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A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials

2006; Elsevier BV; Volume: 96; Issue: 4 Linguagem: Inglês

10.1093/bja/ael020

1471-6771

Ryan Davies, Paul S. Myles, Jon M. Graham,

Pain Management and Opioid Use

Epidural analgesia is considered by many to be the best method of pain relief after major surgery. It is used routinely in many thoracic surgery centres. Although effective, side-effects include hypotension, urinary retention, incomplete (or failed) block, and, in rare cases, paraplegia. Paravertebral block (PVB) is an alternative technique that may offer comparable analgesic effectiveness and a better side-effect profile. We undertook a systematic review and meta-analysis of all relevant randomized trials comparing PVB with epidural analgesia in thoracic surgery. Data were abstracted and verified by both authors. Studies were tested for heterogeneity, and meta-analyses were done with random effects or fixed effects models. Weighted mean difference (WMD) was used for numerical outcomes and odds ratio (OR) for dichotomous outcomes, both with 95% CI.We identified 10 trials that had enrolled 520 thoracic surgery patients. All of the trials were small (n<130) and none were blinded. There was no significant difference between PVB and epidural groups for pain scores at 4–8, 24 or 48 h, WMD 0.37 (95% CI: −0.5, 121), 0.05 (−0.6, 0.7), −0.04 (−0.4, 0.3), respectively. Pulmonary complications occurred less often with PVB, OR 0.36 (0.14, 0.92). Urinary retention, OR 0.23 (0.10, 0.51), nausea and vomiting, OR 0.47 (0.24, 0.53), and hypotension, OR 0.23 (0.11, 0.48), were less common with PVB. Rates of failed block were lower in the PVB group, OR 0.28 (0.2, 0.6). PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery. Epidural analgesia is considered by many to be the best method of pain relief after major surgery. It is used routinely in many thoracic surgery centres. Although effective, side-effects include hypotension, urinary retention, incomplete (or failed) block, and, in rare cases, paraplegia. Paravertebral block (PVB) is an alternative technique that may offer comparable analgesic effectiveness and a better side-effect profile. We undertook a systematic review and meta-analysis of all relevant randomized trials comparing PVB with epidural analgesia in thoracic surgery. Data were abstracted and verified by both authors. Studies were tested for heterogeneity, and meta-analyses were done with random effects or fixed effects models. Weighted mean difference (WMD) was used for numerical outcomes and odds ratio (OR) for dichotomous outcomes, both with 95% CI. We identified 10 trials that had enrolled 520 thoracic surgery patients. All of the trials were small (n<130) and none were blinded. There was no significant difference between PVB and epidural groups for pain scores at 4–8, 24 or 48 h, WMD 0.37 (95% CI: −0.5, 121), 0.05 (−0.6, 0.7), −0.04 (−0.4, 0.3), respectively. Pulmonary complications occurred less often with PVB, OR 0.36 (0.14, 0.92). Urinary retention, OR 0.23 (0.10, 0.51), nausea and vomiting, OR 0.47 (0.24, 0.53), and hypotension, OR 0.23 (0.11, 0.48), were less common with PVB. Rates of failed block were lower in the PVB group, OR 0.28 (0.2, 0.6). PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery. Thoracotomy and upper abdominal surgery are associated with severe postoperative pain and marked impairment of respiratory function.21Kavanagh BP Katz J Sandler AN Pain control after thoracic surgery. A review of current techniques.Anesthesiology. 1994; 81: 737-759Crossref PubMed Scopus (228) Google Scholar31McMahon AJ Russell IT Ramsay G et al.Laparoscopic and minilaparotomy cholecystectomy: a randomized trial comparing postoperative pain and pulmonary function.Surgery. 1994; 115: 533-539PubMed Google Scholar40Sabanathan S Eng J Mearns AJ Alterations in respiratory mechanics following thoracotomy.J R Coll Surg Edinb. 1990; 35: 144-150PubMed Google Scholar Postoperative analgesia regimens often include a regional anaesthetic technique because complete analgesia with a single agent or method may not be possible.13Eng J Sabanathan S Post-thoracotomy analgesia.J R Coll Surg Edinb. 