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Letters to the Editor: Letter to the Editor

Walk Down, Not Up to Find the Paravertebral Space

Porter, Steven B., MD; Robards, Christopher B., MD; Clendenen, Steven R., MD

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doi: 10.1213/ANE.0b013e318295290b
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To the Editor

We have 2 comments regarding Gardiner et al.’s1 discussion of the benefits of bilateral paravertebral blocks for outpatients undergoing breast augmentation. First, in the interest of safety, when performing paravertebral blocks, we believe that it is preferable to walk caudad off the transverse process because the initial contact point may not be transverse process but rather the rib.2 If the rib is contacted and the needle is walked superiorly, the risk of pneumothorax is theoretically greater, when compared with walking caudad as the rib can act as a backstop (Fig. 1). Walking caudad and contacting the more superficial transverse process tells the anesthesiologist that the initial point of contact was rib. This safety mechanism does not exist if the first move is to walk cephalad. This theoretical risk may be particularly great in obese patients with poor surface anatomy. The patients in this study averaged a body mass index of close to 20, which does not reflect our patient population. Second, although Gardiner et al.’s1 results demonstrated that paravertebral block is likely of benefit in these patients, operating conditions for subpectoral breast augmentation and postoperative analgesia may be further improved through the blockade of additional nerves. These include blockade of the lateral and medial pectoral nerves.4 These nerves may explain why although Gardiner et al.1 state that “PVB [paravertebral blockade] success was confirmed in all patients with bilateral cold sensation testing,” there was no difference in their pain scores in the recovery room when compared with those who were not blocked. We also note that the pain score difference although statistically significant at discharge (Ref. 1, Table 4a) seems relatively high even in the blocked group (maximum pain score 7, average pain score 3.3). If paravertebral blockade is not sufficient to cause a clinically significant reduction in pain for a given procedure, perhaps it should be avoided because there are inherent risks involved.

Figure 1
Figure 1:
Depiction of initial contact with the rib the transverse process in a paravertebral block. Adapted from Bleckner3 with permission from the Henry M. Jackson Foundation for the Advancement of Military Medicine.

Steven B. Porter, MD

Christopher B. Robards, MD

Steven R. Clendenen, MD

Department of Anesthesiology

Mayo Clinic

Jacksonville, FL


1. Gardiner S, Rudkin G, Cooter R, Field J, Bond M. Paravertebral blockade for day-case breast augmentation: a randomized clinical trial. Anesth Analg. 2012;115:1053–9
2. Greengrass RA, Duclas R Jr. Paravertebral blocks. Int Anesthesiol Clin. 2012;50:56–73
3. Buckenmaier C, Bleckner L Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: Borden Institute. 2008
    4. Desroches J, Grabs U, Grabs D. Selective ultrasound guided pectoral nerve targeting in breast augmentation: How to spare the brachial plexus cords? Clin Anat. 2013;26:49–55

    Cited By

    This article has been cited 1 time(s).

    Anesthesia & Analgesia
    In Response
    Gardiner, S; Rudkin, G; Field, J; Cooter, R
    Anesthesia & Analgesia, 117(1): 281.
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