S3:E1 "Paravertebral: The King of Nerve Blocks 👑 (Part I)"

We may be in the middle of dry January, but I'm still using a wet needle. I'm Jeff Gadsden. We are royally excited to bring to you this regal episode featuring the one, the only, the king of blocks, the paravertebral block. I'm Amit Pawa. And this is Block it like it's hot. 

Hey, Jeff. Happy New Year. It's 2025, another year and another season. Hey, Ahmed. Happy New Year to you too. 

I I can't believe that we're speaking what is now in our third season. I know. Who knew we'd have so so much reasonable stuff to talk about, and dad jokes? Well, I mean, dad jokes are kind of that's the bit about the podcast that I feel stressed about every time because we seem to have have created a bit of a reputation for delivering at a certain level, and you always beat me. So I feel I feel under pressure about that. 

Oh, I don't know about always beating you, but, like yeah. Anyway, forget forget the, the hardcore science. Let's let's focus on the the dad jokes. Hey. Did you have a good festive season? 

What'd you get up to? Lots of mince pies by the fire and your top hat with a glass of sherry, perhaps? Well, you know what? I missed a trick. The top hat was actually put away for the winter season. 

But yes. Oh, no. Yeah. I know. You know, we gotta I've gotta keep it pristine for every outing that it has. 

So it it was tucked away. I put it to bed for for into hibernation. But we had plenty of mince pies, and some of my favorite Christmas pudding was consumed. And then, you know, we spent time with Kate's family and with my family, but then after that, we did something a little bit crazy. Oh, what'd you do? 

Well, you know that I was suffering with some big apple withdrawal. And, of course, I'm not referring to the fruits. We headed back to one of our favorite cities. I've hung out in New York City for a few days between Christmas and New Year's. That Twixmas period, it was so much fun. 

Wait. What did you call that? Twixmas? Twixmas. Twixmas. 

Are you not familiar with that? No. No. I'm not. Listen. 

I hope I've not made something up. This is another thing. I you know, I've got such a rep for making words up like symmetrization. Do you remember that one? But yeah. 

But Twixmas, I'm sure, is that period between Christmas and New Year's. I love it. So, yeah, Merry Twixmas. I I think I think that's the thing. At least I I've always called it. 

I'm I'm adopting that now. Write write it down so I don't forget it for next year. Well, that's so great, man. I I New York at Christmas time and the holiday season is such a special place. I saw some of your posts, but what did you what were the highlights? 

What did get up to? Again, I'm I'm sorry about those posts. I kinda get a bit excited when I go on holiday. So I love them. I feel like I'm, you know, right back there. 

Well, we did some cool stuff. We checked out have you seen that right opposite the Louis Vuitton store on Fifth Avenue, they put this hoarding up. So they've got scaffolding outside the building. I didn't realize it was scaffolding. I actually thought it was a whole building, but and on top of the scaffolding, they put this Louis Vuitton suitcase facade. 

So the whole building looks like a sequence of suitcases stacked one on top of another with the Louis Vuitton. I said that three times. We need to get some money for that break. It's crazy. So, we went, we we went to check that building out, which I've seen all over TikTok, and, of course, I recorded my own TikTok, on that. 

What do we do? We walk the High Line. I've heard about the High Line for ages, and we've never actually walked it. So I managed this time to go walk the High Line, which was so cool, like this elevated walkway park. Right. 

We did ice skating in Central Park. We checked out the Rockefeller Christmas tree. Yeah. We saw a musical. We did a couple of cool restaurants that we hung out in Times Square. 

So, dude, I think we did a lot for our third trip two years. So we oh, I was wonderful time. That's amazing. I'm so happy for you guys. Thank you, man. 

Well, listen. What about you? I you know, I've told you about all the things that I did. What did you do over the festive season? I'm curious. 

Over Twixmas? Well Over Twixmas? Yeah. You know, I've, I've been pretty fortunate with my schedule in years past in terms of having time off at Twixmas. But, but this year, had to pay the piper and work most of that week. 

Oh. So not very exciting, except I got up to go in to work on the twenty seventh, and there was a page saying that there was a burst pipe in the hospital and all cases were on hold. Now Uh-huh. This has happened before, and, you know, like, the small leaks here and there, they have to make sure that whatever small amount of water doesn't get into the sterile processing department and is cleaned up, etcetera. But this was this was different. 

This is a 12 inch chilled water pipe at high flow. So imagine imagine what that, like, that's 30 centimeters. You know? That's a lot of water. It was directly over the emergency room and radiology. 

Oh my goodness. And there were videos floating around on TikTok and Reddit, which Duke was not so pleased about. I'm sure. Showing people wading through a river in ED with, like, this, you know, a pretty decent current. Anyway, long story short, we had to close our ER for a few days. 

So my weekend call shifts were kinda weirdly devoid of appendectomies and hip fractures and stuff. But, yeah, bit of a different, different twixtmas. That's crazy. You said, like, literally, the hospital was flooded. I mean, that is literally crazy. 

Oh my god. Yeah. It was what's amazing is how quickly they pivoted. Like, they had work crews twenty four seven. They had tents outside the ED. 

Yeah. So we could get patients in eventually, but for twenty four hours, we had to divert things. Anyway, but let me tell you about Christmas. So Uh-huh. You know, I've I want to do nice things for my family and my wife every year. 

