It has been well documented that a paravertebral block (PVB) reduces the stress response in patients with breast cancer, and PVB has been used in various surgical procedures and for the management of chronic pain.1 PVB is a form of regional anesthesia and was first performed by Hugo Sellheim of Leipzig, Germany in 1905 as a replacement for spinal anesthesia.2 The literature describes PVB being used in the thoracic and lumbar regions in a unilateral and bilateral fashion. PVB may be used for multiple surgical procedures, including, but not limited to, thoracotomy, laparoscopic or open cholecystectomy, colectomy, gastrectomy, abdominal and inguinal hernia repairs, appendectomy, transurethral prostatectomy, hip replacement, and total knee replacement.3 At The University of Texas MD Anderson Cancer Center, we primarily use PVB for breast cancer–related surgeries, including mastectomies, axillary dissections, and breast reconstruction.
The thoracic paravertebral space is the space on each side of the vertebrae. For breast surgery, we use the T1 through T6 paravertebral spaces. Anterolaterally, the space is formed by parietal pleura; medially, the space is formed by the vertebral body, intervertebral disk, and intervertebral foramen; and posteriorly, the space is formed by the superior costotransverse ligament. The intercostal space is lateral to the paravertebral space and contains the intercostal nerve, and the epidural space is medial to it. In the paravertebral space, the spinal nerves are not covered by the fascial sheath.4
PVB is used for unilateral and bilateral breast surgery, as well as postmastectomy breast reconstruction. To be candidates for undergoing PVB, patients have to meet certain minimum requirements. First, the surgical field should not exceed the area being covered by the block. Second, the anesthesiologist, the surgeon, and the patient should agree on the necessity of the block. The patient's anatomy should be compatible with the block, as discussed below. We also routinely perform PVB in patients who are undergoing bilateral mastectomies with breast tissue expander placements (Figs. 52-1 and 52-2).
Patient positioning for the block.
In an attempt to be time efficient, placement of the PVB is performed in the preoperative holding area.4 During the actual placement of the paravertebral block, the patient is fully monitored (oxygen saturation as measured by pulse oximetry, electrocardiogram, noninvasive blood pressure with supplemental oxygen) with resuscitation and intubation equipment immediately available if necessary.4 At MD Anderson Cancer Center, we routinely block the Thoracic 1 (T1) through Thoracic 6 (T6) paravertebral spaces for many of our breast surgical procedures (eg, modified radical mastectomy, total mastectomy, axillary dissections, cosmetic breast surgical procedure such as tissue expanders, breast augmentation with implants, and mastopexy). Most of the patients who undergo PVB also receive a general anesthetic during surgery. The PVB ...