Use of general anesthetic only vs general anesthetic combined with paravertebral block for perioperative pain management after first rib resection

Amit N. Patel, MD, MS, Karen U. Finlay, BS, Katharina C. Schyra, BS, Comeco C. Jones, BSN, Robert E. Black, BS, Larry J. Dullye, DO, Linda W. Jennings, PhD, H. A. Tillmann Hein, MD, Harold C. Urschel, Jr., MD, and Michael A. E. Ramsay, MD

From the Department of Surgery (Patel, Urschel) and the Department of Anesthesiology and Pain Management (Finlay, Schyra, Jones, Black, Dullye, Jennings, Hein, Ramsay), Baylor University Medical Center, Dallas, Texas.

This manuscript won the 2001 Institute of Surgical Pain Management Award for Excellence.

Corresponding author: Amit N. Patel, Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246.

Background: Patients presenting with thoracic outlet compression often suffer from chronic pain syndrome. The surgical modality of choice to treat these patients is first rib resection with cervical sympathectomy. However, postoperative pain management can be challenging in this patient population. Therefore, a lower cervical and upper thoracic paravertebral block (PVB) is performed as a measure to improve analgesic management. This study compares the postoperative opioid requirement and pain assessment of patients undergoing transaxillary first rib resection who receive a general anesthetic (GA) combined with a PVG with those who receive only GA.

Methods: After institutional review board approval, 68 patients undergoing transaxillary first rib resection with cervical sympathectomy were studied. All patients received similar GA by the same anesthesiologist. Twenty-nine patients were administered only a GA. The PVB was performed at the C7 and T1 levels with up to 10 mL of 0.5% ropivacaine injected at each site, for a total dose not exceeding 0.5 mg/kg. Postoperative pain scores and opioid use were converted to morphine equivalents for comparison. Data were examined using nonparametric statistical analysis with the Wilcoxon signed rank test and repeated measures of variance. A P value <0.05 was considered significant.

Results: Patients in the PVB group had a mean pain score at discharge from the postanesthesia care unit (PACU) of 2.5 (+/- 1.8) compared with 4.4 (+/- 3.0) in the GA group (P = 0.007). The amount of pain medication given in the PACU, however, did not differ between groups. Patients with a PVB had a significantly lower pain score in the PACU compared with pain on admission.

Conclusion: Our study showed that PVBs for first rib resections result in a significant decrease in postoperative pain but no significant decrease in opioid usage. (BUMC Proceedings 2002;15:374-375)