So I took Cory to one of our local orchards Mhmm. And we stood there holding hands and admiring the trees for about half an hour. It wasn't the Apple Watch she was expecting, apparently. Oh. Sorry. 

That was the weirdest laugh because I was so invested in this story. I was like, where's it gonna go? Where's it gonna go? Oh, yeah. Oh my god. 

Already, that's a contender for the joke of the joke of this episode. Okay. Okay. No. But but for reals, for Christmas for Christmas, I got Corey new beads for her abacus. 

It's the little things that count. I thought I just get them in there get them in there early. You know? Get get the jokes in there. Oh my god. 

Anyway. Yeah. Oh, wow. That took me by surprise. I've gotta say that was great. 

Thank you. I'm I'm glad. I'm glad. Hey. Listen. 

We need to start this season strong. So what have our listeners got to look forward to in this episode? Well, you know what, Jeff? I figured we skirted around this block quite a lot, but not really giving it the attention it deserved. So for this episode, Jeffrey Charles Gadsden, I wanted to deal with regional anesthesia royalty. 

We are, of course, going to talk about the paravertebral block. Oh, the paravertebral. Yes. I was wondering why you use my royal middle name, Charles. You know, I've actually got two middle names. 

Oh, no. I didn't know the second. What what's the other one? Yeah. Yeah. 

Frederick. No. It's not. Jeffrey Charles Frederick Yeah. Gadsden. 

Yeah. Yeah. I know. I know. Why do you use that? 

You need to use that. I think that's brilliant. It's just it's a lot. You know? Anyway Jeff Chip Fred Ganston. 

Oh, Chip. Yeah. I went by Chuck for a while in in Chuck. High school. What's the official what's the official sort of shortening version of Charles? 

Is Chip is Chip one of them? Did I just make that up, or is it is it Chuck? Chuck Charlie Chuck, I think, is mostly what people would go for, but Chip I kinda like Chip. Yeah. I I don't know where that came from. 

I could be a Chip. Chip's got a, like, chill guy vibe. You know? Yeah. I think so. 

I think so. Okay. Let's get into para So listen. Let let Let's get into paravertebral. Paravertebral? 

Paravertebral. I I can't listen. The problem with doing this international podcast is that I don't know how to say words normally now, and I'm kind of mixing my Americanisms and my, my UK, English pronunciation. But anyway, listen. Did you know that we not only have gynecologists to thank for our children, we also have gynecologists to thank for the paravertebral block because it was pioneered by a chap called Hugo Selheim of Leipzig in Germany. 

Do you know when that was? No. I don't know. What accent was that? Irish? 

I don't know. I was yeah. I was heading towards the German accent, but then it took a wrong turn. But, actually, my friend, it is nineteen o five that I think you'll find this was, initially did pioneer, and it was used for abdominal analgesia. Really? 

That was that was good. That was a good accent. Really? By a gynecologist? You know what? 

I I I already sense I I sense this is gonna go badly from here. So, but I I think I nailed German. I think they can tick that one off. Right? Tick. 

Bing. Okay. But but after this guy so that is back in nineteen o five, so not that long ago. And then there a few other guys. So when I was looking through the hit you know, the the history of this, because I've done it in a few presentations, a chap called Arthur Lorne in 1911 who coined the term paravertebral conduction anesthesia. 

And then there's a mystery person. I've never managed to find out what their first initial stands for. So in 1919, somebody called m Kapis, k a p p I s, used, paravertebral injection for surgical anesthesia for abdominal surgery, but I've never been able to find out what the m stands for. So m Kapis in 1919. So it's kind of been around since the early nineteen hundreds, but they fell out of favor in the mid nineteen hundreds. 

I'm not really sure why. Have you got any ideas? Yeah. It's weird. Right? 

Like, how does something that works so well, as we'll talk about, then kind of fall out of favor? Was was it that epidural analgesia sort of became more in vogue? And I imagine there's some technical and we'll talk about this more, but, you know, I think a lot of people would get leery about sticking needles so close to some high stakes real estate back there. Yeah. Yeah. 

And I guess, ultimately, if it's a if it's predominantly meant for a unilateral type of anesthesia, analgesia, and the epidural came into the fall there, and that was something that could give you bilateral, something more complete anesthesia slash analgesia. I can guess that that may be why it became, a if that it became less popular. But there's a couple of names I'm sure you remember. Ethan and Wyatt in 1979, shortly after my birth. They popularized, the paravertebral block, and they they wrote a nice paper, and then that they sort of became more of a thing. 

But, again, like anything in medicine, they weren't quiet again, certainly from my point of view, until the era of ultrasound and the next generation greats like John McDonald, Manas Karamaka, Cedric Luye, Peter Marhofer, Blanco, Ben Ari, blah all the all these guys started publishing about them Mhmm. Mainly with the use of ultrasound. So it's kind of been one of those those techniques in medicine that's kind of gained wax and waned in popularity over the years, which, again, I find fascinating, but there's potentially a lot of reasons why. I mean, do you remember your first paraveral block? I don't know if I remember my first one, but I remember one of the earliest ones. 

Because Okay. I trained in the nineteen hundreds or, like, you know, late nineteen turn of the turn of the century, let's say. I started residency in 1999, so technically, yeah. Oh, that's true. But so we were we were doing landmark based. 

Uh-huh. And I do remember being talked through this. Okay. You're gonna draw out a line two and a half centimeters from the midline. You're gonna stick a needle in and hope that you hit the transit process Uh-huh. 

