British Journal of Anaesthesia, 118 (2): 159–66 (2017)

doi: 10.1093/bja/aew387
Review Article

REVIEW ARTICLE

Paravertebral block in paediatric abdominal

surgery—a systematic review and meta-analysis
of randomized trials
E. A. Page and K. L. Taylor*
Department of Anesthesia and Pain Medicine, Hospital for Sick Children, 555 University Avenue, Toronto,
Ontario M5G 1X8, Canada

*Corresponding author: E-mail: katherine.taylor@sickkids.ca

Abstract
The increased popularity of paravertebral block (PVB) can be attributed to its relative safety and comparable efficacy when
compared with epidural analgesia. It has thus been recommended for open cholecystectomy and other less painful sur-
geries such as inguinal herniorraphy and appendectomy. We performed a systematic review of PVB in paediatric abdominal
conditions to assess its clinical efficacy and side effects compared with other analgesic therapies.
A search of Medline, Embase, and Web of Science and hand-searching references from inception date to May 2016 was
done. Relevant studies were randomized clinical trials in patients 0–18 years old comparing PVB (single shot or continuous
catheter) with any comparator and analgesic medication. Pain scores, rescue analgesia and adverse events were compared.
The systematic reviews identified six trials enrolling 358 paediatric patients. PVB medications included bupivacaine, ropiva-
caine, lidocaine, and fentanyl. Surgical procedures included inguinal herniorraphy, cholecystectomy, and appendectomy.
The standardized mean difference in early pain scores favoured PVB: 0.85 [95% confidence interval (CI) 0.12–1.58] at 4–6 h
and 0.64 (95% CI 0.28–1.00) at 24 h. One study reported a reduced length of stay. Parental [odds ratio (OR) 5.12 (95% CI 2.59–
10.1)] and surgeon [OR 6.05 (95% CI 2.25–16.3)] satisfaction were higher in those receiving a PVB. No major complications
occurred with a PVB.
PVB resulted in minimally improved pain scores for up to 24 h after surgery, reduced rescue analgesia requirements, and
increased surgeon and parental satisfaction. PVB is a good alternative to caudal and ilioinguinal block in paediatric abdomi-
nal surgery.

Key words: anaesthesia, regional; general surgery; paediatrics; review, systematic

Paravertebral block (PVB) is becoming more popular in paediat- cate, allowing the local anaesthetic to spread cranially and
rics as an alternative to epidural analgesia.1 The paravertebral caudally (limited by the psoas muscle at L1) to cover multiple
space is a triangular-shaped space bordered by the transverse dermatomes and produce a multilevel block, even from a sin-
process and superior costotransverse ligament posteriorly, the gle injection.2 The local anaesthetic can also spread laterally to
parietal pleura anteriorly, and the lateral edge of the vertebral the intercostal space and medially to the epidural space,
body and intervertebral discs medially. The spaces communi- although the latter is rare.3

C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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159
 160 | Page and Taylor

