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Ann Thorac Surg 2000;69:975-976
© 2000 The Society of Thoracic Surgeons

Correspondence

Extrapleural intercostal nerve block

Jonathan A. Richardson, FRCAa, Alan J. Mearns, FRCSa

a Anaesthesia Department, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, England BD9 6RJ, England, UK

To the Editor

We read with interest the paper by Watson and colleagues, "Pain Control After Thoracotomy: Bupivacaine Versus Lidocaine in Continuous Extrapleural Intercostal Nerve Blockade" (Ann Thorac Surg 1999;67:825–9), and we congratulate them on an interesting and useful study. We ourselves, in a busy thoracic surgical unit, have an approximately 13-year experience with the technique, which has involved many hundreds of patients and many clinical studies [1]. We value this opportunity to comment on an aspect of their work.

On studying the text and their diagrams (Figs 1 to 3) in relation to performance of the technique, we are concerned that catherization may have taken place somewhat too laterally. We have always believed, right from the original description of the technique [2], that insertion of the catheter so that it lies alongside the vertebral column is necessary. The reason for this is that it is important to block not only the anterior ramus of the intercostal nerve (which would have been blocked in the description by Watson and colleagues), but also the posterior ramus and the sympathetic chain [3]. These structures will less reliably be blocked if local anesthetic is placed at some distance from the vertebral bodies [4], and the result can be unrelieved back and shoulder pain, respectively [3].

In a number of studies, we have examined the mode of action and the efficacy of extrapleural intercostal nerve blockade. Blockade of intercostal nerves appears to take place in the paravertebral space [5]. In the paravertebral gutter, but not more laterally [6], spread of local anesthetic can take place freely to involve a larger number of dermatomes than the surgically effected defect in the extrapleural fascia (usually two dermatomes above and two below the level of the thoracotomy) [4]. This is important if chest drain pain (especially if placed lower in the chest than the thoracotomy wound) is to be avoided. If all the neurologic structures mentioned above are blocked, the quality of afferent inhibition can be profound and is potentially greater than any other form of regional anesthesia for the trunk, including epidural and spinal anesthesia [4, 7]. With the excellent analgesia that can be obtained, the high degree of preservation of preoperative lung function postoperatively, and the ease of the technique and its relative lack of contraindications, side effects, and complications, we look upon continuous extrapleural intercostal nerve blocks as the regional analgesic method of choice for thoracotomy pain relief. We welcome the contribution of Watson and colleagues.

References

  1. Sabanathan S., Richardson J., Shah R. Continuous intercostal nerve block for pain relief after thoracotomy. Ann Thorac Surg 1995;59:1261-1263.[Free Full Text]
  2. Sabanathan S., Bickford Smith P.J., Pradhan G.N., Hashimi H., Eng J.B., Mearns A.J. Continuous intercostal nerve block for pain relief after thoracotomy. Ann Thorac Surg 1988;46:425-426.[Abstract]
  3. Sabanathan S., Richardson J., Mearns A.J. Management of pain in thoracic surgery. Br J Hosp Med 1993;50:114-120.[Medline]
  4. Richardson J., Lönnqvist P.A. Thoracic paravertebral blockade. A review. Br J Anaesth 1998;81:230-238.[Free Full Text]
  5. Eng J., Sabanathan S. Site of action of continuous extrapleural intercostal nerve block. Ann Thorac Surg 1991;51:387-389.[Abstract]
  6. Johansson A., Renck H., Aspelin P., Jacobsen H. Multiple intercostal blocks by single injection? A clinical and radiological investigation. Acta Anaesthesiol Scand 1985;29:524-528.[Medline]
  7. Richardson J., Jones J., Atkinson R. The effect of thoracic paravertebral blockade on somato-sensory evoked potentials. Anesth Analg 1998;87:373-376.[Abstract/Free Full Text]




This Article
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Alan J. Mearns
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