In the axial plane, the thoracic paravertebral space (TPS) is a triangle with the base turned towards the vertebral spine, the parietal pleura and the endothoracic fascia are the antero-lateral border and the internal intercostal membrane is the posterior border. The apex points into the intercostal space laterally. The TPS communicates with the epidural space via the intervertebral foramina, with the mediastinum antero-medially, and with the intercostal space laterally.

The internal intercostal membrane is continuous with the internal intercostal muscle (between the external intercostal muscles and the innermost intercostal muscles) laterally and the superior costotransverse ligament medially.

The TPS extends down to the vertebral body of L1.

The needle is inserted with a lateral to medial in-plane approach.

Absolute contraindications

– patient refusal

– allergy to local analgesics

– neoplasia in the thoracic paravertebral space

– empyema in the thoracic paravertebral space

– infection at the site of injection

Relative contraindications

– coagulopathy/anticoagulation

– ipsilateral diaphragmatic paresis

– pneumothorax (0.5%)

– sympathetic blockade with hypotension and bradycardia

– block failure 10%

The thoracic paravertebral block was described the first time by Dr. Hugo Sellheim in 1905.

Analgesia after

– breast surgery

– thoracic surgery

– chest trauma

– abdominal surgery (inguinal herniorrhaphy, appendectomy, nephrectomy)

– upper limb surgery

Colour Doppler mode can be very useful to identify blood vessels surrounding deeply located target nerves.

Basic UGRA can be performed solely with a high-frequency linear probe.

Advanced and expert UGRA require high-frequency linear as well as low-frequency curved array probes.

Basic UGRA can be performed only with ultrasound without supplemental electrical nerve stimulation (ENS) technique.

Advanced and expert UGRA require a combination of ultrasound and ENS for various blocks.

ENS is obsolete for most blocks for the purpose of nerve localisation. However, sometimes peripheral nerves are not visible with ultrasound and ENS can be useful in order to confirm nerve identity.

Generally, the main purpose of ENS is a safeguard in order to assist avoiding accidental piercing of peripheral nerves and intraneural injection.

The learning objective of the expert ultrasound guided regional anaesthesia program is to obtain in-depth sonoanatomical theoretical knowledge about the selected expert nerve blocks.