A librarian conducted a literature search of the following

Editor’s key points electronic databases: Web of Science (1945–present), Embase
• Paravertebral block (PVB) has an accepted role in adult (1947–present), and Medline (1946–present). Search terms
included paravertebral near block* or catheter*. The full search
thoracic surgery.
strategies for each database are supplied in appendices 1–3. The
• The benefits of PVB include lower risk of sympathetic
date of the search was May 20, 2016. Two reviewers independ-
block and neuraxial injury.
ently applied inclusion criteria from a review of the titles,
• This study identifies some beneficial effects of PVB in
abstracts, and keywords. Disagreements were resolved by dis-
paediatric practice.
cussion until consensus was reached. References were then
• Larger randomized trials are needed to confirm or refute
hand-searched by one reviewer.
these findings. Data were extracted using a data collection form by one
reviewer. The following items were recorded: operation, sample
size, intervention groups, details of the interventions, sizes of
intervention groups, age, outcome definition, outcome units,
The block is simple to perform, especially with ultrasound and outcomes data. Where a pain score was reported at a time
guidance, which reduces the time to complete the block.4 PVB has point for activity, movement, and rest, the worst score for the
relatively few complications and comparable efficacy to epidural time point was used. Authors of original papers were contacted
analgesia in adult thoracic surgery.1 Advantages of PVB include with up to two e-mail attempts.
unilateral blockade and limiting the haemodynamic changes The risk of bias of each study was assessed independently by
(including hypotension) and stress response resulting from a bilat- two reviewers according to the guidelines in the Cochrane
eral sympathetic block. PVB provides a more complete somatosen- Reviewer’s Handbook.10 Studies were assessed for random
sory block than an epidural without the risk of epidural-related sequence generation, allocation concealment, blinding of partic-
unintentional spinal cord damage.5 In theory, this allows higher ipants and personnel, blinding of outcome assessors, incom-
doses of local anaesthetic to be used with less risk.6 In adults, plete outcome data, selective reporting, and any other potential
randomized controlled trials (RCTs) have shown that PVB results source of bias. Any discrepancies were resolved by discussion. A
in a prolonged period of targeted analgesia and a reduced risk of loss to follow-up rate of 10% was considered the threshold for
postoperative nausea, vomiting, and complications.1 A recent attrition bias.
review of bilateral PVB in both adults and children having midline Meta-analysis was performed using Review Manager
surgery demonstrated that the risk of systemic toxicity is low (RevMan for Windows, version 5.3; Cochrane Collaboration,
despite large doses of local anaesthetic.3 PVB has extremely low Oxford, UK). The summary measure was the standardized mean
failure and complication rates in children.7 difference for pain score and the mean difference for time to
The majority of evidence for PVB points to its efficacy com- supplementary analgesia use. The summary measure was the
pared with epidural analgesia for thoracic surgery and open odds ratio (OR) for postoperative vomiting, site tenderness,
cholecystectomy. Increasingly, PVB has been recommended for parental satisfaction, and need for rescue analgesia, and the
other less painful surgeries, such as inguinal hernia repair and mean difference for LOS. Subgroup analysis by operation type
appendectomy, where an epidural would not normally be con- (inguinal hernia repair) was performed.
sidered.8 For these lower abdominal surgeries, PVB would be Variations in study design and the possible risk of bias
considered more invasive than the common alternatives such (methodological heterogeneity) are presented in Table 1.
as caudal, ilioinguinal block or local anaesthesia infiltration. Statistical heterogeneity was calculated using the I2 statistic to
The European Society for Paediatric Anaesthesiology (ESPA) has account for the variability in each effect estimate that could be
provided instructions for ultrasound-guided thoracic paraverte- due to a true difference between studies. We considered <30%
bral blocks on their website. This includes abdominal surgeries as low, 30–60% as moderate, and >60% as high.
such as inguinal hernia repair and appendectomy. The refer- Statistical significance was defined as P<0.05. A random
enced supporting evidence is based on four systematic reviews effects model with 95% confidence intervals (CIs) was used due
and one RCT, but all trials were done in adults.9 to anticipated heterogeneity and small sample sizes. To synthe-
We asked the PICO (patient problem or population, interven- size raw data reported in 95% CIs, the method described in the
tion, comparison, and outcomes) question: in paediatric Cochrane Reviewer’s Handbook was used to convert these to
abdominal surgery conditions (P), does paravertebral block (I) standard deviations (SDs) via the inverse of the t distribution.10
compared with all other techniques (C) result in improved clini-
cal outcomes (O)?

