Paravertebral blocks vs. Intercostal blocks...

[Ligament]

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Hi All,

What are your thoughts on paravertebral blocks vs. intercostal blocks for the treatment of ribalgia and intercostal neuralgia? I've recently been doing some paravertebral blocks with good results and questioning when I should choose either.

 

[Aether2000]

At least 1/3 to 1/2 the time, the paravertebral blocks track epidurally, and that is why a paravertebral chemoneurolysis block should never be performed. The local anesthetic/steroid paravertebral blocks are therefore a combination lateral epidural block plus multilevel intercostal block

 

[Ligament]

Thanks algos. So let's say you do not plan on neurolysis in the future. Which would you go with?

At least 1/3 to 1/2 the time, the paravertebral blocks track epidurally, and that is why a paravertebral chemoneurolysis block should never be performed. The local anesthetic/steroid paravertebral blocks are therefore a combination lateral epidural block plus multilevel intercostal block

 

[Aether2000]

My preference is paravertebral block but effectively one may perform a paravertebral over the top of the TP or TF under the TP and achieve the same effect. The over the top approach enters the paravertebral space posterior to the reflection of the rib, and spreads typically over several vertebral body heights, whereas the TFESI may not spread more than over one intercostal nerve. The extraforaminal approach under the TP effectively gives the same results as a paravertebral block.
Much depends on the pathology. For instance, a rib fracture anterior to the mid axillary line may benefit more from significant spread as in a paravertebral block, extraforaminal block, multiple intercostal blocks, single intercostal high volume block (30cc), or epidural whereas pathology posterior to the axillary line may respond to a single nerve intercostal block or TFESI.

 

[ParaVert]

ligament,

Haven't seen you since Denver, hope you're doing well.

I did tons of these for breast surgery as an anesthesia resident. Even as a blind technique, it almost always works. There is significantly less risk of pneumo vs. intercostals and the analgesia spreads nicely. They might have a good role as a quick, in-office diagnostic block pre-RFTC. And, they should be theoretically safer than thoracic transforaminal in the lower T-spine where Adamkewitz may be lurking.

There was some buzz at last weekend's ASRA meeting over the current lack of procedure code for paravertebral injection. Are people coding this as selective nerve root block or intercostal?