Ann Thorac Surg 1995;59:1261-1263
© 1995 The Society of Thoracic Surgeons
Update
Continuous Intercostal Nerve Block for Pain Relief after Thoracotomy
As Originally Published in 1988:
Updated in 1995 by Sabaratnam Sabanathan, FRCS, Jonathan Richardson, FRCA, and Rajesh Shah, FRCS
Department of Thoracic Surgery, Bradford Royal Infirmary, Bradford, England
We have demonstrated the effectiveness of continuous intercostal nerve block for postthoracotomy analgesia in which a catheter is placed in the paravertebral space under direct vision by the surgeon before chest closure [1]. Prospective, randomized, double-blind, placebo-controlled trials confirmed the efficacy of this method not only in relieving postoperative pain after thoracotomy but also in reducing the early loss of postoperative pulmonary function, more rapidly restoring pulmonary mechanics, and minimizing postoperative pulmonary complications [2, 3] (Table 1
).
The mechanism of action of the continuous extrapleural intercostal nerve block is via the paravertebral spread of local anaesthetic [9] (Table 2). Intercostal nerves, their collateral branches and posterior primary rami, and the thoracic sympathetic chain all pass through the paravertebral space, making it an ideal site for blockade of the various afferent nociceptive nerve impulses [3]. Spread of a mean of six dermatomes (range, five to seven) has been demonstrated by injection of methylene blue at thoracotomy and infusion of contrast medium in postoperative patients [9]. Paravertebral block is comparable with epidural block in respect to pain relief but without the well-known side effects of the epidural analgesia [5] (see Table 1
). Effective perioperative analgesia with continuous extrapleural intercostal nerve block also has been demonstrated to reduce the incidence of chronic postthoracotomy neuralgia [8].
We have built on our basic technique in two ways that have been made possible by our greater understanding of the pathophysiology of pain [12]. We believe that preemptive analgesia is of utmost importance in major surgical procedures, and therefore all patients about to undergo thoracotomy receive a percutaneous paravertebral block followed by continuous extrapleural intercostal nerve block postoperatively [12]. Careful observation of the efficacy of the percutaneous preincisional block using 15 mL of 0.5% bupivacaine has demonstrated a mean somatic block of five dermatomes (range, one to eight) and a mean sympathetic block of eight dermatomes (range, six to ten) [11]. The second development, which has been very important, is the use of balanced analgesia beginning preoperatively and consisting of opiate premedication combined with nonsteroidal antiinflammatory premedication [12]. In a recently concluded study, we were able to demonstrate that a balanced analgesic regimen comprising preoperative pain prophylaxis and postoperative maintenance analgesia by nonsteroidal antiinflammatory drugs and continuous extrapleural intercostal nerve block resulted in total afferent blockade (both somatic and sympathetic) after thoracotomy [7]. The expected postoperative decline in lung function was demonstrated not to be obligatory but is due primarily to incisional pain and thus is preventable by effective analgesia [7].
The technique of insertion of extrapleural cannula has been described previously [1, 13]. The essential steps are as follows. At the end of operation, the parietal pleura is raised from the posterior chest wall up to the vertebral bodies from two intercostal spaces above and below the thoracotomy incision, exposing the paravertebral space. A small defect is made in the extrapleural fascia into the paravertebral space using Lahey's forceps. A percutaneously inserted cannula is passed through the defect into the paravertebral space under direct vision and advanced 2 to 3 cm to lie against the costovertebral joints. The pleura is reattached, if possible, and the paravertebral space is infused for 5 days with 0.5% bupivacaine at a rate of 0.1 mL/kg body weight per hour with an on-line bacterial filter.
Footnotes
Address reprint requests to Dr Sabanathan, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
References
- Sabanathan S, Bickford-Smith PJ, Pradhan GN, Hashimi H, Eng J-B, Mearns AJ. Continuous intercostal nerve block for pain relief after thoracotomy. Ann Thorac Surg 1988;46:425–6.[Abstract]
- Berrisford RG, Sabanathan S, Mearns AJ, Bickford-Smith PJ. Pulmonary complications after lung resection: the effect of continuous extrapleural intercostal nerve block. Eur J Cardiothorac Surg 1990;4:407–11.[Abstract]
- Sabanathan S, Mearns AJ, Bickford Smith PJ, et al. Efficacy of continuous extrapleural intercostal nerve block on post-thoracotomy pain and pulmonary mechanics. Br J Surg 1990;77:221–5.[Medline]
- Mozell EJ, Sabanathan S, Mearns AJ, Bickford-Smith PJ, Majid MR, Zografos G. Continuous extrapleural intercostal nerve block after pleurectomy. Thorax 1991;46:21–4.[Abstract/Free Full Text]
- Richardson J, Sabanathan S, Eng J-B, et al. Comparison between continuous epidural morphine and extrapleural bupivacaine for relief of post thoracotomy pain. Ann Thorac Surg 1993;55:377–80.[Abstract]
- Richardson J, Sabanathan S, Rogers C. Thoracotomy wound exploration in a single lung transplantation recipient under extrapleural paravertebral nerve blockade. Eur J Anaesthesiol 1993;10:135–6.[Medline]
- Richardson J, Sabanathan S, Mearns AJ, Evans C, Bembridge J, Fairbrass M. Efficacy of pre-emptive analgesia and continuous intercostal nerve block on post-thoracotomy pain and pulmonary mechanics. J Cardiovasc Surg 1994;35:219–28.[Medline]
- Richardson J, Sabanathan S, Mearns AJ, Sides C, Goulden CP. Post-thoracotomy neuralgia. Pain Clinic 1994;7:87–97.
- Eng J-B, Sabanathan S. Site of action of continuous extrapleural intercostal nerve block. Ann Thorac Surg 1991;51:387–9.[Abstract]
- Berrisford RG, Sabanathan S, Mearns AJ, Clarke BJ, Hamdi A. Plasma concentrations of bupivacaine and its enantiomers during continuous extrapleural intercostal nerve block. Br J Anaesth 1993;70:201–4.[Abstract/Free Full Text]
- Cheema SPS, Ilsley D, Richardson J, Sabanathan S. A thermographic study of paravertebral analgesia. Anaesthesia 1995;50:118–21.[Medline]
- Sabanathan S, Richardson J, Mearns AJ. Management of pain in thoracic surgery. Br J Hosp Med 1993;50:114–20.[Medline]
- Berrisford RG, Sabanathan S. Direct access to the paravertebral space at thoracotomy [Letter]. Ann Thorac Surg 1990;49:854.[Medline]
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