And then pull back and re angle, go in under the centimeter. And Yeah. I'm like, alright. That sounds scary, to say the least. But I remember one one time I was it must have been my third or fourth one. 

Kept going, kept going, kept going. And someone else had the the syringe and aspirating, and all of sudden, I saw this big air bubble track coming through. Oh, yeah. Yeah. Yeah. 

Yep. So hey. Patient did fine. They actually Okay. Like, never had breathlessness, and we did a chest x-ray, and it was like this minimal pneumothorax. 

But, yeah, I have caused a pneumothorax with a with a blind PVB. So that's not many people could say that for sure, but that's interesting. Yeah. At some point, what must remind me, I wanna talk about the mechanism behind creating pneumothorax because that's something I need to still get my head around a bit. It's not just about popping a hole in something. 

But, yeah, we'll come on to that in a second. So I do remember my very first paravertebral block, and it's really interesting. Oh, nice. So I remember index case number one. So I was a senior registrar on call at Guy's Hospital, and I'd never done a paravertebral block ever. 

And I was supervising a junior resident who, had come from India and obviously had completed their training. So I was actually a consultant in India, but was working their way up the ladder in The UK was, was my junior. Sure. And there was a patient having a thoracic surgery done, and he said, oh, can we do a paravertebral block? And I said, you know, I've never done one. 

They said, oh, I'll teach you. And I was like, okay. Well, this is a bit weird, but, you know, he was very experienced. So we you know, he I got a Turing needle and a loss of resistance to air Oh. Syringe. 

And he he told me the same, the same landmarks that you did. He's like, right. You know? Yeah. Here, you're gonna you pop your needle in, and you're go into you, until you hit bone, so transverse process. 

And then you just walk past it, and when you get lost resistance, they they will go in about a centimeter after that. And that's what I did, and it seemed really easy. And we injected the drug, and everything was fine. And, actually, when they went in for thoracic surgery, they were able to see that blurb of local antidote we injected in the paravertebral space. So that was really weird, but it seemed ridiculously easy because I did exactly what this guy told me to do. 

But you know what? I have never done a landmark paravertebral since. Yeah. Well, I'm not surprised. I mean, it it I'm glad I'm glad that went well, but, you know, we did a study. 

We like you, I have I only do paravertebral with ultrasound now because Yeah. Why wouldn't you if you have the imaging technique to do this? But there are still there are still some that that like to teach this. And Uh-huh. So we asked the question, now that you can see what you're doing, how many times were we actually not in the right place with the old technique? 

And so we had Robert Nichols from from Valkyrie who makes these amazing high fidelity anatomic simulators make us a paravertebral. He took a he took an image of his wife's spine. He took like, I got a CT scan or something, created the bones and the ribs, and then made the soft tissue, and including he included a a paravertebral space up and down where it ought to be, and then inserted a little small camera at the end of it, in the caudal end of it, so you could actually, on a separate monitor watch the paravertebral space. We had trainees and consultants say, Alright, here, here's how you do a paravertebral, now go and do one and see where the needle ended up. You could, of course, you could see, oh, you're in the peritubal space, or your needle was never in the PV space, or your needle went through and through and you're in the pleura. 

And you might not be surprised to hear that over half the time the needle was not in the right spot. So either a fail, meaning it was never in the perivatuberous space, and we'll talk more about sort of what that means in the anatomy and Uh-huh. How our conception of that has changed a bit. But a substantial amount of the time, the needle was in the pleura. So you you know what? 

So I actually heard about your study quite, a while ago because doctor Iwana Kostash, who created the MTP, the midpoint between transverse and pleura block that we, we published a while back Yeah. She had seen your work on this, and and it kind of really invigorated her passion in ultrasound guided paravertebral blocks just for the fact that, you know, you'd shown that a lot of the time when we think we're doing landmark blocks, we're not getting where we want to. So it's fascinating. And I and I know that, John McDonald who taught me the paravertebral block quite would often say, you know, every time when you when you move lateral from the, the tip of the spinous process, you yeah. And you you either at that point, you go, you know, you go lateral and and go straight down or you drop down by a centimeter. 

You're hoping that the first bone you're making contact with is a transverse process. But, of course, it might be that you're making contact with the rib. Yes. And then when you walk off the rib, you know what the next thing is. And that and that that, you know, we're when we're working on blind assumptions, there's a lot of things that are unknown. 

So I think that study is fascinating. And do know what? We actually have one of those simulators. GE very kindly bought us one of these simulators, but I have never figured out how to use the cameras. Oh, yeah. 

So now that I've now I've heard about this, because there's something about filling the space with saline or something. I don't know. I need I need to I need to look into this, but maybe I'm gonna have a play with seeing if I can work out how to use this camera. Okay. Cool, man. 

So, you know, let's let's take a step back and talk about what we can use this block for. So we this is this is our number one go to for mastectomy and other breast cases, but we do use it for a lot of other things. How about how about you? Yeah. So I think, at my institution, the two, biggest indications are thoracic surgery, number one. 

So our thoracic kinesis are quite often doing a preemptive presurgical, single shot, maybe maybe double shot, thoracic perivirtual block, and and we're using them for mastectomies. I'm probably the the biggest practitioner of, perivirtual blocks for mastectomies at my place, but more and more of our previous fellows who've now come back as consultants are doing that. Oh, good. Thoracic's followed by breast. Yeah. 