Results of the search

Methods There were 280 publications identified in the electronic data-
Inclusion criteria were RCTs with paediatric participants 0–18 base search and 115 duplicates were removed. Six studies were
years of age, with no year or language restrictions. Any level of included in the final, quantitative analysis. The PRISMA11 flow
PVB for a surgical operation in which an incision was made in diagram is reported in Figure 1. Four study authors were con-
the abdomen, including laparoscopic, inguinal, and renal sur- tacted by e-mail and none provided additional data. No addi-
gery, was included. All drug combinations for PVB and all com- tional studies were found by hand-searching.
parators (general anaesthesia, other nerve blocks or placebo) All included studies were RCTs published in English. The
were included. total number of participants in the six studies was 358. All par-
The primary outcomes were pain scores and requirement for ticipants were <18 years old. Table 1 provides a full description
rescue analgesia. Secondary outcomes were length of stay (LOS), of the characteristics of the included studies. All studies
satisfaction, and clinically relevant adverse effects, such as described single-shot techniques. Naja and colleagues12 13 pub-
postoperative nausea and/or vomiting and other complications. lished two studies of inguinal herniorraphy, one comparing
 Paravertebral block in paediatric abdominal surgery | 161

Table 1 Characteristics of included studies.n/N, intervention/total; chole, cholecystectomy; appy, appendectomy; lap, laparoscopic; GA,
general anaesthesia; INB, ilioinguinal nerve block; CB, caudal block; LI, local injection at laparoscopic ports; US, ultrasound; NS, nerve
stimulator; PVB, paravertebral block. a20 ml of the mixture contained 6 ml lidocaine, 2%; 6 ml lidocaine, 2%, with 1/200,000 epinephrine;
6 ml bupivacaine, 0.5%; 1 ml fentanyl, 50 lg ml1; and 1 ml clonidine, 75 lg ml1. b20 ml of the mixture contained 6.5 ml lidocaine, 2%; 6 ml
lidocaine, 2%, with 1/200,000 epinephrine; 6 ml bupivacaine, 0.5%; 1 ml fentanyl, 50 lg ml1; and 0.5 ml clonidine, 150 lg ml1

Study n/N Age, Surgery Control Guide PVB single shot Method of Lost to
years randomization follow-up, %

Eldeen 201615 20/40 2–5 Open Epidural: 0.25% US, both 0.25% bupiva- Computer PVB: 0
chole bupivacaine caine (0.5 ml randomization Epidural: 0
(0.5 ml kg1), fen- kg1), fentanyl
tanyl (1 lg kg1) (1 lg kg1)
Naja et al. 200512 25/50 5–12 Hernia GA NS Local anaesthetic Sealed envelopes PVB: 0 GA: 0
repair mixturea
(0.3 ml kg1)
Naja et al. 200613 40/79 5–12 Hernia INB: Local anaes- NS, PVB Local anaesthetic Sealed envelopes PVB: 0 INB: 2.5
repair thetic mixtureb only mixtureb
(0.3 ml kg1) (0.3 ml kg1)
Splinter and 18/36 3–16 Open appy Band-Aid No 0.2% ropivacaine Random number PVB: 0 Band-
Thomson (0.25 ml kg1) table Aid: 0
201017 with epinephr-
ine 1:200,000
(maximum
5 ml)
Tug et al. 201114 35/70 3–7 Hernia CB: 0.25% levobu- No 0.25% levobupiva Random number PVB: 0 CB: 0
repair piva-caine (1 ml caine (0.2 ml table
kg1) kg1)
Visoiu et al. 41/83 8–17 Lap chole LI: 0.5% ropivacaine No 0.5% ropivacaine Computer-gener- PVB: 2.38 LI: 0
201516 (0.1 ml kg1) (0.1 ml kg1) ated random
(maximum 5 ml) (maximum number table
5 ml)