1993; 38: 62-68PubMed Google Scholar Epidural analgesia with local anaesthetic, opioid, or both has become commonplace and has been regarded as the ‘gold standard’.48Wildsmith JA Developments in local anaesthetic drugs and techniques for pain relief.Br J Anaesth. 1989; 63: 159-164Crossref PubMed Scopus (22) Google Scholar A survey of analgesic techniques, after thoracotomy, in Australian hospitals showed that 79% of respondents regarded epidural blockade as the best available technique.6Cook TM Riley RH Analgesia following thoracotomy: a survey of Australian practice.Anaesth Intensive Care. 1997; 25: 520-524PubMed Google Scholar A similar survey of UK practice, after upper abdominal surgery, found that 80% of anaesthetists considered epidural analgesia to be the best mode of pain relief.5Cook TM Eaton JM Goodwin AP Epidural analgesia following upper abdominal surgery: United Kingdom practice.Acta Anaesthesiol Scand. 1997; 41: 18-24Crossref PubMed Scopus (27) Google Scholar Epidural blockade has been shown to reduce the intraoperative surgical stress response and has possible advantages for cardiovascular, respiratory, coagulation, gastrointestinal, metabolic and immune function.25Liu S Carpenter RL Neal JM Epidural anesthesia and analgesia; their role in postoperative outcome.Anesthesiology. 1995; 82: 1474-1506Crossref PubMed Scopus (941) Google Scholar39Rigg JRA Does regional block improve outcome after surgery?.Anesth Intensive Care. 1991; 19: 404-411PubMed Google Scholar However, thoracic epidurals can cause hypotension, neurological injury,15Grant RP Con: every postthoracotomy patient does not deserve thoracic epidural analgesia.J Cardiothorac Vasc Anesth. 1999; 13: 355-357Abstract Full Text PDF PubMed Scopus (19) Google Scholar and are contra-indicated in the presence of coagulopathy or local sepsis. Thoracic paravertebral block (PVB) has enjoyed a resurgence in recent years.36Richardson J Lonnqvist PA Thoracic paravertebral block.Br J Anaesth. 1998; 81: 230-238Crossref PubMed Scopus (225) Google Scholar The paravertebral space is a wedge-shaped space that lies to the side of the vertebral column and contains the spinal (intercostal) nerve, the dorsal ramus, the rami communicantes and the sympathetic chain.29Macintosh RR Bryce-Smith R Local Analgesia–Abdominal Surgery. 2nd Edn. Livingstone, Edinburgh1962Google Scholar Placement of local anaesthetic within the paravertebral space produces unilateral somatic and sympathetic block, which is advantageous for unilateral surgical procedures of the chest and abdomen.19Karmakar MK Thoracic paravertebral block.Anesthesiology. 2001; 95: 771-780Crossref PubMed Scopus (403) Google Scholar The classic technique described for PVB is a posterior approach using loss of resistance to air or saline as the superior costotransverse ligament is traversed.11Eason MJ Wyatt R Paravertebral thoracic block—a reappraisal.Anaesthesia. 1979; 34: 638-642Crossref PubMed Scopus (303) Google Scholar Recent modifications to this technique have utilized a nerve stimulator.23Lang SA The use of a nerve stimulator for thoracic paravertebral block.Anesthesiology. 2002; 97: 521Crossref PubMed Scopus (3) Google Scholar47Wheeler LJ Peripheral nerve stimulation end-point for thoracic paravertebral block.Br J Anaesth. 2001; 86: 598-599PubMed Google Scholar Alternatively, catheters can be placed in the paravertebral space intraoperatively under direct vision by the surgeon before chest closure.1Berrisford RG Sabanathan SS Direct access to the paravertebral space at thoracotomy.Ann Thorac Surg. 1990; 49: 854Abstract Full Text PDF PubMed Scopus (36) Google Scholar42Sabanathan S Smith PJ Pradhan GN Hashimi H Eng JB Mearns AJ Continuous intercostal nerve block for pain relief after thoracotomy.Ann Thorac Surg. 1988; 46: 425-426Abstract Full Text PDF PubMed Scopus (114) Google Scholar The literature can be confusing, as the technique has been described by several different terms: PVB; continuous intercostal nerve block; extrapleural intercostal nerve