Paravertebral Block versus Epidural Block for Post-thoracotomy Analgesia: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

 SHIZhen , LIJu-chen ,  JIANGXiao-jing

Department of Anesthesiology, the First Affiliated Hospital, China Medical University, Shenyang 110001, China;

Corresponding?author：

JIANGXiao-jing, Email: jiangsophie@hotmail.com

Keywords：

Paravertebral block; Epidural block; Post-thoracotomy analgesia; Systematic review; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.20150092

Video：

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Objective To systematically review the efficacy of paravertebral block (PVB) versus thoracic epidural block (TEB) for post-thoracotomy analgesia. Methods We electronically searched databases including The Cochrane Library (Issue 9, 2013), PubMed, EMbase, Springer, CNKI, CBM, VIP and WanFang Data from 1980 to September 2013, to collect randomized controlled trials (RCTs) of PVB versus TEB for post-thoracotomy pain management. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data and assessed the methodological quality of included studies. Then, meta-analysis was performed using RevMan 5.2 software. Results Thirteen RCTs involving 608 patients were included. The results of meta-analysis showed that:the PVB group got higher VAS score at 48 h than the TEB group (WMD=-0.36, 95%CI -0.54 to -0.71), but more patients of the PVB group chosen remedial method to release pain in epidural than in paravertebral. In addition, there were no differences in VAS scores at 6 h and 24 h between two groups. As for the analgesia related complication:compared with the TEB group, the PVB group has lower rate of hypotension (RR=0.18, 95%CI 0.08 to 0.41), urinary retention (RR=0.24, 95%CI 0.11 to 0.54), nausea and vomiting (RR=0.42, 95%CI 0.25 to 0.70). There were no significant differences between two groups in postoperative pulmonary complication (RR=0.52, 95%CI 0.10 to 2.76), postoperative FEV₁ level (WMD=2.93, 95%CI -4.52 to 10.38) and duration of hospital stay (WMD=-0.19, 95%CI -0.89 to 0.50). The PVB group had lower risk of chronic pain than that of the TEB group (RD=-0.12, 95%CI -0.23 to -0.01). Conclusion Current evidence shows PVB has the similar efficacy as TEB in post-thoracotomy pain management, with lower risk of analgesia related complication and lower risk of post-thoracotomy chronic pain. Due to limited quality and quantity of the included studies, more high quality and large-scale RCTs are needed to verify the above conclusion.

Citation： SHIZhen, LIJu-chen, JIANGXiao-jing. Paravertebral Block versus Epidural Block for Post-thoracotomy Analgesia: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2015, 15(5): 550-558. doi: 10.7507/1672-2531.20150092 Copy

1.	Macrae WA. Chronic pain after surgery. Br J Anaesth, 2001, 87(1):88-89.
2.	王赫, 孫喜家, 馬虹. 不同自控鎮痛方式對胸腹部手術后并發癥影響的Meta分析. 中國循證醫學雜志, 2010, 10(11):1285-1292.
3.	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(4):418-426.
4.	Perttunen K, Nilsson E, Heinonen J, et al. Extradural, paravertebral and intercostal nerve blocks for postthoracotomy pain. Br J Anaesth, 1995, 75(5):541-547.
5.	Kaiser AM, Zollinger A, De Lorenzi D, et al. Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain. Ann Thorac Surg, 1998, 66(2):367-372.
6.	Bimston DN, McGee JP, Liptay MJ, et al. Continuous paravertebral extrapleural infusion for post-thoracotomy pain management. Surgery, 1999, 126(4):650-656.
7.	Richardson J, Sabanathan S, Jones J, et al. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth, 1999, 83(3):387-392.
8.	黃燕娟, 鄒建平, 韋涌初, 等. 經胸膜穿刺置管持續PVB用于剖胸術后鎮痛的臨床研究. 中國現代醫學雜志, 2003, 13(10):53-55.
9.	Casati A, Alessandrini P, Nuzzi M, et al. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol, 2006, 23(12):999-1004.
10.	Messina M, Boroli F, Landoni G, et al. A comparison of epidural vs. paravertebral blockade in thoracic surgery. Minerva Anestesiol, 2009, 75(11):616-621.
11.	Gulbahar G, Kocer B, Muratli SN, et al. A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg, 2010, 37(2):467-472.
12.	Pintaric TS, Potocnik I, Hadzic A, et al. Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med, 2011, 36(3):256-260.
13.	Kanazi GE, Ayoub CM, Aouad M, et al. Subpleural block is less effective than thoracic epidural analgesia for postthoracotomy pain:a randomised controlled study. Eur J Anaesthesiol, 2012, 29(4):186-191.
14.	Grider JS, Mullet TW, Saha SP, et al. A randomized, double-blind trial comparing continuous thoracic epidural bupivacaine with and without opioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain. J Cardiothorac Vasc Anesth, 2012, 26(1):83-89.
15.	付強, 鄭傳東. 開胸術后應用PVB的臨床研究. 實用醫院臨床雜志, 2012, 9(4):107-108.
16.	Kobayashi R, Mori S, Wakai K, et al. Paravertebral block via the surgical field versus epidural block for patients undergoing thoracotomy:a randomized clinical trial. Surg Today, 2013, 43(9):963-969.
17.	Elsayed H, McKevith J, McShane J, et al. Thoracic Epidural or Paravertebral Catheter for Analgesia After Lung Resection:Is the Outcome Dfferent? J Cardiothorac Vasc Anesth, 2012, 26(1):78-82.
18.	Tanaka K, Watanabe R, Harada T, et al. Extensive application of epidural anesthesia and analgesia in a university hospital:Incidence of complications related to technique. Reg Anesth, 1993, 18(1):34-38.
19.	Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8:Assessing risk of bias in included studies. In:Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available at:www.cochrane-handbook.org.
20.	袁金秋, 劉雅莉, 楊克虎, 等. 系統評價在評價納入研究的質量評價方法調查. 中國循證醫學雜志, 2012, 12(2):238-242.
21.	Krdzalic A, Klokocovnik T, Krdzalic G, et al. The influence of cardiopulmonary by-pass on respiratory function in patients who underwent coronary disease surgery. Med Arh, 2013, 67(2):97-100.
22.	Ranucci M, Balduini A, Ditta A, et al. A systematic review of bio-compatible cardiopulmonary bypass circuits and clinical outcome. Ann Thorac Surg, 2009, 87(4):1311-1319.