nerve stimulator–guided PVB with general anaesthesia and one in only one of the six studies.16 However, in all five12–15 17
comparing nerve stimulator–guided PVB with ilioinguinal nerve remaining studies the anaesthetist and/or surgeon did not par-
block. One study compared PVB with caudal block in children ticipate in the outcome measurements. Three12 14 15 studies did
also undergoing inguinal hernia repair.14 One study compared not report any personnel or participant blinding, therefore it
ultrasound-guided PVB with ultrasound-guided epidural in was assumed that this was not done and all received high per-
patients with cyanotic congenital heart disease undergoing formance bias ratings.
open cholecystectomy.15 One study compared PVB with local Blinding of outcome assessment was separated by primary
anaesthetic injection at port sites in children undergoing lapa- outcomes because all pain assessments by hospital staff were
roscopic cholecystectomy.16 Finally, one study compared PVB blinded but parental assessment of pain and satisfaction was
(using loss of resistance technique) with a placebo of Band-Aids not blinded. Detection bias risk assessment was therefore sepa-
in paediatric patients undergoing open appendectomy.17 rated into assessment of pain outcomes, assessment of rescue
analgesia outcomes, and assessment of other outcomes (such
as satisfaction and complications). One study15 did not report
Risk of bias in included studies the blinding status of any of the three outcome assessments
Figure 2 summarizes the risk of bias assessment in each domain and another14 did not report the blinding status for parents and
for the six included studies. these were rated as unclear risk. All three outcome groups in
two of the studies16 17 were rated as low risk for detection bias.
Two studies12 13 had non-blinded parents assessing satisfac-
Allocation (selection bias) tion and pain scores after the child was discharged, introducing
All studies were at low risk of selection bias from random bias at this measurement time period. These studies were
sequence generation, however, five of the six studies did not therefore rated as high risk for detection bias for pain outcomes
report adequate information for allocation concealment, there- and other outcomes.
fore the risk of selection bias was unclear. Two12 13 of these five
studies reported using sealed opaque envelopes but did not
Incomplete outcome data (attrition bias)
state if they were sequentially numbered.
One study excluded an intended patient after allocation for
technical reasons and they were not included in the analysis.16
Blinding (performance bias and detection bias) No study exceeded the attrition threshold for patients lost to
Due to the nature of interventions, blinding the anaesthetist, follow-up and therefore all six studies were at a low risk of attri-
surgeon, and participating child with a placebo block was done tion bias.
 162 | Page and Taylor

280 records identified through database searching

MEDLINE (n=80)
115 duplicated records
EMBASE (n=135)

Web of science (n=65)

165 records after duplicates removed

158 records excluded:

43 non-abdominal studies

35 irrelevant studies

26 sudies in adults

20 case reports

14 reviews

9 retrospective studies

6 conference abstracts

165 records screened 5 commentaries or letters

1 full-text article excluded, done

7 full-text articles assessed for eligibility in adults

6 studies for final inclusion in meta-analysis

Figure 1 PRISMA flow diagram.

Selective reporting (reporting bias) Pain score

Five of the six studies reported the same outcomes as were pre- Five authors reported data on pain scores. Two studies reported
specified in the methods and one study14 appeared to be miss- pain on a 0–10 visual analogue scale (VAS).12 13 One study used a
ing outcome data according to the methods, which reported col- 0–100 VAS,16 one used a FLACC (Face, Legs, Activity, Cry, and
lecting heart rate, blood pressure, and SpO2 at 5, 10, 15, 30, and Consolability) score,14 and one used a CHEOPS (Children’s Hospital
60 minutes and 2, 4, 6, 12, 18, and 24 h postoperatively, although of Eastern Ontario Pain Scale) score.15 The data from Eldeen15 were
these data were absent from the results. not included in the meta-analysis because there was no 95% CI,
SD, interquartile range, or other measure of mean distribution pro-
Other potential sources of bias vided. Therefore, four studies12–14 16 were included in the pain
meta-analysis, which due to the different scales used was
Only one study16 specified receiving financial support. One reported as a standardized mean difference. Figure 3 represents
study15 calculated power retrospectively, but it is unclear how forest plots for these data. There was a significant standardized
this might affect the conclusions drawn. mean difference favouring PVB [0.85 (95% CI 0.12–1.58)] for early
pain scores (4–6 h), although inconsistency was also high (I2¼88%).
The same four studies12–14 16 reported pain scores at 24 h.
Effects of interventions There was no significant standardized mean difference [-0.38
Table 2 summarizes effect estimates for all of the outcomes (95% CI 0.99–0.24)], which may have been attributed to block
included in the meta-analysis. duration. The inconsistency was high (I2¼84%). Of note, the
 Paravertebral block in paediatric abdominal surgery | 163

Splinter 2010

Eldeen 2016
Visoiu 2015

Naja 2006

Naja 2005
Tug 2011
+ + + + Random sequence generation (selection bias)
?

