Complications of Paravertebral, Intercostal Nerve Blocks and Interpleural Analgesia

  • Nirmala R. Abraham Hidalgo
  • F. Michael Ferrante


Paravertebral, intercostal nerve blocks and interpleural analgesia are used to provide intermittent, temporary, or continuous anesthesia or analgesia in the thoracic and abdominal regions. These regional techniques may be appropriate alternatives to the standard methods of providing analgesia (i.e., epidural analgesia, intravenous opioids) for selected groups of patients. These analgesic techniques have been used to treat pain related to thoracotomy,1,2 rib fractures,3, 4, 5 trauma,6 and chronic pain.7 In recent years, utilization of these techniques has been extended to include breast surgery,8,9 shoulder surgery,10,11 laparoscopic cholecystectomy,12 and inguinal hernia repair.13 Paravertebral blocks have recently been described as an effective means of providing analgesia after hepatectomy.14


Nerve Block Intercostal Nerve Parietal Pleura Postoperative Pain Management Thoracic Epidural Analgesia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Concha M, Dagnino J, Cariaga M, Aguilera J, Aparicio R, Guerrero M. Analgesia after thoracotomy: epidural fentanyl/bupivacaine compared with intercostals nerve block plus intravenous morphine. J Cardiothorac Vase Anesth 2004;18(3):322–326.CrossRefGoogle Scholar
  2. 2.
    Taylor R, Massey S, Stuart-Smith K. Postoperative analgesia in video-assisted thoracoscopy: the role of intercostal blockade. J Cardiothorac Vasc Anesth 2004;18(3):317–321.PubMedCrossRefGoogle Scholar
  3. 3.
    Karmakar MK, Critchley LAH, Ho AM-H, Gin T, Lee TW, Yim APC. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest 2003;123:424–431.PubMedCrossRefGoogle Scholar
  4. 4.
    Karmakar MK, Ho AM-H. Acute pain management of patients with multiple fractured ribs. J Trauma 2003;54:615–625.PubMedCrossRefGoogle Scholar
  5. 5.
    Osinowo OA, Zahrani M, Softah A. Effect of intercostal nerve block with 0.5% bupivacaine on peak expiratory flow rate and arterial oxygen saturation in rib fractures. J Trauma 2004;56:345–347.PubMedCrossRefGoogle Scholar
  6. 6.
    Gilbert J, Hultman J. Thoracic paravertebral block: a method of pain control. Acta Anaesthesiol Scand 1989;33:142–145.PubMedCrossRefGoogle Scholar
  7. 7.
    Johnson LR, Rocco AG, Ferrante FM. Continuous subpleural-paravertebral block in acute thoracic herpes zoster. Anesth Analg 1988;67:1105–1108.PubMedGoogle Scholar
  8. 8.
    Kairaluoma PM, Bachmann MS, Korpinen AK, Rosenberg PH, Pere PJ. Single-injection paravertebral block before general anesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy. Anesth Analg 2004;99(6): 1837–1843.PubMedCrossRefGoogle Scholar
  9. 9.
    Naja MZ, Ziade MF, Lonnqvist PA. Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. Eur J Anaesthesiol 2003;20(ll):897–903.PubMedCrossRefGoogle Scholar
  10. 10.
    Koorn R, Tenhundfeld-Fear KM, Miller C, Boezaart A. The use of cervical paravertebral block as the sole anesthetic for shoulder surgery in a morbid patient: a case report. Reg Anesth Pain Med 2004;29(3):227–229.PubMedGoogle Scholar
  11. 11.
    Boezaart AP, de Beer J F, Nell M. Early experience with continuous cervical paravertebral block using a stimulating catheter. Reg Anesth Pain Med 2003;28(5):406–413.PubMedGoogle Scholar
  12. 12.
    Naja MZ, Ziade MF, Lonnqvist PA. General anaesthesia combined with bilateral paravertebral blockade (T5-6) vs. general anaesthesia for laparoscopic cholecystectomy: a pro-spective, randomized clinical trial. Eur J Anaesthesiol 2004;21(6):489–495.PubMedGoogle Scholar
  13. 13.
    Weltz CR, Klein SM, Arbo JE, Greengrass RA. Paravertebral block anesthesia for inguinal hernia repair. World J Surg 2003;27(4):425–429.PubMedCrossRefGoogle Scholar
  14. 14.
    Ho AM-H, Karmakar MK, Cheung M, Lam GCS. Right thoracic paravertebral analgesia for hepatectomy. Br J Anaesth 2004;93(3):458–461.PubMedCrossRefGoogle Scholar
  15. 15.
    Matthews PJ, Govenden V. Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy. Br J Anaesth 1989;62:204–205.PubMedCrossRefGoogle Scholar
  16. 16.
    Tenicela R, Pollan SB. Paravertebral-peridural block technique: a unilateral thoracic block. Clin J Pain 1990;6(3):227–234.PubMedCrossRefGoogle Scholar
  17. 17.
    Engberg G. Relief of postoperative pain with intercostal blockade compared with the use of narcotic drugs. Acta Anaesthesiol Scand 1978;suppl 70:36–38.Google Scholar
  18. 18.
    Engberg G. Respiratory performance after upper abdominal surgery. A comparison of pain relief with intercostal blocks and centrally acting analgesics. Acta Anaesthesiol Scand 1985;29:427–433.PubMedCrossRefGoogle Scholar
  19. 19.
    Purcell-Jones G, Pither CE, Justins DM. Paravertebral somatic nerve block: a clinical, radiographic, and computed tomographic study in chronic pain patients. Anesth Analg 1989;68:32–39.PubMedCrossRefGoogle Scholar
  20. 20.
    Conacher ID, Kokri M. Postoperative paravertebral blocks for thoracic surgery. A radiological appraisal. Br J Anaesth 1987;59:155–161.PubMedCrossRefGoogle Scholar
  21. 21.
    Mowbray A, Wong KKS, Murray JM. Intercostal catheterization: an alternative approach to the paravertebral space. Anaesthesia 1987;42:958–961.PubMedCrossRefGoogle Scholar
  22. 22.
    Cheema S, Richardson J, McGurgan P. Factors affecting the spread of bupivacaine in the adult thoracic paravertebral space. Anaesthesia 2003;58:684–711.PubMedCrossRefGoogle Scholar
  23. 23.
    Conacher ID. Resin injection of thoracic paravertebral spaces. Br J Anaesth 1988;61: 657–661.PubMedCrossRefGoogle Scholar
  24. 24.
    Naja MZ, Ziade MF, El Rajab M, El Tayara K, Lonnqvist PA. Varying anatomical injection points within the thoracic paravertebral space: effect on spread of solution and nerve blockade. Anaesthesia 2004;59:459–463.PubMedCrossRefGoogle Scholar
  25. 25.
    Asato F, Goto F. Radiographic findings of unilateral epidural block. Anesth Analg 1996;3:519–522.Google Scholar
  26. 26.
    Wooley EJ, Vandam LD. Neurological sequelae of brachial plexus nerve block. Ann Surg 1959;149(1):53.CrossRefGoogle Scholar
  27. 27.
    Moore DC. Regional Block: A Handbook for Use in the Clinical Practice of Medicine and Surgery. 4th ed. Springfield, IL: Charles C Thomas; 1965:200.Google Scholar
  28. 28.
    Shaw WM. Medial approach for paravertebral somatic nerve block. JAMA 1952;148(9): 742–744.Google Scholar
  29. 29.
    Eason MJ, Wyatt R. Paravertebral thoracic block — a reappraisal. Anaesthesia 1979;34: 638–642.PubMedCrossRefGoogle Scholar
  30. 30.
