British Journal of Radiology (2009) 82, 790-791
© 2009 British Institute of Radiology
doi: 10.1259/bjr/83773691
Continuous paravertebral block in a patient with multiple rib fractures: a radiological conundrum?
Thoracic paravertebral block (PVB) is a peripheral nerve block technique that blocks the thoracic somatic spinal nerves in the paravertebral space. The boundaries of the thoracic paravertebral space are traditionally defined as the parietal pleura anteriorly, the costotransverse ligament posterolaterally and limited by the vertebral bodies medially [1]. As PVBs are usually performed in the operating theatre or pain clinic setting, they may be unfamiliar to other medical specialists. A loss-of-resistance technique (LORT) is commonly employed to locate the paravertebral space [1]. The passage of the block needle through the costotransverse ligament and hence into the paravertebral space is detected as a loss of resistance to air or saline. The use of air for this technique will result in air entering the paravertebral space. Continuous PVB has been described in the pain management of patients with multiple rib fractures [2]. We describe a case of a continuous PVB in a patient with multiple rib fractures presenting as a radiological diagnostic conundrum.
A 65-year-old man presented with left-sided rib fractures of the 6th to 8th ribs, following a fall. He had a background history of chronic obstructive pulmonary disease. The pain team were asked to review him because he had developed a left basal consolidation and was unable to cough or expectorate sputum because of thoracic pain. A left-sided continuous PVB was performed using a LORT with air and an 18 G Tuohy needle and epidural catheter set. The block was performed at the T7 level, 2.5 cm from the midline. Needle entry into the paravertebral space was confirmed by loss of resistance with 3–5 ml of air. 15 ml of 0.25% bupivacaine with adrenaline (1:200 000) was administered and the catheter inserted. After 15 min, the patient had good pain relief and was able to cough vigorously. 30 min after block performance, the patient underwent a CT of the thorax as part of his respiratory investigations.
The radiologist reviewing the CT scan was unaware that a PVB had been performed and reported evidence of air (2–3 ml) outside the left parietal pleura (Figure 1
). This was suggestive of a small pneumomediastinum secondary to multiple rib fractures. There followed a period of confusion as to whether this was a resolving or new finding. However, subsequent communication with the pain team confirmed the cause of the diagnosis.
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Figure 1. The white arrow indicates air in the paravertebral space with spread medially, anterior to the verterbral body.
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This case highlights the need for good communication between healthcare professionals, especially when unfamiliar anaesthetic or analgesic techniques are used. These CT images also confirm previous MRI [3] and radiological [4] findings in that the medial boundary of the paravertebral space can extend anteriorly to the vertebral bodies via the areolar connective tissue between the vertebral bodies and the endothoracic fascia [5].
S Mannion
1 and
M Murphy
2
Departments of 1 Anaesthesiology and 2 Radiology, South InfirmaryVictoria University Hospital, Cork, Ireland
Correspondence: S Mannion, Departments of Anaesthesiology, South Infirmary–Victoria University Hospital, Cork, Ireland. E-mail: mannionstephen{at}hotmail.com
Received for publication June 7, 2009.
Revision received June 11, 2009.
References
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- Karmakar MK, Critchley LA, Ho AM, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest 2003;123:424–31.[CrossRef][Medline]
- Barrett J, Harmon D, Loughnane F, Finucane B, Shorten G. Paravertebral block. In: Barrett J, Harmon D, Loughnane F, Finucane B, Shorten G, editors. Peripheral nerve blocks and peri-operative pain relief. 1st edn. Philadelphia, PA: WB Saunders, 2004. 135–38.
- Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of contralateral spread anterior to the vertebral bodies. Br J Anaesth 2000;84:263–5.[Abstract/Free Full Text]
- Karmakar MK, Gin T, Ho AM. Ipsilateral thoraco-lumbar anaesthesia and paravertebral spread after low thoracic paravertebral injection. Br J Anaesth 2001;87:312–6.[Abstract/Free Full Text]