+ ? Allocation concealment (selection bias)

?

?
+ - - - - - Blinding of participants and personnel (performance bias)

+ + + - - ? Blinding of outcome assessment (detection bias): pain outcomes

+ + + + + Blinding of outcome assessment (detection bias): rescue analgesia outcomes

?

+ + - - Blinding of outcome assessment (detection bias): other outcomes

?

+ + + + + + Incomplete outcome data (attrition bias)

+ - + + + + Selective reporting (reporting bias)

+ + + + + Other bias
?

Figure 2 The review authors’ judgements about each risk of bias item for each included study.

Table 2 Effect estimates. SMD, standardized mean difference; IV, inverse variance; RE, random effects; MD, mean difference; OR, odds
ratio; MH, Mantel–Haenszel

Outcome Studies Participants Statistical method Effect estimate (95% CI)

Pain score at 4–6 h 4 282 SMD (IV, RE) 0.85 (1.58 to  0.12)
Pain score at 24 h 4 282 SMD (IV, RE) 0.38 (0.99–0.24)
Pain score at 4–6 h (inguinal) 3 199 SMD (IV, RE) 1.19 (1.49 to  0.88)
Pain score at 24 h (inguinal) 3 199 SMD (IV, RE) 0.64 (1.00 to  0.28)
Time to first analgesic requirement, h 2 76 MD (IV, RE) 1.67 (3.93–7.27)
Number of patients needing supplemental analgesia (inguinal) 3 199 OR (MH, RE) 0.17 (0.08–0.34)
Postoperative vomiting 2 76 OR (MH, RE) 0.32 (0.07–1.56)
Site tenderness 3 212 OR (MH, RE) 5.15 (1.08–24.59)
Parental satisfaction 3 199 OR (MH, RE) 5.12 (2.59–10.12)
Surgeon satisfaction 2 129 OR (MH, RE) 6.05 (2.25–16.26)

mean pain scores from one study16 were provided as expected treatment effect, with a mean difference of 1.67 h (95% CI 3.93–
scores from a linear mixed-effects model since the raw data 7.27) and a high level of inconsistency (I2¼95%). Figure 3 shows a
were not available. forest plot for these data.

Hernia repair Hernia repair

Subgroup analysis of pain scores after hernia repair included The three inguinal hernia repair studies12–14 provided data on
three studies.12–14 At 4–6 h postoperatively there was a significant the number of patients needing supplemental analgesia post-
standardized mean difference in favour of PVB [1.19 (95% CI operatively. This showed a favourable treatment effect of PVB
0.88–1.49)] and inconsistency was low (I2¼0%). At 24 h there was [OR 0.17 (95% CI 0.08–0.34)] and low inconsistency (I2¼10%). Of
also a significant standardized mean difference in favour of PVB note, in one study six patients14 (two PVB and four caudal
[0.64 (95% CI 0.28–1.00)] and inconsistency was moderate patients) had a failed block, defined as needing rescue analge-
(I2¼35%). Appendix 4 shows forest plots for pain scores in this sia after 2 h. The mean duration of analgesia was 1300 min for
subgroup. PVB (SD 120–1440 min).14 A further 4 patients in the PVB group
and 12 patients in the caudal group needed supplemental
analgesia.
Rescue analgesia
Tug and colleagues14 provided data on time to first analgesic
requirement for the PVB cohort but not the control. Eldeen15
LOS
and Splinter and Thomson17 reported complete data on time to One study12 showed that the rate of same-day discharge after
first analgesic requirement, which did not show a significant inguinal hernia surgery was significantly increased in the PVB
 164 | Page and Taylor

