Reply by the Authors of the Original Article

Is Single Level Paravertebral Analgesia Enough for Controlling Postoperative Pain in VATS?

We have read the comments by Dr Çubuk on our article[1] about paravertebral catheter continuous infusion in video-assisted thoracoscopic surgery (VATS) patients. We have appreciated the authors' interest in this technique and we would like to solve their concerns one by one.

First of all, they assert that paravertebral analgesia can successfully work only in the metamerus where it is positioned. Therefore, it should be effective only in the camera port intercostal space and not in the other intercostal spaces where utility thoracotomy and second port are.

We replay that it is common opinion[2] that most of the pain after VATS arises from the camera port because this intercostal nerve is pressed by the Thoracoport movements during surgery and by chest tube in the post-op. Moreover, second access and utility thoracotomy are usually considered painless because spreading of ribs and second Thoracoport are rigorously avoided.

Furthermore, paravertebral space is a continuous anatomical space running alongside the dorsal column. This, unlike intercostal blocks, allows local analgesia diffusion in the adjacent paravertebral spaces and a wider pain control.

Second, they assert that subpleural hematoma could lead to misdiagnosis during the follow-up. Our replay is that we have never found any paravertebral pleural thickenings at patients' follow-up by CT scan. It is probably a very rare occurrence. However, in case of a suspicious finding, we suggest a PET/CT to distinguish a metastatic disease from scar tissue.

To conclude, we have completed a prospective randomized study comparing this technique with the gold standard intravenous opioid patient-controlled analgesia (PCA). Our data statistically support that paravertebral analgesia is even more effective than PCA; therefore, we strongly encourage this technique in VATS patients.

• References

• 1 Cioffi U, Raveglia F, Rizzi A, Di Mauro P, De Simone M, Baisi A. Paravertebral Analgesia in Video-Assisted Thoracic Surgery: A New Hybrid Technique of Catheter Placement for Continuous Anesthetic Infusion. Thorac Cardiovasc Surg 2014
• 2 Wildgaard K, Petersen RH, Hansen HJ, Møller-Sørensen H, Ringsted TK, Kehlet H. Multimodal analgesic treatment in video-assisted thoracic surgery lobectomy using an intraoperative intercostal catheter. Eur J Cardiothorac Surg 2012; 41 (05) 1072-1077