Is paravertebral block the new standard of care for postoperative analgesia after thoracoscopic surgery?
Editorial Commentary

Is paravertebral block the new standard of care for postoperative analgesia after thoracoscopic surgery?

Alberto Aiolfi1 ORCID logo, Davide Bona1 ORCID logo, Galyna Shabat2 ORCID logo, Marco Resta3 ORCID logo, Luigi Bonavina2 ORCID logo

1Division of General Surgery, Department of Biomedical Science for Health, IRCCS Galeazzi-Sant’Ambrogio, University of Milan, Milan, Italy; 2Division of General and Foregut Surgery, Department of Biomedical Science for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy; 3Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, Anesthesiology and Intensive Care Unit, University of Milan, Milan, MI, Italy

Correspondence to: Luigi Bonavina, MD, FACS (Hon). Division of General and Foregut Surgery, Department of Biomedical Science for Health, IRCCS Policlinico San Donato, University of Milan, Via Festa del Perdono, 7, 20122 Milano, MI, Italy. Email:

Comment on: Wu Z, Wang Q, Wu C, et al. Paravertebral vs Epidural Anesthesia for Video-assisted Thoracoscopic Surgery: A Randomized Trial. Ann Thorac Surg 2023;116:1006-12.

Keywords: Paravertebral block (PVB); analgesia; epidural analgesia; postoperative pain

Submitted Dec 13, 2023. Accepted for publication Feb 26, 2024. Published online Apr 10, 2024.

doi: 10.21037/jtd-23-1896

Effective pain control is critical for quick recovery of patients undergoing video-assisted thoracoscopic surgery (VATS). Thoracoscopy has improved but not eliminated the need of sustained analgesia in patients undergoing surgery for both lung and esophageal disease. Yet, 25–45% of patients are estimated to experience at least moderate pain requiring escape medication in the form of intravenous opioids even beyond postoperative day 4 (1,2). Postoperative chest pain is multifactorial and associated with the intercostal, sympathetic, vagus, and phrenic nerve pathways. Inadequate analgesia delays patient recovery and prolongs hospital stay. When not appropriately prevented and treated, pain results in a higher risk of developing atelectasis and pneumonia (3). Nowadays, regional anesthesia techniques in combination with multimodal systemic analgesia are the preferred options for patients undergoing minimally invasive lung and esophageal surgical procedures. For a long time, thoracic epidural analgesia (TEA) has represented the gold standard of care in these patients. However, despite a more extended sensory block compared to the paravertebral block (PVB), TEA can fail for technical reasons in up to 15–30% of patients (4-6) and is associated with hypotension and risk of neurological complications (7). A Cochrane review showed moderate-quality evidence of comparable efficacy between TEA and PVB after thoracotomy, and fewer minor side-effects associated with PVB (8). PVB remains a reasonable alternative to TEA, but relatively few comparative studies have assessed its efficacy in the setting of VATS (9,10).

The authors of this randomized clinical trial (11) should be commended for their effort to improve the technique of surgeon-guided video-assisted PVB and to compare this method to TEA. In short, they showed that creation of an extra pleural pocket just lateral to the sympathetic chain under VATS guidance can facilitate the placement of a paravertebral catheter and can help to secure it to avoid early dislodgment. A total of 176 patients diagnosed with a solitary pulmonary nodule and eligible for a three-port thoracoscopy were included in the PVB group (n=88) and TEA group (n=88), respectively. The groups were well-matched. Six patients in the TEA group were excluded (4 for technical difficulties in catheterization, 2 declined study participation for pain). Overall, four patients in whom conversion to thoracotomy occurred were included in the final analysis. Two intercostal chest tubes were inserted at the end of the procedure. Patient-controlled postoperative analgesia with 0.2% ropivacaine was set to deliver 1 mL bolus with a lockout interval of 15 minutes and a background infusion rate of 5 mL/hour for up to 2 days with the goal to keep the visual analogue scale (VAS) score below 4. If pain control was poor, rescue opioid analgesia was provided with intramuscular 10 mg of morphine equivalent. Main findings were that both the median time to place the catheter (5 vs. 14 minutes, P<0.001) and the failure rate (0% vs. 6.8%, P=0.038) were significantly lower in the PVB group compared to the TEA group. Postoperative outcomes on postoperative day 0–2, which included conversions to thoracotomy, major morbidity, the VAS pain scores at rest and with coughing, the number and doses of rescue analgesic medication received, the overall satisfaction scores, and the rate of patients discharged with oral analgesics were comparable in the two groups. The mean length of hospital stay was 2 days in both groups.

