Comparison of Paravertebral Block and Erector Spinae Plane Block in Thoracotomy Using Nociception Level Index Monitoring: A Prospective Randomized Trial.

OBJECTIVE

Paravertebral block (PVB) is considered the gold-standard regional technique for thoracotomy analgesia, whereas the erector spinae plane block (ESPB) has gained popularity. However, evidence comparing these 2 techniques in open thoracotomy remains inconsistent. The nociception level (NOL) index provides a more objective assessment of intraoperative nociception. This study aimed to compare the analgesic efficacy of preoperative PVB and ESPB during thoracotomy using NOL-guided opioid administration.

DESIGN

Prospective randomized clinical trial.

SETTING

Single tertiary-care university hospital.

PARTICIPANTS

Fifty-seven patients who underwent elective thoracotomy surgeries were included in this study.

INTERVENTIONS: Patients were randomized to receive preoperative ultrasound-guided PVB or ESPB at the T5 level using 20 mL of 0.25% bupivacaine.

MEASUREMENTS AND MAIN

RESULTS

Intraoperative opioid infusion rate was titrated with the NOL index. Intraoperative remifentanil and postoperative morphine consumptions, pain scores at rest and during coughing, rescue analgesic need, and adverse events were recorded. Intraoperative remifentanil consumption was significantly lower in the PVB group than in the ESPB group (431.4 ± 287.7 mcg vs 863.6 ± 385.5 mcg, p < 0.001). Total 24-hour postoperative morphine use was also lower in the PVB group (15.2 ± 6.6 mg vs 20.1 ± 6.6 mg, p = 0.002). Numeric rating scale (NRS) scores at rest were significantly lower in the PVB group at 9 and 12 hours, while NRS scores during coughing were significantly lower at all postoperative time points.

CONCLUSIONS

In patients undergoing thoracotomy, PVB provided superior intraoperative and postoperative analgesia compared with ESPB, with significantly reduced opioid requirements and lower pain scores. Objective nociception monitoring with the NOL index demonstrated that ESPB may be insufficient for major thoracic surgery.