Perioperative Pain Relief by Thoracic Paravertebral Block for Wide Excision of Chest Wall Mass.

Paravertebral block is an appropriate method for intraoperative and postoperative pain relief in hemithorax operations .Effectiveness of this type of pain management have already been shown in breast surgery .Its effect on controlling chest wall pain is clear and remarkable. In our case despite of wide extension of lesion and penetration of ulcer to the deep part of thorax after excision, the patient had a very comfortable and painless recovery.

Case Report

A 45-year-old woman was admitted to the hospital with a very deep lesion on her left chest wall (figure 1-2) .She was very cachectic and smelling pus from her ulcer made her very nervous and frightened.

Figure 1

Pre operation ulcer

Figure 2

Pre operation ulcer

The appearance of ulcer was purulent and necrotic but there was no evidence of cellulitis or redness around the ulcer.

In physical examination she had no finding except the ulcer mentioned above and severe weight loss which started a couple of years ago.

She had a past history of modified radical mastectomy on the left side 3 years ago and she was referred for postoperative chemo-radiotherapy which was refused by her as she denied her cancer diagnosis till recent year which this horrible ulcer appeared slowly on the previous operation scar on her left chest wall.

Her doctor ordered an MRI of her chest and abdomen and also a routine blood test.

MRI showed a deep penetration of chest wall mass to the pleural layers and extensive erosion of chest wall bone (Figure 3).CBC and blood values didn’t show any remarkable changes .She seemed metastasis free. She was a candidate for wide excision of chest wall mass and affected layers.

Figure 3

MRI: Deep penetration of ulcer to chest wall layers

In the operating room paravertebral block was performed on the left 3dr thoracic vertebral lamina with 15 cc Bupivucaine 0.5 % plus Adrenaline 1:200000 and then patient anesthetized with combination of Propofol 80 mg and Atracurium 20 mg. During anesthesia she took 50 mcg /kg /min Propofol and 2 mcg/kg/min Remifentanil .Every 25 minutes she took 5 mg Atracurium for muscle relaxation.

Wide excision of the ulcer and affected chest wall was performed and the affected ribs and pleura was removed extensively (Figure 4) .The defect was filled with Proline mesh tightly and the right breast was rotated as a graft to the left side and fixed over the site of excision (Figure 5).

Figure 4

Wide excision of ulcer and chest wall

Figure 5

Patient's appearance after extubation

She was quiet stable during the operation and then muscle relaxant was reversed at the end of the operation and hypnotic and analgesic infusion was stopped.

She became awake very soon without any pain or discomfort. Her vital signs remained unchanged and she was pain-free until 20 hours after operation .The day after surgery she was able to walk in her room and she had a tolerable postoperative pain with oral analgesic. Chest physiotherapy started with no pain on the second postoperative day. She discharged from the hospital on the 6th postoperative day.

Discussion

Paravertebral analgesia in breast surgery has been done successfully since 1970s. The most brilliant results have been achieved in different studies about its efficacy on pain management and duration of analgesia [1-9].

This method of pain control can reduce the pain and additional analgesia rarely needs in this procedure. When we use continuous paravertebral block by insertion of paravertebral catheter we can extend the duration of block until the drainage catheter removal.

In this case in spite of deep penetration of the ulcer and wide excisional surgery only with a single dose of local analgesic in the 3rd thoracic paravertebral space she was remarkably pain free and it was very helpful for her rehabilitation and physiotherapy. She was able to breathe deeply and expand her chest smoothly just after the operation.

Pain control with opioids can delay recovery and rehabilitation in these patients and reduce co-operation and also hospital stay may increase with respiratory complications of opioids. Painless postoperative period in such extensive chest wall operation in this patient reveals efficacy of the method for visceral pain management. This method has less complication but more benefits in hemi-thoracic procedures.

Conclusion

Paravertebral block not only is an appropriate anesthesia method which could decrease hospital stay, hospital costs and postoperative complications but also it is a simple and feasible method in the most cases and can provide a very suitable analgesia for biopsy and operation and postoperative analgesia in hemi-thoracic procedures [3-8].