In the study by Wu et al., the trial category was not clarified (i.e., superiority, equivalence, or non-inferiority) whereas, even if the power analysis was performed, we do not know if an adequate number of patients were enrolled in the study. Further, we do not know whether the design of this randomized clinical trial may have overestimated the effects of PVB since patients who underwent conversion to thoracotomy were not excluded from the final intention-to-treat analysis (12). We also do not know whether an opioid-sparing protocol for rescue analgesia could have produced similar results. The study was not double blinded and the very short follow-up does not allow to speculate about the possible persistence or recurrence of pain beyond postoperative day 2. Last but not least, the results of this single-center study may not be generalizable to other hospital settings. Despite these limitations, the Authors have indeed shown that the technique of implanting a catheter for postoperative continuous PVB analgesia after VATS is safe and effective, and provides similar short-term pain control compared to TEA. The study results also suggest that intraoperative surgeon-guided PVB can avoid discomfort/pain and potential adverse events during epidural catheter placement in the awake state. For the above reasons, surgeon-guided PVB may represent the preferred option for postoperative analgesia management after VATS.

Similar to the transversus abdominis plane block in laparoscopic procedures (13), the ultrasound (US)-guided technique with pre-emptive local anesthetic infiltration of the port sites to avoid sensitization and amplification of the nociceptive signals before entry in the thoracic cavity could prove useful and safe for PVB. However, pain control may fail due to poor sonographic visualization, and the catheter for continuous analgesia is often misplaced with the US-guided technique (14,15). Interestingly, a recent randomized clinical trial including 196 patients undergoing diverse types of lung resections has demonstrated the noninferiority of PVB performed by surgeons under video thoracoscopic view compared with PVB performed by anesthesiologists using the US-guided technique in terms of opioid consumption during the first 48 hours (16). A procedural failure occurred in 6% of PVB-VATS group and in 10% of PVB-US group. The mean opioid consumption was not inferior in the per-protocol and in the modified intention-to-treat analysis and after adjustment for the type of surgery. Duration of anesthesia was shorter in the PVB-VATS group (P=0.04). Pain VAS scores at rest and while coughing, mean hospital opioid consumption, postoperative overall complications, length of hospital stay, rate of 30-day readmission, rate of analgesic consumption at 30 days, and global satisfaction for pain management were similar in both groups.

In the study by Wu et al., postoperative pain relief by surgeon-guided PVB with catheter placement was similar to that of TEA in patients undergoing thoracoscopic resection of lung nodules. We believe that this method may also apply to major thoracoscopic/robotic lung resections and esophagectomies, and should be considered a suitable option in the context of multimodal analgesic regimens after video-assisted thoracic surgery. Compared to TEA, PVB is associated with a better side-effect profile (17). Although serious complications of TEA are rare if contraindications are respected, we believe that TEA is not a panacea as the overall incidence of failure may be high even in high-volume centers and hypotension can cause reduction in splanchnic blood flow and ischemia of the gastric substitute after esophagectomy (18). TEA may still be considered an option when the chance to convert to an open surgical approach is high. However, with the widespread diffusion of enhanced recovery after surgery pathways, locoregional anesthesia including PVB has gained popularity in the perioperative management for minimally invasive thoracic surgery. The recent PROSPECT guidelines for pain management after VATS consider PVB as the first-line analgesic approach in combination with paracetamol and non-steroidal anti-inflammatory drugs or dexmedetomidine, and opioids as a rescue therapy. Use of TEA for postoperative analgesia is not recommended due to the risk of hypotension, urinary retention, and potential lower limb weakness which can delay early rehabilitation (19).

A one-size-does-not-fit-all approach is appropriate in the context of postoperative multimodal analgesia considering that between 30% and up to 80% of patients report that moderate to severe pain is not adequately treated in the days after surgery (20). Importantly, poorly controlled intra- and postoperative pain is associated with complications, such as delirium and infections, and represents a potential risk factor for developing disabling postsurgical pain (17,21-23). Unfortunately, there is a lack of high-quality studies comparing TEA and PVB in combination with standardized adjuvant therapies. Therefore, it seems logical that a patient-centered analgesic titration should be the main research goal. Further randomized and multicenter trials are needed to validate this hypothesis, to define the optimal use of systemic analgesia and rescue opioids (24-26), and to fill the existing gap in long-term chronic pain assessment and outcomes after VATS.


This work was endorsed by AIRES (Associazione Italiana Ricerca ESofago).

Funding: None.


Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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  1. Pang J, You J, Chen Y, et al. Comparison of erector spinae plane block with paravertebral block for thoracoscopic surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Surg 2023;18:300. [Crossref] [PubMed]
  2. Kingma BF, Visser E, Marsman M, et al. Epidural analgesia after minimally invasive esophagectomy: efficacy and complication profile. Dis Esophagus 2019;32:doy116. [Crossref] [PubMed]
  3. Biere SS, van Berge Henegouwen MI, Bonavina L, et al. Predictive factors for post-operative respiratory infections after esophagectomy for esophageal cancer: outcome of randomized trial. J Thorac Dis 2017;9:S861-7. [Crossref] [PubMed]
  4. Davies RG, Myles PS, Graham JM. 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. Br J Anaesth 2006;96:418-26. Erratum in: Br J Anaesth 2007;99:768. [Crossref] [PubMed]
  5. Motamed C, Farhat F, Rémérand F, et al. An analysis of postoperative epidural analgesia failure by computed tomography epidurography. Anesth Analg 2006;103:1026-32. [Crossref] [PubMed]
  6. Hermanides J, Hollmann MW, Stevens MF, et al. Failed epidural: causes and management. Br J Anaesth 2012;109:144-54. [Crossref] [PubMed]
  7. Barbera C, Milito P, Punturieri M, et al. Serratus anterior plane block for hybrid transthoracic esophagectomy: a pilot study. J Pain Res 2017;10:73-7. [Crossref] [PubMed]
  8. Yeung JH, Gates S, Naidu BV, et al. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016;2:CD009121. [Crossref] [PubMed]
  9. Kang K, Meng X, Li B, et al. Effect of thoracic paravertebral nerve block on the early postoperative rehabilitation in patients undergoing thoracoscopic radical lung cancer surgery. World J Surg Oncol 2020;18:298. [Crossref] [PubMed]
  10. Huang QW, Li JB, Huang Y, et al. A Comparison of Analgesia After a Thoracoscopic Lung Cancer Operation with a Sustained Epidural Block and a Sustained Paravertebral Block: A Randomized Controlled Study. Adv Ther 2020;37:4000-14. [Crossref] [PubMed]
  11. Wu Z, Wang Q, Wu C, et al. Paravertebral vs. Epidural Anesthesia for Video-assisted Thoracoscopic Surgery: A Randomized Trial. Ann Thorac Surg 2023;116:1006-12. [Crossref] [PubMed]
  12. Aiolfi A, Bonitta GL, Tosi D, Rausa E, et al. Two decades of surgical randomized controlled trials: worldwide trends in volume and methodological quality. Br J Surg 2023;110:1556. [Crossref] [PubMed]
  13. Resta M, Bernardi D, Bonavina G, et al. Pre-emptive or Preventive Transversus Abdominis Plane Block Analgesia for Laparoscopic Surgery? J Am Coll Surg 2021;232:114-5. [Crossref] [PubMed]
  14. Luyet C, Herrmann G, Ross S, et al. Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go? Br J Anaesth 2011;106:246-54. [Crossref] [PubMed]
  15. Feenstra ML, Ten Hoope W, Hermanides J, et al. Optimal Perioperative Pain Management in Esophageal Surgery: An Evaluation of Paravertebral Analgesia. Ann Surg Oncol 2021;28:6321-8. [Crossref] [PubMed]
  16. Chenesseau J, Fourdrain A, Pastene B, et al. Effectiveness of Surgeon-Performed Paravertebral Block Analgesia for Minimally Invasive Thoracic Surgery: A Randomized Clinical Trial. JAMA Surg 2023;158:1255-63. [Crossref] [PubMed]
  17. D'Ercole F, Arora H, Kumar PA. Paravertebral Block for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018;32:915-27. [Crossref] [PubMed]
  18. Richards ER, Kabir SI, McNaught CE, et al. Effect of thoracic epidural anaesthesia on splanchnic blood flow. Br J Surg 2013;100:316-21. [Crossref] [PubMed]
  19. Feray S, Lubach J, Joshi GP, et al. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2022;77:311-25. [Crossref] [PubMed]
  20. Meissner W, Zaslansky R. A survey of postoperative pain treatments and unmet needs. Best Pract Res Clin Anaesthesiol 2019;33:269-86. [Crossref] [PubMed]
  21. van Boekel RLM, Warlé MC, Nielen RGC, et al. Relationship Between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study. Ann Surg 2019;269:856-65. [Crossref] [PubMed]
  22. Bonavina G, Zackova M, Bet L, et al. Comment on the Need to Fill a Gap in the Assessment of Neurological Status Before Elective Surgery. Ann Surg Open 2023;4:e252. [Crossref] [PubMed]
  23. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth 2013;111:711-20. [Crossref] [PubMed]
  24. Kharasch ED, Clark JD. Opioid-free Anesthesia: Time to Regain Our Balance. Anesthesiology 2021;134:509-14. [Crossref] [PubMed]
  25. Shanthanna H, Ladha KS, Kehlet H, et al. Perioperative Opioid Administration. Anesthesiology 2021;134:645-59. [Crossref] [PubMed]
  26. Aiolfi A, Nosotti M, Micheletto G, et al. Pulmonary lobectomy for cancer: Systematic review and network meta-analysis comparing open, video-assisted thoracic surgery, and robotic approach. Surgery 2021;169:436-46. [Crossref] [PubMed]
Cite this article as: Aiolfi A, Bona D, Shabat G, Resta M, Bonavina L. Is paravertebral block the new standard of care for postoperative analgesia after thoracoscopic surgery? J Thorac Dis 2024;16(4):2677-2680. doi: 10.21037/jtd-23-1896

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