Posterior Intercostal Nerve Block With Liposomal Bupivacaine: An Alternative to Thoracic Epidural Analgesia David C. Rice, MB, BCh, Juan P. Cata, MD,

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Posterior Intercostal Nerve Block With Liposomal Bupivacaine: An Alternative to Thoracic Epidural Analgesia David C. Rice, MB, BCh, Juan P. Cata, MD, Gabriel E. Mena, MD, Andrea Rodriguez-Restrepo, MD, Arlene M. Correa, PhD, Reza J. Mehran, MD The Annals of Thoracic Surgery Volume 99, Issue 6, Pages 1953-1960 (June 2015) DOI: 10.1016/j.athoracsur.2015.02.074 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Photograph of a patient in right lateral decubitus position showing the proposed line of injection for a percutaneous posterior intercostal nerve blockade, 5 to 7 cm lateral to the anatomic midline. Note that this is lateral to the location of classic paravertebral blockade (2.5 cm lateral to the anatomic midline). The Annals of Thoracic Surgery 2015 99, 1953-1960DOI: (10.1016/j.athoracsur.2015.02.074) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Thoracoscopic visualization allows accurate injection of liposomal bupivacaine into the intercostal space without violation of the parietal pleura. Note that the site of injection is at the level of the innermost intercostal muscles and that the drug tracks medially to the paravertebral space. Methylene blue was added to the liposomal bupivacaine for purposes of illustrating the extent of subpleural spread only. The Annals of Thoracic Surgery 2015 99, 1953-1960DOI: (10.1016/j.athoracsur.2015.02.074) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Pain scores and narcotic requirements for patients who received (A–C) liposomal bupivacaine or (D–F) thoracic epidural analgesia. The dashed lines indicate thoracotomy; the solid lines indicate minimally invasive surgery. Wilcoxon signed rank test. (Max = maximum; MSO4 = morphine sulfate; POD = postoperative day.) The Annals of Thoracic Surgery 2015 99, 1953-1960DOI: (10.1016/j.athoracsur.2015.02.074) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions