or saline than epidural fat. This
encourages further needle advancement and hence pleural
penetration. In patients who are either tender, obese or very
muscular, prior location of the aiming point of the
transverse process may be impossible. Scar tissue in the

Expiratory pressure (nimHg)

Fig. 1. A scatter plot of the inspiratory and expiratory pressures during 29 successive thoracic paravertebral cannulations. The solid triangles
represent imtramuscular pressures and the open triangles the paravertebral pressures. In all patients an inversion in the respiratory cycling
of pressure occurred upon entry into the paravertebral space.

Anui,.vrhi,siu, Volume 5 I. February 1996


paravertebral space, e.g. in post-thoracotomy neuralgia,
greatly interferes with the appreciation of a loss of
resistance. Even with the aid of X ray screening with
contrast, injection may not always provide clear, readily
identifiable images [ 5 ] . This lack of specificity and sensitivity
contributes to a substantial failure rate.
We have demonstrated sudden lowering of pressures and
pressure inversion as the superior costo-transverse ligament
is breached, providing an easy, objective and reproducible
method of correct space location. In muscle, the pressure is
greater on inspiration than expiration either because erector
spinae is active during inspiration, or because it is
compressed by the expansion of the chest cage against the
elastic confines of the skin. When the needle tip is advanced
beyond muscle, there is a sudden lowering of pressures and
pressure inversion occurs (a sudden swing towards negative
pressure on inspiration) when the paravertebral space is
reached, due to the transmission of increased subatmo-
spheric intrapleural pressure on inspiration. Inadvertent
puncture of the pleura would readily be appreciated as both
inspiratory and expiratory pressures would be subatmo-
spheric. This is important if this block is to be followed by
anaesthesia and ventilation during surgery o r discharge
from hospital in the case of chronic pain day case patients.
Thoracic paracertebral space location 139
We conclude that tactile or radiographic identification of
the paravertebral space should be replaced or supplemented
by pressure monitoring. Sensitivity and specificity is
improved and correct needle placement becomes objective
and reproducible. We hope this modification will encourage
further study of this very useful, but relatively neglected,
method of unilateral afferent blockade.
References
[I] EASONMJ, WYATTR. Paravertebral thoracic block-a
reappraisal. Anaesthesia 1979; 34: 63842.
[2] GIESECKE K, HAMBERCER B, JARNBERG PO, KLINGSTEDT
C.
Paravertebral block during cholecystectomy: effects on
circulatory and hormonal responses. British Journal of
Anaesthesia 1988; 61: 6 5 2 4 .
[3] SABANATHAN S, RICHARDSON, J, MEARNS AF. Management of
pain in thoracic surgery. British Journal of Hospital Medicine
1993; 5 0 11420.
[4] KIRVELA 0, ANTILAH. Thoracic paravertebral block in
chronic postoperative pain. Regional Anaesthesia 1992; 17:
348-50.
[5] LONNQVIST PA, HESSER U. Location of the paravertebral space
in children and adolescents in relation to surface anatomy
assessed by computed tomography. Paediatric Anaesthesia
1992; 2 285-9.
Anaesthesia, Volume 51, February 1996