Pain score at 4-6 hours

Paravertebral block Control Std. mean difference Std. mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV. random, 95% CI IV, random, 95%CI
Naja 2005 2.76 2.36 25 5.81 2.81 25 23.8% –1.16 [–1.76, –0.55]
Naja 2006 2.6 1.56 40 3.9 0.92 39 25.5% –1.00 [–1.47, –0.53]
Tug 2011 1.1 0.3 35 1.7 0.5 35 24.8% –1.44 [–1.97, –0.91]
Visoiu 2015 42.5 26.93 41 39 27.28 42 25.9% 0.13 [–0.30, 0.56]

Total (95% CI) 141 141 l00.0% –0.85[–1.58, –0.12]

Heterogeneity; Tau2=0.49; Chl2=25.34, df=3 (P<0.0001); I2= 88%
Test for overall effect Z=2.30 (P=0.02) –2 –1 0 1 2
Favours paravertebral Favours control
Pain Score at 24 hours
Paravertebral block Control Std. Mean Difference Std. mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV. random, 95% CI IV, random, 95%CI
Naja 2005 1.79 0.94 25 3.29 1.89 25 23.3% –0.99 [–1.58, –0.40]
Naja 2006 1.4 1.56 40 2.6 1.85 39 25.6% –0.70 [–1.15, –0.24]
Tug 2011 1 0.3 35 1.1 0.3 35 25.3% –0.33 [–0.80, 0.14]
Visoiu 2015 42.18 28.73 41 29.98 25.91 42 25.9% 0.44 [0.01, 0.88]

Total (95% CI) 141 141 100.0% 0.38 [–0.99, 0.24]

Heterogeneity; Tau2=0.33; Chl2=19.29, df=3 (P<0.0002); I2= 84%
Test for overall effect Z=1.21 (P=0.23) –2 –1 0 1 2
Favours paravertebral Favours control
Time to first analgesic requirement
Paravertebral block Control Mean Difference Mean difference
Study or subgroup Mean SD Total Mean SD Total Weight IV. random, 95% CI IV, random, 95%CI
Eldeen 2016 17.3 2.02 20 18.42 2.04 20 51.2% –1.12 [–238, 0.14]
Splinter 2010 7.1 4.4 18 2.5 1.6 18 48.8% 4.60 [2.44, 6.76]
Tug 2011 21.67 22 35 0 0 35 Not estimable

Total (95% CI) 38 38 100.0% 1.67 [–3.93, 7.27]

Heterogeneity; Tau2=15.54; Chl2=20.07, df=1 (P<0.00001); I2= 95%
Test for overall effect Z=0.58 (P=0.56) –10 –5 0 5 10
Favours control Favours paravertebral
Number of patients needing supplemental analgesia after inguinal surgery
Paravertebral block Control Odds ratio Odds ratio
Study or subgroup Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI
Naja 2005 8 25 22 25 21.7% 0.06 [0.01, 0.28]
Naja 2006 7 40 20 39 41.5% 0.20 [0.07, 0.56]
Tug 2011 6 35 16 35 36.8% 0.25 [0.08, 0.74]

Total (95% CI) 100 99 100.0% 0.17 [0.08, 0.34]

Total events 21 58
Heterogeneity: Tau2=0.04: chi2=2.22, df=2 (P=0.33); I2=10%
Test for overall effect Z=4.91 (P<0.00001) 0.01 0.1 1 10 100
Favours paravertebral Favours control

Figure 3 Forest plots comparing PVB with any comparator on pain scores and need for rescue analgesia for all surgeries.

group (80% compared with 52% in the general anaesthesia vascular puncture at a rate of 2.4% in the PVB group and 9.5% in
group, P<0.05). No patients with PVB stayed >24 h, compared the port site injection group. No study reported time to complete
with 16% in the general anaesthesia group (P<0.05). block.

