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3548
A retrospective analysis of two regional techniques for postoperative analgesia after percutaneous nephrolithotomy (PCNL): Retrolaminar Block (RB) versus Thoracic Paravertebral Block (TPVB)
Fri, April 7, 10:15-11:45 am
Salon 5

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A retrospective analysis of two regional techniques for postoperative analgesia after percutaneous nephrolithotomy (PCNL): Retrolaminar Block (RB) versus Thoracic Paravertebral Block (TPVB)

Introduction:

 

The thoracic paravertebral space is bound medially by the vertebral column, anteriorly by the parietal pleura, and posteriorly by the superior costotransverse ligament. It contains the thoracic spinal nerves and sympathetic chain. Classically, the paravertebral nerve block has been performed by injecting local anesthetic (LA) directly into the paravertebral space. The retrolaminar approach to the paravertebral block (RB) has recently been described as a simpler, potentially safer technique that achieves similar patterns of analgesia without requiring needle placement in close proximity to the neuraxis or pleura. This approach involves injection of LA into the plane between lamina and paraspinous muscles, and has been used for analgesia for breast surgery and rib fractures.1,2

 

Study purpose:

 

This is a retrospective study to compare the effectiveness of these 2 different approaches to the PVB for postoperative analgesia in percutaneous nephrolithotomy (PCNL) at the authors’ institution. Primary outcomes include: PACU Visual Analogue Scale (VAS) for pain (“pain score”) and total intraoperative and postoperative opioid use (in IV Morphine equivalents). 

 

Method:

 

Medical charts of 164 adult patients who underwent PCNL by either of two urologists at the authors’ institution were reviewed from July 2014 to April 2016.

•44 subjects were excluded from this analysis. These subjects did not receive a TPVB and served as controls to a separate study3. 5 of them had incomplete data.

115 remaining subjects were included in this analysis: 10 retrolaminar vs 105 TPV approach 

Discussion/results:

 

The results of this study suggest the following:

• There is no difference in intraoperative and PACU opioid requirements, which suggest equivalent efficacy between the two approaches.
• The retrolaminar approach may be an option for patients with higher weights and BMIs who may be challenging candidates for the TPVB, and also at higher risk for block complications.
•Lower intraoperative phenylephrine requirement with the RB compared to the TPVB implies less sympathetic blockade.

 

There are several limitations to this study:

•Limited number of subjects in the retrolaminar group
•Potential pitfalls of retrograde analysis of VAS scores
-Preexisting pain is infrequently recorded in perioperative assessments
-Pain at rest but not with movement was not recorded.
-Location of the pain was also inconsistently documented, so pain outside of the PVB coverage were not detailed.
•Inappropriate administration of pain medication (i.e. used to treat agitation)
•Accuracy in reporting pain may be affected by postoperative confusion or excessive sedation.

 

A randomized control trial is needed to confirm the noninferiority of RB in analgesic effectiveness compare to TPVB in patients who undergo PCNL. 

If both approaches are in fact equivalent, then the RPVB may be the preferred approach due to its potentially better safety profile. 

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