Extrapleural paravertebral analgesia post thoracotomy

Thoracic epidural has become the default standard for post-thoracotomy analgesia. However, it is not without its side effects - hypotension, fluid retention, urinary retention, shoulder tip pain etc. Extrapleural, paravertebral local anaesthetic infusion serves a similar purpose and in almost all comparitive trials, the extrapleural has been shown to be superior.
References:

  1. A prospective, randomised comparison of peroperative and continuous balanced epidural or paravertebral bupivicaine on post-thoracotomy pain, pulmonary function and stress responses Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. Br J Anaesth 1999 Sep;83(3):387-92;
  2. Pain relief for thoracotomy. Comparison of morphine requirements using an extrapleural infusion of bupivicaine. Carabine UA, Gilliland H, Johnston JR, McGuigan J. Reg Anaesth 1995 Sep-Oct;20(5):412-1

IMG_2635.JPG
This is a left postero-lateral thoracotomy; the spine is to the bottom of the picture and the shoulder to the right. The basal drain can be seen to the let over the diaphragm and the aorta is visible running across the image from right to left. The forceps are holding a flap of pleura which has been lifted beginning to create an extra pleural pocket. 		IMG_2638.JPG
The pleura is lifted medially as far as the sympathetic chain. There is no need to bring it more medially as this risks damaging intercostal vessels.
IMG_2640.JPG
The view is now rotated 90 degrees and we are lookingh towards the apex of the pleural cavity. A Roberts forceps is developing an extrapleural tunnel alongside the sympathetic chain as it runs alongside the aorta. This tunnel can be extended as far as the stellate ganglion withiout difficulty. There virtually exists a tunnel along the track of the sympathetic chain. 		IMG_2643.JPG
With the view again changed to looking from the back a 1/8th inch Redivac has been placed in the extrapleural tunnel. It can be brought out through the thoracotomy or through a separate stab incision and connected to a Luer lock. An infusion of Chirocaine 0.5% is then run at 5mls per hour. It usually remains in place till the drains are removed. It can be supplemented by the use of a narcotic PCA (patient controlled analgesia) system.