block; extrapleural PVB; and retropleural analgesia.20Karmakar MM Critchley L Continuous extrapleural intercostal nerve block for post thoracotomy analgesia in children.Anaesth Intensive Care. 1998; 26: 115-116PubMed Google Scholar However, it has been demonstrated radiologically, that the site of action of local anaesthetic via an extrapleural intercostal catheter is primarily via the paravertebral space.14Eng J Sabanathan S Site of action of continuous extrapleural intercostal nerve block.Ann Thorac Surg. 1991; 51: 387-389Abstract Full Text PDF PubMed Scopus (52) Google Scholar Proponents of PVB claim it is simple, safe, easy to learn, and with a low incidence of complications.19Karmakar MK Thoracic paravertebral block.Anesthesiology. 2001; 95: 771-780Crossref PubMed Scopus (403) Google Scholar26Lonnqvist PA MacKenzie J Soni AK Conacher ID Paravertebral blockade. Failure rate and complications.Anaesthesia. 1995; 50: 813-815Crossref PubMed Scopus (307) Google Scholar32Naja Z Lonnqvist PA Somatic paravertebral nerve blockade. Incidence of failed block and complications.Anaesthesia. 2001; 56: 1184-1188Crossref PubMed Scopus (269) Google Scholar43Sabanathan S Has postoperative pain been eradicated?.Ann R Coll Surg Engl. 1995; 77: 202-209PubMed Google Scholar The safety of paravertebral infusions allows management of these patients on the surgical wards, often avoiding the need for high dependency or intensive care beds that may be felt necessary for patients with thoracic epidurals.4Conacher ID Post-thoracotomy analgesia.Anesthesiol Clin North America. 2001; 19: 611-625Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar44Thomas PW Sanders D Sweeting CJ Berrisford RG In defence of paravertebral blockade.Br J Anaesth. 2002; 88: 743PubMed Google Scholar Paravertebral blockade is an appealing option in patients in whom epidural analgesia may be contra-indicated (local sepsis, coagulopathy, pre-existing neurological disease and difficult thoracic spine anatomy). Many studies have shown thoracic PVB to be an effective form of analgesia after thoracotomy, multiple fractured ribs, major breast surgery and inguinal hernia repair.19Karmakar MK Thoracic paravertebral block.Anesthesiology. 2001; 95: 771-780Crossref PubMed Scopus (403) Google Scholar41Sabanathan S Richardson J Shah R Continuous intercostal nerve block for pain relief after thoracotomy. Updated in 1995.Ann Thorac Surg. 1995; 59: 1261-1263Abstract Full Text PDF PubMed Scopus (30) Google Scholar A narrative review of pain control techniques after thoracic surgery concluded that it was impossible to determine from the available literature whether paravertebral blockade is useful for postoperative analgesia after thoracotomy.21Kavanagh BP Katz J Sandler AN Pain control after thoracic surgery. A review of current techniques.Anesthesiology. 1994; 81: 737-759Crossref PubMed Scopus (228) Google Scholar A recent editorial in this journal concluded that the best methods of pain relief after thoracotomy would have to be sought from evidence-based anaesthesia.45Vaughan RS Pain relief after thoracotomy.Br J Anaesth. 2001; 87: 681-683Crossref PubMed Scopus (12) Google Scholar We therefore performed a meta-analysis of randomized trials comparing thoracic PVB with epidural analgesia, to evaluate efficacy and safety. A systematic review of relevant randomized trials comparing PVB with epidural analgesia for postoperative pain relief was undertaken. The MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials were searched by two of the authors using the following combinations of search terms: paravertebral, extrapleural intercostal, continuous intercostal, epidural, extradural, and peridural. No language restrictions were applied. The papers were retrieved to identify relevant studies for inclusion in the meta-analysis. The reference lists of these papers were scrutinized to identify further relevant studies. In addition, we contacted some known researchers in the field. Reports were included if the study was a randomized trial comparing PVB with thoracic epidural analgesia in thoracic surgery, and including administration