Thoracic-paravertebral blocks: comparative anatomical study with different injection techniques and volumes

We hypothesized that different injection techniques and volumes in thoracic-paravertebral blocks (TPVB) lead to different patterns of dye spread. In particular, we investigated whether an alternating injection technique leads to complete staining of all adjacent intercostal nerves.

This comparative anatomical investigation was performed using 10 or 20 mL of dye (Alcian Blue) in 10 unfixed donor cadavers (54 injections) that were designated for education or research purposes.

In landmark-guided TPVB, the thoracic-paravertebral space (TPVS) was either not stained at all (spread of dye in the paraspinal muscles, n=3) or the dye was predominantly found in the epidural space (n=3). In ultrasound-guided TPVB, the TPVS was correctly identified in all cases (n=48). The sympathetic trunk was stained in 84.6% of injections (multi-injection technique: 100%), independent of injection technique and volume. The epidural space was stained more frequently (p≤0.001) if both the puncture site (sagittal transducer position) and guidance of the needle were more medial (77.8%). Finally, a higher injection volume (20 vs 10 mL) resulted in a higher number of stained intercostal nerves (p=0.04).

For ultrasound-guided techniques, a higher injection volume resulted in a larger number of stained intercostal nerves. Staining of the sympathetic trunk was independent of the injection technique. Epidural spread was observed significantly less frequently if the injection was lateral (transducer transversal) or with a strictly cranial injection direction (transducer sagittal). Landmark-guided injections reliably achieved the TPVS (and the epidural space) only after a needle advance of 2.5 cm after initial contact with the transverse process.