1. Macrae WA. Chronic pain after surgery. Br J Anaesth, 2001, 87(1):88-89.
2. 王赫, 孫喜家, 馬虹. 不同自控鎮痛方式對胸腹部手術后并發癥影響的Meta分析. 中國循證醫學雜志, 2010, 10(11):1285-1292.
3. 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(4):418-426.
4. Perttunen K, Nilsson E, Heinonen J, et al. Extradural, paravertebral and intercostal nerve blocks for postthoracotomy pain. Br J Anaesth, 1995, 75(5):541-547.
5. Kaiser AM, Zollinger A, De Lorenzi D, et al. Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain. Ann Thorac Surg, 1998, 66(2):367-372.
6. Bimston DN, McGee JP, Liptay MJ, et al. Continuous paravertebral extrapleural infusion for post-thoracotomy pain management. Surgery, 1999, 126(4):650-656.
7. Richardson J, Sabanathan S, Jones J, et al. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth, 1999, 83(3):387-392.
8. 黃燕娟, 鄒建平, 韋涌初, 等. 經胸膜穿刺置管持續PVB用于剖胸術后鎮痛的臨床研究. 中國現代醫學雜志, 2003, 13(10):53-55.
9. Casati A, Alessandrini P, Nuzzi M, et al. A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol, 2006, 23(12):999-1004.
10. Messina M, Boroli F, Landoni G, et al. A comparison of epidural vs. paravertebral blockade in thoracic surgery. Minerva Anestesiol, 2009, 75(11):616-621.
11. Gulbahar G, Kocer B, Muratli SN, et al. A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg, 2010, 37(2):467-472.
12. Pintaric TS, Potocnik I, Hadzic A, et al. Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med, 2011, 36(3):256-260.
13. Kanazi GE, Ayoub CM, Aouad M, et al. Subpleural block is less effective than thoracic epidural analgesia for postthoracotomy pain:a randomised controlled study. Eur J Anaesthesiol, 2012, 29(4):186-191.
14. Grider JS, Mullet TW, Saha SP, et al. A randomized, double-blind trial comparing continuous thoracic epidural bupivacaine with and without opioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain. J Cardiothorac Vasc Anesth, 2012, 26(1):83-89.
15. 付強, 鄭傳東. 開胸術后應用PVB的臨床研究. 實用醫院臨床雜志, 2012, 9(4):107-108.
16. Kobayashi R, Mori S, Wakai K, et al. Paravertebral block via the surgical field versus epidural block for patients undergoing thoracotomy:a randomized clinical trial. Surg Today, 2013, 43(9):963-969.
17. Elsayed H, McKevith J, McShane J, et al. Thoracic Epidural or Paravertebral Catheter for Analgesia After Lung Resection:Is the Outcome Dfferent? J Cardiothorac Vasc Anesth, 2012, 26(1):78-82.
18. Tanaka K, Watanabe R, Harada T, et al. Extensive application of epidural anesthesia and analgesia in a university hospital:Incidence of complications related to technique. Reg Anesth, 1993, 18(1):34-38.
19. Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8:Assessing risk of bias in included studies. In:Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available at:www.cochrane-handbook.org.
20. 袁金秋, 劉雅莉, 楊克虎, 等. 系統評價在評價納入研究的質量評價方法調查. 中國循證醫學雜志, 2012, 12(2):238-242.
21. Krdzalic A, Klokocovnik T, Krdzalic G, et al. The influence of cardiopulmonary by-pass on respiratory function in patients who underwent coronary disease surgery. Med Arh, 2013, 67(2):97-100.
22. Ranucci M, Balduini A, Ditta A, et al. A systematic review of bio-compatible cardiopulmonary bypass circuits and clinical outcome. Ann Thorac Surg, 2009, 87(4):1311-1319.

Chinese Journal of Evidence-Based Medicine

Paravertebral Block versus Epidural Block for Post-thoracotomy Analgesia: A Systematic Review

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