Analgesia for minimally invasive thoracic surgery: comparing thoracic paravertebral to erector spinae plane block-a...

Minimally invasive thoracic surgery (MITS) has become the primary approach for the vast majority of thoracic surgeries, facilitating improved recovery. Still, control of postoperative pain is challenging, which can substantially threaten recovery. Prophylactic thoracic paravertebral block (TPVB) is a common approach to facilitate analgesia after MITS. Recently, erector spinae plane block (ESPB) has been widely employed as a technically easier alternative. It is still unclear which technique is associated with lower postoperative opioid administration and faster recovery.

In this analysis utilizing hospital registry data, patients who underwent MITS and received either TPVB or ESPB at Beth Israel Deaconess Medical Center between 2020 and 2024 were eligible for inclusion. We excluded patients with American Society of Anesthesiologists (ASA) physical status classification>IV, patients with known pregnancy, and patients undergoing trauma surgery or procedures in addition to one-sided MITS. The primary outcome was opioid consumption in the postanesthesia care unit (PACU), assessed by cumulative oral morphine equivalents (OME). Secondary outcomes included the time to first opioid administration, PACU length of stay (LOS), and hospital LOS. Multivariable negative binomial regression analysis was applied, adjusting for patient and procedural characteristics.

A total of 404 patients were included in the final study cohort (283 ESPB and 121 TPVB), receiving a median (IQR) of 25.5 mg OME (15.0-42.5) in the PACU. After adjustment, patients receiving TPVB required 9.4 mg less OME (95% CI -15.7 to -3.0, p<0.01) when compared with ESPB. The predicted time to first opioid administration was 11.4 min shorter for TPVB (95% CI 1.3 to 21.5, p=0.03). Adjusted analyses revealed a 118 min shorter LOS in the PACU (95% CI -216 to -20, p=0.02) and 1.2 fewer days in the hospital (95% CI -1.6 to -0.7, p<0.001) for patients receiving TPVB.

TPVB compared with ESPB for MITS was associated with decreased opioid use in PACU and shorter PACU and hospital LOS. These findings provide a rationale for prospective trials to investigate factors contributing to enhanced postoperative recovery with TPVB as compared with ESPB.