The pleura is visible as a hyperechoic line with “pleura sliding” in synchrony with respiration

This is different from the rib that has an anechoic acoustic shadow and no lung sliding

The needle is advanced with real-time in-plane technique and aims at the triangular thoracic paravertebral space underneath the internal intercostal membrane and the needle tip should be placed right next to the anechoic acoustic shadow of the transverse process; a “pop” is often felt when the needle tip penetrates the internal intercostal membrane

After assuring negative aspiration for blood 15-20 mL of local anaesthetic is injected. The TPS is seen to expand and push the pleura downwards

The local anaesthetic should be injected into the anterior part of the TPS anterior to the endothoracic fascia; this assures that the local anaesthetic spreads longitudinally inside the TPS and that sympathectomy is produced

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

– informed consent

– monitoring

– intravenous access (and maybe sedation)

– sitting position, relaxed and slumped

– demarcate landmarks

– infiltrate with local anaesthetics

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 space is located where the intercostal muscles meet the transverse processes

Analgesia after

– breast surgery

– thoracic surgery

– chest trauma

– abdominal surgery (inguinal herniorrhaphy, appendectomy, nephrectomy)

– upper limb surgery

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

A catheter can be placed with ultrasound guidance and in-plane technique in the caudal space

The sacral hiatus can be visualised in transverse view displaying the typical rounded cornua sacrales with acoustic shadows and the anechoic caudal canal deep to the sacral part of the supraspinous ligament