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Thoracic-paravertebral blocks: comparative anatomical study with different injection techniques and volumes
  1. Ronald Seidel1,
  2. Andreas Wree2 and
  3. Marko Schulze2
  1. 1 Anesthesiology, HELIOS Medical Center, Schwerin, Germany
  2. 2 Institute of Anatomy, University of Rostock, Rostock, Germany
  1. Correspondence to Dr Ronald Seidel, Anesthesiology, HELIOS Medical Center, Schwerin 19049, Germany; ronald-seidel{at}


Background and objectives We hypothesized that different injection techniques and volumes in thoracic-paravertebral blocks (TPVB) lead to different patterns of dye spread. In particular, we investigated whether an alternating injection technique leads to complete staining of all adjacent intercostal nerves.

Methods This comparative anatomical investigation was performed using 10 or 20 mL of dye (Alcian Blue) in 10 unfixed donor cadavers (54 injections) that were designated for education or research purposes.

Results In landmark-guided TPVB, the thoracic-paravertebral space (TPVS) was either not stained at all (spread of dye in the paraspinal muscles, n=3) or the dye was predominantly found in the epidural space (n=3). In ultrasound-guided TPVB, the TPVS was correctly identified in all cases (n=48). The sympathetic trunk was stained in 84.6% of injections (multi-injection technique: 100%), independent of injection technique and volume. The epidural space was stained more frequently (p≤0.001) if both the puncture site (sagittal transducer position) and guidance of the needle were more medial (77.8%). Finally, a higher injection volume (20 vs 10 mL) resulted in a higher number of stained intercostal nerves (p=0.04).

Conclusion For ultrasound-guided techniques, a higher injection volume resulted in a larger number of stained intercostal nerves. Staining of the sympathetic trunk was independent of the injection technique. Epidural spread was observed significantly less frequently if the injection was lateral (transducer transversal) or with a strictly cranial injection direction (transducer sagittal). Landmark-guided injections reliably achieved the TPVS (and the epidural space) only after a needle advance of 2.5 cm after initial contact with the transverse process.

  • regional anesthesia
  • neuraxial blocks: combined spinal/epidural
  • anatomy
  • ultrasound in pain medicine

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  • Contributors All authors listed in the manuscript have contributed substantially to the design of the study, interpretation of results, revised the manuscript and gave final approval for publication. RS and MS conducted the study and analyzed the data. RS drafted the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.