of a local anaesthetic agent. Lumbar epidural block and epidural opioid-only regimens were excluded. All methods of insertion of PVB (whether before operation by the anaesthetist or intraoperatively by the surgeon) were included. All studies were examined to identify parameters that could be compared between papers. Data from the studies were independently checked by two of the authors (R.G.D. and P.S.M.). If data were not available from the original publication, the authors were contacted via email to request this information. We were able to compare the following variables between studies: pain scores at 4–8 h,2Bigler D Dirkes W Hansen R Rosenberg J Kehlet H Effects of thoracic paravertebral block with bupivacaine versus combined thoracic epidural block with bupivacaine and morphine on pain and pulmonary function after cholecystectomy.Acta Anaesthesiol Scand. 1989; 33: 561-564Crossref PubMed Scopus (43) Google Scholar3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar8De Cosmo G Aceto P Campanale E et al.Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: Effects on pain relief, pulmonary function and patient satisfaction.Acta Med Rom. 2002; 40: 340-347Google Scholar10Dhole S Mehta Y Saxena H Juneja R Trehan N Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar30Matthews PJ Govenden V Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy.Br J Anaesth. 1989; 62: 204-205Crossref PubMed Scopus (97) Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar 24 h,3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar8De Cosmo G Aceto P Campanale E et al.Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: Effects on pain relief, pulmonary function and patient satisfaction.Acta Med Rom. 2002; 40: 340-347Google Scholar18Kaiser AM Zollinger A De Lorenzi D Largiader F Weder W Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.Ann Thorac Surg. 1998; 66: 367-372Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar30Matthews PJ Govenden V Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy.Br J Anaesth. 1989; 62: 204-205Crossref PubMed Scopus (97) Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar46Wedad M Zaki MK Haleem M The effect of addition of wound infiltration with local anaesthetics to interpleural block on post-thoracotomy pain, pulmonary function and stress response in comparison to thoracic epidural and paravertebral block.Eg J Anaesth. 2004; 20: 67-72Google Scholar 48 h;3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar8De Cosmo G Aceto P Campanale E et al.Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: Effects on pain relief, pulmonary function and patient satisfaction.Acta Med Rom. 2002; 40: 340-347Google Scholar18Kaiser AM Zollinger A De Lorenzi D Largiader F Weder W Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.Ann Thorac Surg. 1998; 66: 367-372Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar46Wedad M Zaki MK Haleem M The effect of addition of wound infiltration with local anaesthetics to interpleural block on post-thoracotomy pain, pulmonary function and stress response in comparison to thoracic epidural and paravertebral block.Eg J Anaesth. 2004; 20: 67-72Google Scholar mean dose of opioids at 24 and 48 h;18Kaiser AM Zollinger A De Lorenzi D Largiader F Weder W Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.Ann Thorac Surg. 1998; 66: 367-372Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar46Wedad M Zaki MK Haleem M The effect of addition of wound infiltration with local anaesthetics to interpleural block on post-thoracotomy pain, pulmonary function and stress response in comparison to thoracic epidural and paravertebral block.Eg J Anaesth. 2004; 20: 67-72Google Scholar number of patients requiring supplemental analgesia;2Bigler D Dirkes W Hansen R Rosenberg J Kehlet H Effects of thoracic paravertebral block with bupivacaine versus combined thoracic epidural block with bupivacaine and morphine on pain and pulmonary function after cholecystectomy.Acta Anaesthesiol Scand. 