Yeah. Yeah. We'll also do it for unilateral incisions in the abdomen, like like a nephrectomy or or something like that when Yeah. You don't need the both sides. The other thing we've we used to do a lot of, and I pulled this out once in a while still, is for inguinal hernia repair. 

Is that right? Yeah. So if someone, like, really either the patient or the surgeon really wants the patient to be quote unquote awake and and not have a full general anesthetic and and for whatever reason can't get a spinal or doesn't want a spinal, this is a a cool technique to do. Oh, wow. I think I don't think I've ever used it for that indication. 

What level do you do your block at then? Low thoracic. Yeah. So t nine, ten, eleven, twelve, and then l one. And what I'll do is use ropivacaine for the first four levels and then use, like, lidocaine for the one. 

Just Uh-huh. Just in case you get a little trickle down to l two or l three, you don't wanna you know, it's one thing to wake up from your hernia and be able to walk out of the hospital, but you don't wanna cause some quads weakness. So How fascinating. And and are you aware of anyone using them for, cardiothoracic surgery? I know there was a, an interest in the past of using epidurals for, for cardiothoracic stuff, but have you, use them for cardiac surgery as opposed to thoracic surgery? 

Yeah. Yeah. Yeah. For we we use we're using them routinely now for a lot of our minimally invasive cardiac surgery where they're using ports and, that sort of thing on on one side of the chest and getting really good results. So this has this has been it's one of those things in our field where, you know, you can push for a block and try to convince the surgical colleague that this is a good thing. 

This has been the reverse, where the surgeon says, this is so good, my patients look so great in the cardiac ICU, We need every patient to get this. Wow. Yeah. So it's, those those are those are fun fun experiences, obviously, when when that happens. Okay. 

Cool. Well, You know, I had one other indication I've used them for, and that was for a I didn't did one for a lap chole laparoscopic cholecystectomy. And that was and the interesting thing is I was teaching on a course where they get the faculty to perform blocks that they get shown to a live audience. So they had found a patient who's having a laparoscopic cholecystectomy and, consented her to have a paravertebral block. So not only did I have to do that for an indication I haven't done before, but I had to do that to a live audience. 

So that was probably the most nerve wracking paravertebral block I've ever done. And and worse things worse, one of the live audience members I was watching was Kijin Chin. So he was in the audience watching me do this block. No pressure. Yeah. 

I've just I just got some PTSD. Well, listen. So I think it's a really sensible review of the, of the anatomy, not or or the indications, not surprisingly, cardiac, thoracic, breast. So from a chest point of view. And then abdominal stuff, you've talked about the use in, you know, unilateral abdominal incisions such as nephrectomy or inguinal hernia repair. 

But what about for trauma cases? Are you are you using them, for any of your trauma cases? Like, like, fractures, for example? For rib fractures. Yeah. 

That's that's the main thing. And, man, what a great block for rib fractures. You know, if we have bilateral rib fractures, an epidural is great, but, you know, one of the things about trauma is you can't control what medications your patients come in on, and a lot of them come in on DOACs and that sort of thing. So Yeah. You have to choose something different. 

Some of my colleagues would choose an ESP. I I do I think I think PDB is is is the king of blocks and is is the one that is going to work the best. And so we'll talk a bit later about anticoagulation and what we think about that. But how about you? So so I a 100%, you know, in terms of indication of rib fractures, I think paravertebrals are a 100% the gold standard. 

However, one of the things that has happened now, we've talked a bit about this in the past, is about skill level and expertise and out of hours. People still are scared of doing the paravertebral blocks, so we'll talk about maybe why later. What's happening is now people are looking for the safer alternative. And one of the potential downsides, and I'm gonna say this once and once alone, one of the potential downsides of of simplifying techniques to regional anesthesia is if you teach people, say, look, if you're scared about doing a paravertebral or if you don't have the skills to do a paravertebral and you do an ESP block instead, is that you'll train a whole host of people up to do ESP blocks. And if they get results that are good enough, they may never progress to doing a paravertebral block. 

So at my institution, what's happening is out of hours, people are more comfortable to perform a serrated anterior plane block or an ESP block for rib fractures because that's where their comfort level lies. So that's what they'll do as a default. And, if the patient does okay, they'll never progress to the next level. So we're in a little gap now where we've we've dealt with the fact that there are many people who were not comfortable to do regional anesthesia for trauma patients before, and now they are, which is great. They can do something and offer them something beneficial. 

And where they wouldn't have put in a thoracic epidural and there was nothing in the middle, now they can do a procedure. But now we still haven't got that cohort of people to migrate up towards performing paravertebral blocks. That's phase two, I guess. Phase one is to get everybody comfortable to do something. But in my institution, yeah, ESP or Serato's plane is the default. 

Paravas was not the default, and I think in the future, it'd be great to step up to make the paravasual choice number one. Well yeah. And that is the downside of the plan a blocks push, right? Is that I'm 100% behind it. I mean, to improve access to regional anesthesia for every patient on the planet, and doing that logically means getting everybody skilled on seven blocks, seven basic blocks. 

But it's interesting we're talking about how the the popularity of this block has ebbed and flowed over the years. I think we're in the beginning of a renaissance for for paravertebral because, you know, I remember when it was a landmark based technique, and we'd have people at workshops saying, hey. Show me how to do this, and thinking, I do not want to teach you that. I I don't feel right taking five minutes to show you a technique without a lot of coaching and watching you do it and saying, woah, stop. Put your needle here, here, here. 

