Surgical anaesthesia for hip surgery in combination with a sacral plexus block as an alternative to general or spinal anaesthesia

Postoperative analgesia after major hip surgery

Combined analgesia of the femoral, obturator and lateral femoral cutaneous nerves

In the axial plane, the thoracic paravertebral space (TPS) is a triangle with the base turned towards the vertebral spine, the parietal pleura and the endothoracic fascia are the antero-lateral border and the internal intercostal membrane is the posterior border

The apex points into the intercostal space laterally

The TPS communicates with the epidural space via the intervertebral foramina, with the mediastinum antero-medially, and with the intercostal space laterally

The internal intercostal membrane is continuous with the internal intercostal muscle (between the external intercostal muscles and the innermost intercostal muscles) laterally and the superior costotransverse ligament medially

The TPS extends down to the vertebral body of L1

The thoracic paravertebral space is located where the intercostal muscles meet the transverse processes

– informed consent

– monitoring

– intravenous access (and maybe sedation)

– sitting position, relaxed and slumped

– demarcate landmarks

– infiltrate with local anaesthetics

– pneumothorax (0.5%)

– sympathetic blockade with hypotension and bradycardia

– block failure 10%

Absolute contraindications:

– patient refusal

– allergy to local analgesics

– neoplasia in the thoracic paravertebral space

– empyema in the thoracic paravertebral space

– infection at the site of injection

Relative contraindications:

– coagulopathy/anticoagulation

– ipsilateral diaphragmatic paresis

The sacral hiatus can be visualised in transverse view displaying the typical rounded cornua sacrales with acoustic shadows and the anechoic caudal canal deep to the sacral part of the supraspinous ligament

A catheter can be placed with ultrasound guidance and in-plane technique in the caudal space

Analgesia after

– breast surgery

– thoracic surgery

– chest trauma

– abdominal surgery (inguinal herniorrhaphy, appendectomy, nephrectomy)

– upper limb surgery

The thoracic paravertebral block was described the first time by Dr. Hugo Sellheim in 1905