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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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Chapter 37 – Paravertebral Blocks

André P. Boezaart, M.D., Ph.D.   Richard W. Rosenquist, M.D.

Continuous Cervical Paravertebral Block

PERSPECTIVE

The cervical paravertebral approach to the brachial plexus is a brachial plexus root or trunk block with the same indications as for the continuous interscalene block. Following interscalene block, patients frequently complain of an uncomfortable “dead feeling” of the arm, which is caused by a dense sensory, motor, and proprioceptive block following a conventional continuous interscalene block. The desire to provide a sensory block with more motor sparing, enabling participation of patients in physical therapy (especially patients with a “frozen shoulder”), was primary in designing the continuous postoperative cervical paravertebral block.

In the plane of the paravertebral space, the roots of the posterior sensory and anterior motor fibers are joined to become the individual nerve roots. This may explain why more electrical current is often required to elicit a motor response when performing a cervical paravertebral block compared with the anterior interscalene approach. This block was originally described by Kappis in the 1920s and modified by Pippa in 1990. As originally described, the block was painful, probably owing to penetration of the paraspinal extensor muscles of the neck. It was infrequently used until recently, when a modification was described that avoids penetrating the extensor cervical muscles. This technique minimizes the pain associated with the approach to the brachial plexus by inserting the needle in the “V” between the levator scapulae and trapezius muscles at the level of the sixth cervical vertebra ( Fig. 37-1 ).

Click to view full size figure

Figure 37-1  Cervical paravertebral block: landmarks for a needle puncture (right oblique view). Note needle insertion in the “V” of the junction of the anterior border of the trapezius and the posterior border of the levator scapulae muscles.


Patient Selection.

A continuous cervical paravertebral block is indicated for anesthesia and postoperative analgesia following upper extremity surgery or for prolonged continuous catheter analgesia in other settings. It is especially suitable for patients with difficult-to-reach interscalene grooves and for inserting a catheter that can be effectively secured. Because nerve stimulation and loss-of-resistance techniques can both be used for placement of this block, it is well suited to postoperative placement or for placement of blocks in patients with painful upper extremity conditions, when motor activation via nerve stimulator may be poorly tolerated.

Pharmacologic Choice.

An initial bolus of 20 to 40 mL of 0.5% bupivacaine, 0.5% to 0.75% ropivacaine, or 0.5% to 0.75% levobupivacaine is usually used (see Table 2–1). When used for postoperative analgesia, this is usually followed by continuous infusion of a lower concentration of the same drug (i.e., 0.25% bupivacaine, 0.2% ropivacaine, or 0.25% levobupivacaine at an infusion rate of 3 to 15 mL/hr).

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