Yeah. But now with the ultrasound guided technique, and we'll talk a bit about how you do it versus how I do it, I think it's very, very safe and the concerns about causing a pneumothorax or some other, you know, complication are I think they're really overstated now with a very safe ultrasound guided approach. So I I and and as as we and there's no doubt the benefit of this block is is tremendous. You can get an entirely anesthetized hemithorax. So you do, you know, awake breast surgery. 

You you and I have talked about this before. So Yeah. So if that's what you can get out of it, there's no the value is amazing, and the risk, I think, is has been minimized with the use of ultrasound. I kinda feel that we've hit a pivotal point here. I think the statement you just made that we are now in that renaissance period now in the paravertebral block is is gonna take off again. 

I I think I feel that you've said something really monumental because I wanna believe that, and I think I think it may happen. So, folks, remember the day that you listened to this is when Jeff predicted the future. I think it's gonna happen. But, actually, I think it's because the ESP block. I think the ESP block has got so many people on that ladder that once they've taken that first step to progress so, again, we'll talk about that later to progress onto doing para virtual block will will will it will happen eventually. 

Eventually. Yeah. Yeah. Now I wanted to talk in about I wanna talk about some of the the nuts and bolts of procedure. The first question is probe choice. 

So most of us at our institutions will have easy access to a linear probe. And do you think the linear probe is suitable? So when using an ultrasound guided linear footprint probe, is that suitable for the majority of paravertebral blocks? It's it depends on the the weight of the patient, the mass of the patient. So linear if I can, curved if I must. 

I think I think that summarizes it really nicely because actually when I first started and I learned these from, John McD, I I only learned them using a linear probe because that you know, most of them, ultra machines I had access to just had one probe on them. So with a linear probe, and if we wanted to get a Curb's Ray probe back in the day, was a bit of a pain. So I may do, with a lot of my blocks using a linear probe, but there was the odd patient where it became difficult. Things are a bit deep or I wanna ask you about this in a second after we talk about positioning. All the absorption of the tissue, be that the fats or be that the muscle was such that it made imaging of deeper structures a little bit more challenging. 

So I struggled. There's definitely a few blocks when I thought, I don't know how I'm gonna manage this. And this is before the ESP, block was described. So I was I kept trying to get my needle deeper and deeper, and I, you know, sometimes I abandoned it because it was difficult. The curved array probe has been an absolute game changer for me. 

So I think you're right. In the right indication, if you got if you don't get a great image of a linear probe, make a very quick decision to switch to a curved array probe because it suddenly makes things a lot easier. But you lose some of that that, that clarity, some of that resolution, obviously. Yeah. Agree. 

You'd agree with that? I agree with that. We'll, unless a patient has a BMI over forty, we'll typically put a sterile probe cover on the linear probe, but have another probe cover ready to go in case in case we can't just see those fine details, and we'll switch to the the curvy. Absolutely. Now this is as I said, this might be controversy number one. 

Here we go. What position do you have your patient in? Sitting Supine. Prone. Supine, did you say? 

Do you do you remember you remember one of the first episodes where I thought I did ESP block supine or something? But yeah. Yeah. Yeah. I'm still I'm still trying to construct I wanna build a bed with a little window in it in it so I can I can sit lie underneath it like Michelangelo and do a a pair of vertebral from below? 

Folks, stay tuned for that video. So sitting prone, lateral, floppy, or sloppy lateral. What are your choices? Sloppy, sloppy. Lateral. 

Sitting. I like sitting. And always have done and always will do? It depends on the situation. Like, if I'm doing it post op sort of pre extubation for a nephrectomy, I'll just put took them lateral. 

I don't know if I've done a prone pervertebral. It seems like it would be, you know, straightforward. So, sitting I like. Okay. So you got the patient sitting. 

Who's in front of them? How are you supporting them? How are you you give me an idea of your setup. Yeah. It's kinda similar to how we'll do most of our neuraxials in the pre op block area. 

Like, we'll have, you know, a bit of sedation, nurses in front sort of supporting them. I don't need them to bend over in the same way that I would for a neuraxial, like, you know, touch your nose to your belly button kind of thing. I am a fan of skin local. Yeah. So Yeah. 

Yeah. I'll admit to you right now, I don't use skin local for most of my blocks. I think of yeah. Yeah. I know. 

I know. I but a bit of sedation gets you through that, this is a case where I think I I can't give too much sedation because then they're gonna fall off the bed because they're sitting. So a a nice little amount of skin local at the at the site is nice. So, yeah, sitting sitting, bit of sedation, nurse holding the patient from the front. How about you? 

Mhmm. Okay. Interesting. You're not a fan. I you're I'm I'm seeing you giving this a one star review now that might take a look. 

I I would not recommend. No. No. No. No. 

Is how I was taught to perform all of my parabertial blocks. So that's exactly what I did. I think because a lot of the time, remember, we were doing these and are doing these not in a specific block room setup, but in our anesthetic room just prior to the Operating Theater. We weren't necessarily getting anesthetic assistance or anesthesia nurses who were dedicated, skilled, or trained in regional anesthesia. They were, you know, helping us with the whole anesthetic journey. 

Some of them were very engaged with helping, with patient positioning, and some of them were less so. And I remember when my early days of doing one of these blocks in a patient sitting, there's me struggling, trying to trying to get my needle in the right place. I was trying to work out why every time I was putting some pressure with the probe and the needle, the patient was wobbling from side to side. And then I looked up, so the anesthetic nurse was leaning on the counter in front of me with the arms folded, actually not participating in helping support the patient itself. So so I had a couple of but a couple of not so supportive assistants, and that made me feel a bit ropey. 

The other thing was, sometimes when you're teaching this technique to people, and certainly when I'm doing bilateral blocks, after a while, the ergonomics of the block are associated with increased fatigue. If you think about it, you're holding your arm away from your body often at shoulders length, or, you know, shoulder height, sometimes a little bit higher if you're doing higher blocks. And whilst you're doing one block, then you come on to the other side. If it's taking a while, it's associated with fatigue. So I found that my residents were getting tired quite easily and getting hand cramps. 

And then, actually, if you're doing a bilateral block, once the first injection's gone in, when you move across the other side, the patient's starting to feel a little bit ropey, then maybe getting a partial sympathectomy from the first block. And I've had, the most beautiful vasovagal episode, which actually I caught on camera Okay. Because I was filming it for a course that I was doing, one of the earlier Elsora courses. I had a colleague of mine called Diego Olivari, who was Portuguese who was visiting us from Portugal at the time, and he was he was performing this technique. We had a a camera set up and everything, you know, all all under consent, everything appropriate. 

And as we're doing the block, it was only because we had full monitoring instituted. The heart rate went from 75, 80 to 30. Yeah. And the patient just went boom. And so you had to pull the needle out and get them get a sup supine in. 

So that's obviously more of an issue if you got the patient sitting up. So I used to be a massive fan of sitting perivertical blocks, and then I moved to lateral or floppy laterals to get them on the side and get them to sort of semi rollover into their front. So what is that? Like a semi prone position? Thus, I used to start doing that, and that was a bit easy, but that was easier to perform. 

But, actually, it's quite difficult to explain what I wanted the patients to do. I'd say to the patient and give them a bit of sedation. Can you get on your side and then sort of sort of roll onto your body, but not really? And the patients were so confused. So, actually, now I do all of mine prone. 

Oh, really? I actually get the patient in. Okay. Cannula in. I said, right. 

Can you lay in your front? And it's just so much easier because they're in one position. They don't move. You can give them as much sedation as you want. You can get them fully monitored. 

They ain't gonna fall over, and you can do either approach in the prone positions. That was a long explanation as to why I've transitioned from, sitting to lateral to floppy lateral to prone. What a lot of people don't like is when a patient's, lying completely prone, you can kind of exaggerate a thoracic lordosis as opposed to a kyphosis unless you put a pillow underneath the chest. And so sometimes it can change the, you know, the way that the spine is curved. So I'll often put a pillow underneath the chest, but that's where I've migrated to now. 

Yeah. That's cool. My only struggle with the prone sometimes for any kind of block procedure is cord management. So the EKG wires and the oximeter and the blood pressure thing, it's, like, wrapped up like a, you know, burrito. And It's almost like you knew what I was gonna go with that because this is one of my pet peeves. 

Yeah. So I say to the my anesthetic assistants the because moment a patient comes into the room, they're like, stick sticking all the wires on it, and I say to him, guys, wait. Put the cannula in. I get the sedation on. I get them prone. 

Then you can put your monitoring on. And they don't like that because I wanna get the monitoring on, but that's the one thing I do. So and for exactly that reason. That's smart. That's clever. 

You're very clever. I'm not that clever. So what kind of what kind of needle do you like? Yeah. So I again, I'm not don't want you to give the impression that I I changed my opinion just because people say things, but I used to use a standard regional block needle. 

A stand you know, a fast a fast, you know, 22 gauge facet tip needle, something like that. And Yep. Up until a point when and and I recorded these videos the first few blocks I did, and I showed them at presentation. I remember two anesthetists were sitting in the audience, and as they were watching the needle the video of this needle approaching the para virtual space, they were both cringing and, you know, not pulling a pleasant face. I was waiting for their faces to go, oh, ah, as they see the pleura drop. 

They didn't. And and afterwards, I remember speaking some after after my talk. Was like, guys, why were you, you know, why were you looking so troubled when you were watching my video? And they said because we could see that sharp tip of your needle beautifully demonstrated in the video, but we could see it headed straight from the pleura. And as an observer, it's like watching a horror movie. 

They didn't know when it was gonna stop. So all they could see was a needle going straight through to the pleura, and and they were anticipating me piercing the pleura. And they they said to me there were two one of them was Susanna Croner. He used to work at East Grinstead. Other was Rafa Blanco. 

They said to me at those stages, why don't you use a Tuohy needle? I was like, why? They said, because look, that Huber tip is such that, you know, you're not gonna be approaching the needle at acute angle with a sharp tip needle. You're gonna have a nice bevel that's gonna kind rest on the pleura as you pop through that superior costotransverse ligament. So from that moment onwards, I sought out the perfect Tuohy needle, and now I use Tuohy needles for everything. 

The only time where I can imagine they're less beneficial is when you're doing your blocks out of plane. But So I use a Tuohy. How about you? It's funny. I I have the reverse experience. 

So I started training with the Tuohy because it was landmark based. And we had markings on the Tuohy needle, right? So you can say, well, I am at five centimeters to the TP. That's right. Hold your fingers on the needle one centimeter back, pull it back, and then bury the needle till your fingers are on the skin. 

