1. Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute – puducherry, India

2. History and what is it Injection of local anaesthetic in a space immediately lateral to where the spinal nerves emerge from the intervertebral foramina Hugo Sellheim of Leipzig in 1905. It was further refined by Lawen (1911) and Kappis (1919) 1970 – Eason increased interest

3. Indications anaesthesia – analgesia Thoracic surgery Liver surgery Inguinal hernia Ambulatory surgery open cholecystectomy Rib fracture Breast surgery High risk patients

5. Margins  wedge-shaped anatomical compartment adjacent to the vertebral bodies  Antero laterally by the parietal pleura, posteriorly by the superior costo transverse ligament,  medially by the vertebrae and intervertebral foramina,  superiorly and inferiorly by the heads of the ribs

7. Para vertebral space

8. Anatomy  the spinal root emerges from the intervertebral foramen and divides into dorsal and ventral rami.  The sympathetic chain lies in the same fascial plane.  Hence, PVB produces unilateral sensory, motor and sympathetic blockade

9. Technique  Conventional technique:- Loss of resistance to air  Single or continuous  Thoracic

10. Technique  sitting or lying down position  the neck flexed, back arched, and shoulders dropped forward  point 2.5 to 3cm lateral to the T4 spine (point of needle entry)  Go PA  Hit transverse process  Attach syringe – LOR  Caudolateral 1 cm movement – feel POP

11. Point of entry

12. Technique

13. 2.5 cm and 1 cm Touhy

14. Drugs –single and catheter  Each level injected with the single- injection technique requires 5 mL  total volumes 30 mL with unilateral injections  to 60 mL with bilateral injections.  A continuous infusion of a lower concentration of the same drug at 5 to 15 mL/hr is commonly used for continuous analgesia

15. One injection – levels  Spreads longitudinal  Spreads lateral  Spreads to other side  Ventral to endothoracic fascia – longitudinal  Dorsal – unpredictable

16. Spread  The space is continuous with the intercostal space laterally, the epidural space medially and the contralateral paravertebral space through the paravertebral and epidural space  PNS  We can use nerve stimulator to see intercostal muscle contraction

17. Complications  failure rate of 6.1%  Inadvertent vascular puncture (6.8%), hypotension (4%),  epidural or intrathecal spread (1%), pleural puncture (0.8%)  Pneumothorax (0.5%)  Horners reported  More with bilateral blocks

19. USG reports

20. Lumbar paravertebral block  Injecting a local anesthetic solution near the lumbar plexus, which is situated in the psoas compartment, anterior to the transverse process of the lumbar vertebral body

21. Lumbar paravertebral block

22. Puncture and procedure

23. Technique  5 cm lateral  PA – slightly medial  Bone hits  Go inferior  Quadriceps muscle contraction – loss of resistance 20 -30 ml  Usually done when epidural/femoral n is not feasible  USG is ideal

24. Cervical paravertebral nerve block  Similar to interscalene block  But posterior sensory fibres are more targeted and hence  Ideal for physiotherapy in frozen shoulder

25. Indications  anesthesia and postoperative analgesia after upper extremity surgery  prolonged continuous catheter analgesia in other clinical settings involving the upper limb.  management of pain due to conditions such as lung tumors infiltrating the brachial plexus (Pancoast tumors)  complex regional pain syndromes.

26. in the window between the levator scapulae and trapezius muscles at C6 level

27.  Loss of resistance  Nerve stimulator  USG

28. Interscalene

29. Technique  sitting or the lateral decubitus position  The patient's neck is slightly flexed forward.  The anesthesiologist stands behind the patient  Advanced anteromedially towards suprasternal notch  Bone – LOR syringe slip anterior  PNS – C5 C6 biceps

30. Catheter – insertion

31. Special USG procedure  patient in lateral decubitus contralateral to the operative side,  Reach behind the ipsilateral thigh, this maneuver helping bring the shoulder down  See nerve roots  Pass needle with vision

32. USG guided cerv. PVB

34. Complications  Close to epidural  Close to intrathecal  Close to vessels

35. Thank you all