1989; 33: 561-564Crossref PubMed Scopus (43) Google Scholar3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar10Dhole S Mehta Y Saxena H Juneja R Trehan N Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar technique failure;2Bigler D Dirkes W Hansen R Rosenberg J Kehlet H Effects of thoracic paravertebral block with bupivacaine versus combined thoracic epidural block with bupivacaine and morphine on pain and pulmonary function after cholecystectomy.Acta Anaesthesiol Scand. 1989; 33: 561-564Crossref PubMed Scopus (43) Google Scholar10Dhole S Mehta Y Saxena H Juneja R Trehan N Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar18Kaiser AM Zollinger A De Lorenzi D Largiader F Weder W Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.Ann Thorac Surg. 1998; 66: 367-372Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar respiratory function at 24 and48 h;3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar8De Cosmo G Aceto P Campanale E et al.Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: Effects on pain relief, pulmonary function and patient satisfaction.Acta Med Rom. 2002; 40: 340-347Google Scholar18Kaiser AM Zollinger A De Lorenzi D Largiader F Weder W Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.Ann Thorac Surg. 1998; 66: 367-372Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar46Wedad M Zaki MK Haleem M The effect of addition of wound infiltration with local anaesthetics to interpleural block on post-thoracotomy pain, pulmonary function and stress response in comparison to thoracic epidural and paravertebral block.Eg J Anaesth. 2004; 20: 67-72Google Scholar urinary retention;2Bigler D Dirkes W Hansen R Rosenberg J Kehlet H Effects of thoracic paravertebral block with bupivacaine versus combined thoracic epidural block with bupivacaine and morphine on pain and pulmonary function after cholecystectomy.Acta Anaesthesiol Scand. 1989; 33: 561-564Crossref PubMed Scopus (43) Google Scholar8De Cosmo G Aceto P Campanale E et al.Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: Effects on pain relief, pulmonary function and patient satisfaction.Acta Med Rom. 2002; 40: 340-347Google Scholar18Kaiser AM Zollinger A De Lorenzi D Largiader F Weder W Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.Ann Thorac Surg. 1998; 66: 367-372Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar30Matthews PJ Govenden V Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy.Br J Anaesth. 1989; 62: 204-205Crossref PubMed Scopus (97) Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar nausea and vomiting;3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar8De Cosmo G Aceto P Campanale E et al.Comparison between epidural and paravertebral intercostal nerve block with ropivacaine after thoracotomy: Effects on pain relief, pulmonary function and patient satisfaction.Acta Med Rom. 2002; 40: 340-347Google Scholar10Dhole S Mehta Y Saxena H Juneja R Trehan N Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar hypotension;3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar10Dhole S Mehta Y Saxena H Juneja R Trehan N Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar30Matthews PJ Govenden V Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy.Br J Anaesth. 1989; 62: 204-205Crossref PubMed Scopus (97) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Crossref PubMed Scopus (243) Google Scholar respiratory depression;3Bimston DN McGee JP Liptay MJ Fry WA Continuous paravertebral extrapleural infusion for post-thoracotomy pain management.Surgery. 1999; 126: 650-656Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar10Dhole S Mehta Y Saxena H Juneja R Trehan N Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2001; 15: 288-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar24Leaver A Yeomans M Shelton A Opie J Graham J A randomised trial comparing thoracic epidural with paravertebral blocks for postoperative analgesia after pneumonectomy. 2006Google Scholar35Perttunen K Nilsson E Heinonen J Hirvisalo EL Salo JA Kalso E Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain.Br J Anaesth. 1995; 75: 541-547Crossref PubMed Scopus (129) Google Scholar38Richardson J Sabanathan S Jones J Shah RD Cheema S Mearns AJ A prospective, randomized