Postoperative vomiting and complications Satisfaction

PVB did not decrease the incidence of postoperative nausea and Three studies,12–14 all in patients having hernia repairs, pro-
vomiting (PONV) [OR 0.32 (95% CI 0.07–1.56); I2¼0%].15 17 ‘Mild’ or vided data on parental satisfaction. This was defined as the
‘minimal’ block site tenderness12 13 16 was significantly number of parents who rated their satisfaction as ‘excellent’,
increased with PVB [OR 5.15 (95% CI 1.08–24.6); I2¼0%]. These and showed a significant treatment effect in favour of PVB [OR
data are presented in forest plots in Appendix 5. 5.12 (95% CI 2.59–10.1)] and low inconsistency (I2¼0%). Two stud-
One study14 reported the incidence of failed blocks, with a ies reported surgeon satisfaction,12 13 with a pooled estimate in
5.7% failure rate in the PVB group and an 11.4% failure rate in favour of PVB [OR 6.05 (95% CI 2.25–16.3); I2¼0%]. Figure 4 shows
the caudal block group. One study16 reported incidences of a forest plot representing these data.
 Paravertebral block in paediatric abdominal surgery | 165

Parental satisfaction
Paravertebral block Control Odds ratio Odds ratio
Study or subgroup Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI
Naja 2005 20 25 11 25 29.3% 5.09 [1.45, 17.92]
Naja 2006 37 40 25 39 25.6% 6.91 [1.80, 26.54]
Tug 2011 26 35 14 35 45.0% 4.33 [1.57, 11.97]

Total (95% CI) 100 99 100.0% 5.12 [2.59, 10.12]

Total events 83 50
Heterogeneity: Tau2=0.00; Chi2=0.29, df=2 (P=0.86); I2=0% 0.05 0.2 1 5 20
Test for overall effect: Z=4.70 (P<0.00001) Favours control Favours paravertebral
Surgeon satisfaction
Paravertebral block Control Odds ratio Odds ratio
Study or subgroup Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI
Naja 2005 22 25 13 25 47.1% 6.77 [1.61, 28.54]
Naja 2006 37 40 27 39 52.9% 5.48 [1.41, 21.33]

Total (95% CI) 65 64 100.0% 6.05 [2.25, 16.26]

Total events 59 40
Heterogeneity: Tau2=0.00; Chi2=0.04, df=1 (P=0.83); I2=0% 0.05 0.2 1 5 20
Test for overall effect: Z=3.57 (P=0.0004) Favours control Favours paravertebral

Figure 4 Forest plots comparing PVB with any comparator on satisfaction for inguinal surgeries.

Discussion Ultrasound-guided PVB blocks have a high success rate and

This meta-analysis of randomized trials demonstrates that PVB appear to be effective in reducing early pain after abdominal
provides a beneficial effect on pain scores at 4–6 h but not at surgery with some site tenderness. There are short-term and
24 h in children after abdominal surgery. The reduction in pain long-term analgesia benefits in hernia surgery. The improve-
scores is minimal at both time points and results are based on a ments in pain scores are minimal for PVB, but importantly the
meta-analysis of only four trials. PVB did not reduce PONV and comparators in two of these studies were other regional anaes-
seemed to be associated with more site tenderness. In the sub- thetic techniques. If anaesthesia providers are already consid-
group analysis of hernia repair, pain scores were reduced by a ering a regional technique for hernia surgery and have the
standardized mean difference of 1.19 at 4–6 h postoperatively. available infrastructure (appropriate monitoring, equipment,
The benefit was maintained at 24 h in this subgroup. There was training, and ultrasound availability), there are advantages to
a small benefit of PVB in reducing rescue analgesia but not for PVB. The parental and surgeon satisfaction scores are strik-
time to first analgesic requirement. Parents and surgeons were ingly favourable for PVB compared with caudal and ilioingui-
satisfied with PVB analgesia. One study reported reduced LOS nal block. The reasons for this are unclear and not available in
with the use of PVB.12 the studies included in this review. Surgeons and parents were
There are a number of limitations to our review based on the not blinded for these responses, so they may be biased. From
quality of the original data. All trials had small sample sizes. our clinical experience, we hypothesize that parents may
Studies used different surgical procedures, comparative variables, appreciate the longer duration of analgesia and the absence of
and measurement scores. We were able to provide subgroup weak legs in their child. The children in these studies were 3–
analysis data for inguinal herniorraphy only. Studies varied in 12 years of age and therefore these adverse effects may have
PVB solution and technique for insertion, and only one study15 been more troublesome than in infants. Surgeon satisfaction is
used ultrasound guidance. The effect sizes were small. also difficult to explain, as in our experience, a PVB takes lon-
Furthermore, the thresholds used (such as a pain VAS 1–10 score ger than the two alternatives and might delay surgery. Of
>4 or 5) for needing rescue analgesia were also variable, as were course, parental satisfaction may influence surgeon
the follow-up periods studied. Given the significant heterogeneity satisfaction.
in the methods of the trials, we were unable to attribute a rating There are few randomized trials of PVB in paediatrics and
to the overall quality of the evidence. In addition, we were unable only one trial included controversial placebo blocks as a control.
to perform a meta-analysis on haemodynamic data, as these Our review of the evidence of PVB compared with ‘standard
were reported in only two studies13 15 using different measures: care’ allows the clinician to make an informed decision about
absolute values and percentage change from baseline. the risks and benefits of PVBs in paediatric abdominal surgeries
Importantly, this review showed a higher reported incidence and provides further explanation to the indications provided on
of site tenderness (described as ‘mild’ or ‘minimal’) with PVB the ESPA website. From this review, we conclude that PVB is an
(8.5%) than other studies. A study by Naja and Lönnqvist6 previ- acceptable alternative for abdominal surgery in children, espe-
ously reported a 1.3% rate of site tenderness in adults and a 0% cially if factors in addition to absolute reduction in pain scores
rate in children7. are significant for individual patients.
 166 | Page and Taylor

