| BackgroundThoracic paravertebral block(TPVB)is a technique to block the ipsilateral Thoracic body and sympathetic nerves by injecting local anesthetics near the intervertebral foramen of the Thoracic spinal nerve.At present,TPVB is widely used in perioperative analgesia management of thoracic surgery.With the development of Enhanced recovery after surgery(ERAS),it is gradually used as an important auxiliary means of multimodal analgesia.With the continuous development of visualization technology,ultrasound-guided TPVB is more and more respected.The classic TPVB believes that the needle tip needs to be located in the deep surface of the Superior costal transverse ligament(SCTL)(break through SCTL)in order to successfully block it.However,due to its anatomical factors,the risk of pneumothorax,hemothorax,vascular and nerve injury is greatly increased.These risks bring certain difficulties and challenges to clinical application.It has been repeatedly observed that injection of local anesthetics into the superficial surface of the SCTL(without breaking through the SCTL)can successfully block the thoracic paravertebral nerve.Importantly,subpleural pressure can be clearly observed under ultrasound images when the drug is injected into the superficial surface of the SCTL.Recent anatomical studies have confirmed that the thoracic paravertebral space is a very narrow space,and the intercostal vessels are very close to the pleura.SCTL does not form a posterior wall closed by the thoracic paravertebral space.There are many nerve block techniques similar to TPVB in clinical practice,such as ultrasound-guided Retrolaminar block(RLB),Erector spinae plane block(ESPB),intercostal /paraspinal nerve block,mid-point transverse process to pleura(MTP)block,Multiple‐injection costotransverse block(MICB),Subtransverse process interligamentary(STIL)block and Costotransverse Foramen(CTF)block.The common feature of these nerve block techniques is that the needle tip does not need to break through the SCTL.Some researchers have proposed that SCTL can be used as a new target for fascial plane block.Up to now,no clinical studies comparing the superficial surface of SCTL(the needle did not break through the SCTL)and the deep surface of SCTL(the needle broke through the SCTL)block of thoracic paravertebral nerve were retrieved.Based on the above research conclusions,combined with our previous clinical practice,ultrasound-guided superficial TPVB injection of local anesthetics in SCTL can provide effective postoperative analgesia for patients undergoing thoracoscopic surgery.Therefore,we designed a prospective,randomized,controlled,single-center clinical study.This study aims to compare ultrasound-guided TPVB with superficial and deep SCTL injection of local anesthetics for postoperative analgesia and recovery quality in patients undergoing thoracoscopic surgery,to explore the feasibility of ultrasound-guided TPVB using SCTL as a reference mark for injection,and to provide new ideas for the clinical operation of ultrasound-guided TPVB.MethodsA total of 106 patients scheduled for elective thoracoscopic surgery in the Department of Thoracic Surgery,the First Affiliated Hospital of Army Medical University from May 2021 to September 2021 were included in this study.According to the random number table method,they were divided into SCTL superficial surface block group(group S)and SCTL deep surface block group(group T).Patients in the two groups were routinely induced and maintained anesthesia.After extubation at the end of operation,ultrasound-guided TPVB was performed,and local anesthetics were injected on the superficial or deep surface of SCTL,combined with patient controlled intravenous analgesia(PCIA).The ultrasound image positioning time,puncture time,the distance from the needle tip of the ultrasound image to the pleura,the pleural pressure of the ultrasound image and puncture related complications were recorded.Visual analogue score(VAS)at rest and during exercise(cough)at 5,10,20,30 min,4,12 and 24h(t0-6)after block was evaluated.The use of analgesic pump(sufentanil consumption,first compression time,effective compression times,actual compression times)within 24 hours after operation,satisfaction survey,and evaluation of quality of recovery(QOR-40)before operation and 24 hours after operation were observedResultsA total of 106 patients were included in this study,and they were divided into group S and group T by random number table method,with 53 cases in each group.In group S,4patients were excluded from the study due to thoracotomy due to surgical methods,and 2patients in group T were excluded from the study because of failure to inject drugs into the blood vessels during puncture.There was no significant difference in gender,age,BMI,anesthesia time and operation time between the two groups.Compared with group T,the puncture time in group S was shortened(P<0.05),the distance from needle tip to pleura measured by ultrasound image was longer(P<0.05),pleural pressure could be observed under ultrasound image in 15 cases of group S,and pleural pressure could be observed under ultrasound image in 51 cases of group T(P<0.05).One case of epidural block occurred in group T.The VAS score at T6 in the state of exercise(cough)in group S was higher than that in group T(P<0.05).Because both of them belonged to the range of mild pain scores,there was no significant difference in analgesic effect clinically.The rest of the two groups of patients resting at each time point and the motion VAS score(cough)condition,under the guidance of ultrasound image positioning time,postoperative analgesia pump usage within 24hours(dosage sufentanil,number of press time,effective press for the first time,the actual number of compressions),satisfaction,and preoperative and postoperative 24 hours QOR-40 score difference no statistical significance(P > 0.05).Conclusions1.SCTL can be used as a reference for ultrasound-guided TPVB injection.Both superficial and deep SCTL injection under ultrasound-guided TPVB combined with PCIA can provide effective analgesia and comparable postoperative recovery quality for VAST patients.2.TPVB with ultrasound-guided superficial injection of local anesthetics in SCTL is more convenient,fast and safe.It is a good auxiliary method to provide effective analgesia and promote the quality of recovery for VAST patients after surgery,and is easy to be clinically generalized. |
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