    Naja Z, Lonnqvist PA. Somatic paravertebral nerve blockade: incidence of failed block and complications. Anaesthesia 2001;56:1184–1188.PubMedCrossRefGoogle Scholar
  31. 31.
    Garutti I, Hervias M, Barrio JM, Fortea F, de la Torre J. Subdural spread of local anesthetic agent following thoracic paravertebral block and cannulation. Anesthesiology 2003;98(4):1005–1007.PubMedCrossRefGoogle Scholar
  32. 32.
    Sharrick NE. Postural headache following thoracic somatic paravertebral nerve block. Anesthesiology 1980;52:360–362.CrossRefGoogle Scholar
  33. 33.
    Selander D, Shuner K-G, Lundborg G. Peripheral nerve injury due to injection needles used for regional anesthesia. Acta Anaesthesiol Scand 1977;21:182–188.PubMedCrossRefGoogle Scholar
  34. 34.
    Moore DC, Hain RF, Ward A, Bridenbaugh DL. Importance of the perineural spaces in nerve blocking. JAMA 1954;156(1):1050–1054.Google Scholar
  35. 35.
    Selander D, Sjostrand J. Longitudinal spread of intraneurally injected local anesthetics: an experimental study of the initial neural distribution following intraneural injections. Acta Anaesthesiol Scand 1978;22:622–634.PubMedCrossRefGoogle Scholar
  36. 36.
    Angerer AL, Su Hu, Head JR. Death following the use of Efocaine: report of a case. JAMA 1954;153(4):329–330.Google Scholar
  37. 37.
    Brittingham TE, Berlin LN, Wolff HG. Nervous system damage following paravertebral block with Efocaine: report of three cases. JAMA 1953;154(4):608–609.Google Scholar
  38. 38.
    Shapiro SK, Norman DD. Neurologic complications following the use of Efocaine. JAMA 1953;152(7):608–609.Google Scholar
  39. 39.
    Jurgens PE. A study of Efocaine. Anesthesiology 1955;16:615, 622.PubMedCrossRefGoogle Scholar
  40. 40.
    McKnight CK, Marshall M. Monoplatythela and paravertebral block. Anaesthesia 1984; 39:1147.PubMedCrossRefGoogle Scholar
  41. 41.
    Finucane BT, Terblanche OC. Prolonged duration of anesthesia in a patient with multiple sclerosis following paravertebral block. Can J Anaesth 2005;52(5):493–497.PubMedCrossRefGoogle Scholar
  42. 42.
    Debreceni G, Molnar Z, Szelig L, Molnar TF. Continuous epidural or intercostal analgesia following thoracotomy: a prospective randomized double-blind clinical trial. Acta Anaesthesiol Scand 2003;47:1091–1095.PubMedCrossRefGoogle Scholar
  43. 43.
    Roviaro GC, Varoli F, Fascianella A, et al. Intrathoracic intercostal nerve block with phenol in open chest surgery: a randomized study with statistical evaluation of respiratory parameters. Chest 1986;90(l):64–67.PubMedCrossRefGoogle Scholar
  44. 44.
    Maiwand MO, Makey AR, Rees A. Cryoanalgesia after thoracotomy: improvement of technique and review of 600 cases. J Thorac Cardiovasc Surg 1986;92:291–295.PubMedGoogle Scholar
  45. 45.
    Tucker GT, Moore DC, Bridenbaugh PO, Bridenbaugh LD, Thompson GE. Systemic absorption of mepivacaine in commonly used regional block procedures. Anesthesiology 1972;37:277.PubMedCrossRefGoogle Scholar
  46. 46.
    Nunn JL, Slavin G. Posterior intercostal nerve block for pain relief after cholecystectomy: anatomical basis and efficacy. Br J Anaesth 1980;52:253–259.PubMedCrossRefGoogle Scholar
  47. 47.
    O’Kelly E, Garry B. Continuous pain relief for multiple fractured ribs. Br J Anaesth 1981; 53:989–991.CrossRefGoogle Scholar
  48. 48.
    Sabanathan S, Beckford-Smith PJ, Pradhan GN, et al. Continuous intercostal nerve block for pain relief after thoracotomy. Ann Thorac Surg 1988;46:425–426.PubMedCrossRefGoogle Scholar
  49. 49.
    Sabanathan S, Mearns AJ, Beckford-Smith PJ, et al. Efficacy of continuous extrapleural nerve block on post-thoracotomy pain. Br J Surg 1990;77:221–225.PubMedCrossRefGoogle Scholar
  50. 50.
    Moore DC, Bridenbaugh DL. Intercostal nerve block in 4333 patients. Anesth Analg 1962;41(1):1–11.PubMedCrossRefGoogle Scholar
  51. 51.
    Moore DC, Bridenbaugh DL. Pneumothorax: its incidence following intercostal nerve block. JAMA 1962;182:1005–1008.Google Scholar
  52. 52.
    Moore DC. Intercostal nerve block for postoperative somatic pain following surgery of thorax and upper abdomen. Br J Anaesth 1975;47:284–286.PubMedGoogle Scholar
  53. 53.
    Nielsen CH. Bleeding after intercostal nerve block in a patient anticoagulated with heparin. Anesthesiology 1989;71:162–164.PubMedCrossRefGoogle Scholar
  54. 54.
    Cory PC, Mulroy MF. Postoperative respiratory failure following intercostal block. Anesthesiology 1981;54:418–419.PubMedCrossRefGoogle Scholar
  55. 55.
    Casey WF. Respiratory failure following intercostal nerve blockade. Anaesthesia 1984; 39:351–354.PubMedCrossRefGoogle Scholar
  56. 56.
    Gallo JA Jr, Lebowitz PW, Battit GE, Bruner JMR. Complications of intercostal nerve blocks performed under direct vision during thoracotomy: a report of two cases. J Thorac Cardiovasc Surg 1983;86(4):628–630.PubMedGoogle Scholar
  57. 57.
    Gauntlett IS. Total spinal anesthesia following intercostal nerve block. Anesthesiology 1986;65(l):82–84.PubMedCrossRefGoogle Scholar
  58. 58.
    Berrisford RG, Sabanathan SS. Direct access to the paravertebral space at thoracotomy. Ann Thorac Surg 1990;49:854.PubMedCrossRefGoogle Scholar
  59. 59.
    Friesen D, Robinson RH. Total spinal anesthesia — a complication of intercostal nerve block. Kans Med 1987;88(3):84–85.PubMedGoogle Scholar
  60. 60.
    Atkinson GL, Shupak RC. Acute bronchospasm complicating intercostal nerve block. Anesth Analg 1989;68:400–401.PubMedCrossRefGoogle Scholar
  61. 61.
    Reiestad F, Stromskag KE. Interpleural catheter in the management of postoperative pain. A preliminary report. Reg Anaesth 1986;11:89–91.Google Scholar
  62. 62.
    El-Naggar MA. Bilateral intrapleural regional analgesia for postoperative pain control: a dose-finding study. J Cardiothorac Anesth 1989;3(5):574–579.PubMedCrossRefGoogle Scholar
  63. 63.
    Reiestad F, Mcllvaine WB, Kvalheim L, et al. Interpleural analgesia in treatment of upper extremity reflex sympathetic dystrophy. Anesth Analg 1989;69:671–673.PubMedGoogle Scholar
  64. 64.
    Reiestad F, McIlvaine WB, Kvalheim L, et al. Successful treatment of chronic pancreatitis with interpleural analgesia. Can J Anaesth 1989;36(6):713–716.PubMedCrossRefGoogle Scholar
  65. 65.
    Durrani Z, Winnie AP, Ikuta P. Interpleural catheter analgesia for pancreatic pain. Anesth Analg 1988;67:479–481.PubMedCrossRefGoogle Scholar
  66. 66.
