Thoracoscopy-Guided vs. Ultrasound-Guided Paravertebral Block in Thoracoscopic Surgery: A Non-Inferiority Randomized Trial.

Background: Thoracic paravertebral block (TPVB) is an established component of multimodal analgesia and enhanced recovery pathways following thoracoscopic lung resection. A surgeon-performed, thoracoscopy-guided approach has been proposed to improve intraoperative workflow, but high-quality comparative data are limited. Methods: In this single-center, randomized, non-inferiority trial, adult patients undergoing thoracoscopic lobectomy or segmentectomy received either thoracoscopy-guided TPBV (T-TPVB) conducted by surgeons or ultrasound-guided TPBV (U-TPVB) conducted by anesthesiologists. Blocks were performed at the end of surgery at the T4 and T7 vertebra levels, using 10 mL of 0.5% ropivacaine per level. The primary outcome was dynamic pain during coughing at 1-6 h postoperatively (visual analog scale, VAS). Secondary outcomes included resting/dynamic pain scores, opioid consumption over 48 h, block-related complications, and procedural time. Results: Seventy-three patients were included in the intention-to-treat analysis. Mean dynamic VAS scores at 1-6 h were 3.3 (T-TPVB) and 3.1 (U-TPVB), with a mean difference of 0.2 (95% CI: -0.3 to 0.7), meeting the non-inferiority criterion (margin 0.9). Secondary outcomes, including pain trajectories and opioid consumption, were comparable between groups. Procedural time was significantly shorter in the T-TPVB group, with no differences in complication rates. Conclusions: Surgeon-performed thoracoscopy-guided TPVB was non-inferior to the standard ultrasound-guided technique for early postoperative pain after thoracoscopic lung resection. Both methods provided comparable analgesic efficacy and safety profiles, while T-TPVB significantly reduced procedural time. This approach may support streamlined perioperative workflows and optimize enhanced recovery protocols in thoracic surgery. (Trial registration number, KCT0006471).