Authors' objectives:

The objective of this review was to make recommendations on the safety and efficacy of thoracic and lumbar paravertebral blocks (PVB) on the basis of a systematic assessment of the peer-reviewed literature. Paravertebral blocks for surgical anaesthesia were compared to general anaesthesia or other regional anaesthetic techniques, while the postoperative analgesia provided by paravertebral blocks was compared to regional blocks or analgesic drugs.

Authors' results and conclusions: A relatively large evidence base of reasonable quality (57 studies including 15 RCTs and describing over one thousand PVB procedures) was available for this systematic review of paravertebral block. However the ability to draw firm conclusions was limited by the high number of indications (two for anaesthesia and nine for analgesia), and the diversity of outcomes and how they were measured. In addition, although nine RCTs of analgesia using PVB were located, the comparators were thoracic epidural block (3 trials), no additional intraoperative analgesia (2 trials),morphine (1 trial), interpleural local anaesthetic (1 trial), nerve block (1 trial) and one trial compared bolus and continuous PVB. For anaesthesia, PVB seems to be a safe procedure which substantially reduces nausea and vomiting in comparison to general anaesthesia (GA), although there is a small risk of pleural and vascular punctures and epidural spread with PVB. While clearly any form of regional block will have more failures than GA, the PVB failure rate was no higher than 20% and patients were more satisfied with PVB than with GA. There was some indication that PVB could achieve shorter hospital stays than GA, but this was poorly reported in the studies. For analgesia, PVB appears to result in about the same degree of effective block as other forms of regional analgesia. The results for pain relief and nausea and vomiting were not as clear, due to limited evidence, however PVB appeared to be as effective and safe as the comparators. As for anaesthesia, there is a small risk of punctures and epidural spread, which would increase if multiple PVB procedures were required (for example, in treating chronic pain). There was little information about the technical difficulty or learning curve for PVB, and no information was available which compared the costs of PVB with GA for anaesthesia, or PVB with local analgesia. However a very small amount of cost data from two studies indicated that between about A$500 to 1,000 could be saved by avoiding an overnight stay after PVB.

Authors' recommendations: On the basis of the evidence presented in this systematic review, The ASERNIP-S Review Group agreed on the following classifications and recommendations concerning the safety and efficacy of paravertebral block for anaesthesia and analgesia: Classifications Evidence rating The evidence-base in this review is rated as average. Safety Paravertebral blocks at the level of the thoracic and lumbar vertebrae are at least as safe as (1) general anaesthesia and other regional anaesthetic techniques for anaesthesia during surgery, and (2) analgesic drugs and other regional blocks for analgesia postoperatively. Efficacy Paravertebral blocks at the level of the thoracic and lumbar vertebrae are at least as effective as (1) general anaesthesia and other regional anaesthetic techniques for anaesthesia during surgery, and (2) analgesic drugs and other regional blocks for analgesia postoperatively. Clinical and Research Recommendations PVB is an advanced technique, which requires a degree of expertise and competence. It is recommended that anaesthetists wishing to use the PVB technique undergo appropriate training and supervised instruction until competent, and there should be ongoing audit of their performance. Additional high quality, prospective randomised controlled trials would strengthen the evidence base for the PVB technique. Cost-effectiveness studies, taking into consideration the Australian healthcare context should also be considered.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.surgeons.org/Content/NavigationMenu/Research/ASERNIPS/default .htm

Year Published: 2006

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Australia

Organisation Name: Australian Safety and Efficacy Register of New Interventional Procedures-Surgical

Contact Address: ASERNIP-S 24 King William Street, Kent Town SA 5067 Australia Tel: +61 8 8219 0900

Contact Name: racs.asernip@surgeons.org

Contact Email: racs.asernip@surgeons.org

Copyright: Australian Safety and Efficacy Register of New Interventional Procedures - Surgical