    Blake DW, Donnan G, Novella J. Interpleural administration of bupivacaine after cholecystectomy: a comparison with intercostal nerve block. Anaesth Intensive Care 1989;17: 269–274.PubMedGoogle Scholar
  67. 67.
    Bachmann-Mennenga B, Boscoping J, Kuhn DFM, et al. Intercostal nerve block, interpleural analgesia, thoracic epidural block or systemic opioid application for pain relief after thoracotomy? Eur J Cardiothorac Surg 1993;7:12–18.PubMedCrossRefGoogle Scholar
  68. 68.
    Mehta Y, Swaminathan M, Mishra Y, Trehan N. A comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vase Anesth 1998;12(2):162–165.CrossRefGoogle Scholar
  69. 69.
    Ben-David B. The falling column: a new technique for interpleural catheter placement. Anesth Analg 1990;71:212.PubMedCrossRefGoogle Scholar
  70. 70.
    Squier RC, Morrow JS, Roman R. Hanging drop technique for intrapleural analgesia. Anesthesiology 1989;70:882.PubMedCrossRefGoogle Scholar
  71. 71.
    Brismar B, Pettersson N, Tokics L, et al. Postoperative analgesia with intrapleural administration of bupivacaine-adrenaline. Acta Anaesthesiol Scand 1987;31:515–517.PubMedCrossRefGoogle Scholar
  72. 72.
    El-Naggar MA, Schaberg FJ Jr, Phillips MR. Intrapleural regional analgesia for pain management in cholecystectomy. Arch Surg 1989;124:568–570.PubMedGoogle Scholar
  73. 73.
    Riegler X, VadeBoncouer TR, Pelligrino DA. Interpleural anesthetics in the dog: differential somatic neural blockade. Anesthesiology 1989;71:744–750.PubMedCrossRefGoogle Scholar
  74. 74.
    Stromskag KE, Hauge O, Steen PA. Distribution of local anesthetics injected into the interpleural space, studied by computerized tomography. Acta Anaesthesiol Scand 1990; 34:323–326.PubMedCrossRefGoogle Scholar
  75. 75.
    Stromskag KE, Minor B, Steen PA. Side effects and complications related to interpleural analgesia: an update. Acta Anaesthesiol Scand 1990;34:473–477.PubMedCrossRefGoogle Scholar
  76. 76.
    Symreng T, Gomez MN, Johnson B, et al. Intrapleural bupivacaine — technical considerations and intraoperative use. J Cardiothorac Anesth 1989;3(2):139–143.PubMedCrossRefGoogle Scholar
  77. 77.
    El-Naggar MA, Bennet B, Raad C, Yogartnam G. Bilateral intrapleural intercostal nerve block. Anesth Analg 1988;67:S57.CrossRefGoogle Scholar
  78. 78.
    Parkinson SK, Mueller JB, Rich TJ, Little WL. Unilateral Horner’s syndrome associated with interpleural catheter injection of local anesthetic. Anesth Analg 1989;68:61–62.PubMedGoogle Scholar
  79. 79.
    Lauder GT. Interpleural analgesia and phrenic nerve paralysis. Anaesthesia 1993; 48:315–316.PubMedCrossRefGoogle Scholar
  80. 80.
    Ferrante FM, Chan VW, Arthur R, Rocco AG. Interpleural analgesia after thoracotomy. Anesth Analg 1991;72:105–109.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Nirmala R. Abraham Hidalgo
    • 1
    • 2
  • F. Michael Ferrante
    • 1
    • 2
  1. 1.Department of AnesthesiologyDavid Geffen School of Medicine at University of California-Los AngelesSanta MonicaUSA
  2. 2.UCLA Pain and Spine CareDavid Geffen School of Medicine at University of California-Los AngelesSanta MonicaUSA

Personalised recommendations