Anyway, so Uh-huh. And I'll still use two of these, obviously, for catheters, but, I like a regular old block needle, you know, with a with a facet tip and the echogenic little divots in it so that I can I get a better visualization of it? Yeah. But I go out of plane. Yeah. 

I wonder if you were an I will never know the answer to this, but if you were an in plane practitioner of paravertebral blocks, as I would say, whether you would you would change your needle time. But it's interesting. There's no doubt that when I've been forced to move to another site and do a para virtual block on another site where they haven't got my needles, of course, I can still perform them. I feel less confident. Or I'd or no. 

I I I don't enjoy the experience as much. There's something about seeing that Tooey needle with the with the Hooper tip going in. I I like that. But anyway so I think I think you can do it with either. Do use the needle you're most comfortable with, but it's just interesting that the the look on the face of these two Anises watching these videos has stuck with me because they were so I don't know. 

I was so disappointed that they were they were nervous that I might puncture the pleura. They said, well, why don't you think, you know, the anger you're going in with, use a use a a tui. So that's what I have done. Well, so I so I think what's important I don't know. Might as well get into the technique now. 

But the way that I'll do this is I'm coming out of plane, so my needle is very, very close to my probe with a three degree angle or a five degree angle so that it's almost parallel to the beam, but it's going but it is traveling slightly underneath the probe, so I can so I can see it as best I can. And while I'm doing that, so you're gonna see some tissue distortion in the Yeah. Erector spinae muscle and that are musculature above the transduce process, And when I'm in that muscle, I'll start to I'm usually the one with the with the syringe, not the needle. The trainees driving it down, and I'll give sequential puffs of saline almost to the point Uh-huh. Where it's a continuous puff of saline. 

So you'll see this Do you hear my sound effects there, by way? Do you hear that? No. I can Sorry. Did you say again? 

Oh, a puff. Puff. Yeah. Puff. Yeah. 

Yeah. Anyway, sorry. And so people talk about the concept of a wet needle for blocks, and I think this is one of those Never heard that. Say that again. A wet needle. 

Oh, a wet needle. Yeah. So the idea being that your sharp needle tip, which horrified your your audience. Yeah. Should always have a leading wave of fluid in front of it. 

So never, like, inject and then move your tip into that fluid rather than get your tip right up to the nerve or run it to the pleura and then inject something. I love this concept. Yeah. And so I love this. I mean, you talked about it with with other blocks like fascial plane blocks, and every block is a fascial plane block and injecting ahead of yourself. 

But I've never heard it described like a a wet needle. Okay. Cool. Sorry. I'm sorry to interrupt your flow. 

No. No. That's it's it's that's exactly the idea. So that as you're coming through, then you get into the intercostal muscle, and you're sort of expanding that with some puff, puff, puff, puff, puff. And then eventually, you'll kinda click through that cost of translusal lignin, and many times, I don't feel it click. 

Yeah. You might more than I do with your TUI needle, but I do. Yeah. But what I like about this technique is that it doesn't require you to have that haptic feedback. You're just you're using visual feedback of the puff, puff, puff, puff, puff, and then all of a sudden, the pleura goes down. 

I like your consistency with that noise. That is your consistent pleura drop noise. You've obviously that you're not making that. That is your standard noise. I love that. 

Standard noise. Yeah. So And I'll I'll I'll do it when when it happens on the screen real time so the the trainee is going and going going and then and then you'll see the plural going. And and and now, like, everybody in the room goes boom. So and so you do that, like, three or four times per case. 

Right? Because you're doing them four levels, I'm guessing. Yeah. Exactly. So I do do remember that feeling when you put do you remember that feeling when you put a cannula in and you can feel that you're in the vein? 

Because sometimes you can hear it. You feel like you're one with the cannula. Yeah. Did you ever get that buzz when you're sticking IV? So the same thing happens with high vertical blocks now. 

So often so now my trainees, certainly the current batch are now they've just got to that point. When the needle passes through the cost of transverse ligament when we're doing our techniques in plane, They can often feel it. Sometimes you can see it on the screen. You can see that little give. They can feel it. 

And sometimes you can feel it as part of your body. You go, yep. I know I'm in. And with the next suggestion, see the pleura drop. So I think that's probably a bit more exaggerated with an in plane technique than an out of plane technique. 

The force is strong with you. I think so. And that when when you when they have reached that point Mhmm. That's when we know, they've they've migrated Padawan School, of Regional Anesthesia. They are now yeah. 

They're there. Now I want to do our next controversial section. Okay? So Oh, okay. Probe orientation, transverse or paramedian sagittal. 

And you'll notice, my friend, that I didn't say parasagittal, which is what everybody says. What is it make the American accent sound so dumb when you say that? Parasagittal. Of course. Don't worry. 

I I got you, bro. I got you. It's parasagittal. No. It's Paramedian sagittal. 

Okay. Sagittal. But it's off the midline. Yeah. But so it do know what? 

And I have to say one of my paravirtual heroes made me feel very stupid at at international conference when I got up and asked the question. But over this point and I said something. I said to him, oh, do you have a transverse probe, position, or do you use a parasagittal? And rather than answer my question first, he corrected me to an audience of four or 500 people and said, I'm not gonna do the accent because that'll give away who it was. But he says, look. 