Authors’ contributions 6. Lönnqvist PA, Richardson J. Use of paravertebral blockade in

children. Tech Reg Anesth Pain Manag 1999; 3: 184–8
K.L.T. and E.A.P made substantial contributions to the concep- 7. Naja Z, Lönnqvist PA. Somatic paravertebral nerve blockade.
tion and design, literature search, and analysis and interpreta- Incidence of failed block and complications. Anaesthesia
tion of data. Both were involved in drafting the manuscript. 2001; 56: 1184–8
Both authors have read and approved the final article. 8. Tighe SQM, Greene MD, Rajadurai N. Paraverterbral block.
Contin Educ Anaesth Crit Care Pain 2010; 10: 133–7
9. Raj N. Thoracic paravertebral block. Available from http://
Acknowledgements
www.euroespa.com/science-education/specialized-sec
The authors thank Alanna Marson for her assistance in the tions/us-regional-anaesthesia/truncal-blocks/thoracic-para
electronic searches for this project. vertebral-block/ (accessed July 1, 2016)
10. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews
of Interventions Version 5.1.0. Cochrane Collaboration, 2011.
Funding Available from http://handbook.cochrane.org (accessed July
25, 2016).
The study was completed without industry sponsorship or
11. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred report-
financial assistance.
ing items for systematic reviews and meta-analyses: the
PRISMA Statement. Open Med 2009; 3: e123–30.
Declaration of interests 12. Naja ZM, Raf M, El Rajab M, Ziade FM, Al Tannir MA,
Lönnqvist PA. Nerve stimulator-guided paravertebral block-
E.A.P has no interest declared. K.L.T. is a member of the ade combined with sevoflurane sedation versus general
Editorial Board for the Journal of Cardiothoracic and Vascular anesthesia with systemic analgesia for postherniorrhaphy
Anaesthesia and a member of the Society of Pediatric pain relief in children: a prospective randomized trial.
Anesthesia (SPA), Congenital Cardiac Anesthesia Society Anesthesiology 2005; 103: 600–5
(CCAS) and the Society of Paediatric Anaesthesia in 13. Naja ZM, Raf M, El Rajab M, et al. A comparison of nerve stim-
Australia and New Zealand (SPANZA). ulator guided paravertebral block and ilio-inguinal nerve
block for analgesia after inguinal herniorrhaphy in children.
Anaesthesia 2006; 61: 1064–106
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Handling editor: P. S. Myles