I'm just gonna stop you there. Listen. ParaMedian sagittal beautifully describes a sagittal plane parallel to the midline that's slightly off center and close to the midline. Parasagittal implies it's parallel to the sagittal plane, which is parallel to the midline. So it's a bit confusing. 

So paramedian sagittal makes it very clear. We're taking a paramedian slice in the sagittal plane. So paramedian, parallel to midline. Anyway, that's it. I'm I'm not gonna say it anymore, and I know people are gonna carry on saying it like they do PEX one and PEX two, but there we go. 

I've done it. I feel satisfied. Okay. Anyway, what's your pro positioning, Jeff? Par Stunned silence. 

He's like, oh my god. Annie, get off your soapbox, man. Yeah. Yeah. Yeah. 

No. No. I I do you hey, man. I want you to feel like you've got all all this off your chest. This is therapy for me, but nobody's listening. 

I I do like a sagittal. And so what I'll do is I'll I'll have the the trainee start well off the midline. So they're seeing ribs. Loving that. And the other nice thing about this is that I'll say, okay. 

Go about like three or four centimeters off the midline. So see that? That's a rib. That's curved, you can see pleura, and now what I want you to do, I want you to slide your probe cephalad, cephalad if you will, and count and see ribs, ribs, ribs, oh, there's the last rib. You can see now your probe is like up on the shoulder of the patient. 

That's rib one. Now come down, two, three, four, and then that way you know precisely where you are, as opposed to guessing, like, there's no there's no need to use surface landmarks for this anymore. So then we have ribs at the correct level, and now I say, slide your probe medial until you see the transition from rib to TP. And I'll actually have them do that a couple of different times. So rib, TP, rib, TP, to be sure that they're getting that TP. 

And then To be sure, to be sure. FR, FR, for real, for real. Now, the problem with that straight paramedian sagittal view over the TP is you no longer see pleura because the pleura is curving inwards now towards the mediastinum, and you you need to see pleura to to do this safely. Right? So Uh-huh. 

You've gone into and you're imaging the paravertebral space in the sagittal plane, and now have them do a very slight tilt outwards. And that brings the pleura into plane. I can still see the TPs. A 100%. I often I'll see the TP and the rib sort of as as one kind of because if you overtilt the beam laterally, your bony landmark moves from transverse process to rib. 

Correct. So you gotta just slightly tilt. Correct. And so now we see we see TP. We see pleura. 

And now if you bring your needle in directly in a paramedian orientation I'm conscious of what I'm saying here. Straight in beside your probe, that creates the little five degree angle difference between needle and beam Yeah. That gives you the beautiful needle imaging. Now, a point I wanna make here is that this is not the the same precise location that we were doing perivertebral in landmark based. We were going straight past the transist process into the biggest portion of the triangular paravertebral space. 

With my technique, you're catching it at the lateral recess. You're still in the paravertebral space, but you're just, you're catching it on more the lateral edge of it. It's not an intercostal block. Mhmm. It is a it is paravertebral still, and we showed that with dye and all that kind of stuff. 

But I I I know there's someone out there that's gonna gonna go, well, what you're describing is not paravertebral because you're not going you should be more medial in your deposition of local, and I I would I would push back at that. So listen. You know, I listening to listening to what you said just then is incredible because it's almost like I floated out of my body and watched myself teach somebody. So I do I pretty much do, exactly what you described. There's a couple of things I wanted to add, though. 

So when I'm getting patients to, when I'm getting patients, when I'm getting my residents to start scanning again, I start lateral because it's much easier to to identify ribs as as it is to kinda get close to midline. You're thinking, is that rib? Is that TP? So it's much easier to be away from the transverse process, definitely on the ribs. I get into slide cranial, or kephelad to to count to the the rib number one. 

But with one additional point I wanted to make is when they've driven the probe as north as they can do and they say, yep. That's rib one, I always get them to slide the probe towards the midline at that point because often rib one has already sort of curved out of the way. So if you're too far lateral, the most keflat rib you'll identify in the middle of the back is rib number two. So at that point, I said when you're up there, drive the probe towards the midline, and then you often see rib number one pop into view. Okay. 

Okay. Now is that rib number one? They go, yes. And they get into slide laterally. It'll disappear. 

You go, right. Okay. That's rib one. That's rib two. So that's the one clarification I wanted to make. 

The thing you do have to be careful of, of course, is if you're too high up in the neck, you'll end up counting the transverse process of c seven. So that's just something to bear in mind. But often, that rib one, that cheek little rib one is stuck out of the way. So that's one thing to add. The other thing is because you're doing your technique outer plane, when you slid from the rib to the transverse process and seen that transition from a curved rib to a rectangular tombstone shaped transverse process, you've done a little bit of a tilt laterally to be able to direct the beam laterally to see the pleura, you stop at that point. 

But if I'm needling in plane from Cordad to Keflad, sometimes that inferior transverse process, depending upon where you position the paravertebral space on the screen, can act as an bony impedance to getting your needle into the right place. So I will often anchor the keflat part of the probe where it is on a transverse process. I'll lift the corded part of the probe up and rotate it out laterally so that it's resting over a rib. So I've got a paramedian sagittal oblique view of the paravertebral space. So that's the one additional step I will add if I'm doing an in plane. 

But apart from that, you know, the the paramedian sagittal scan, I do the same as you, the prep. And with that, we come to the end of part one of our royal episode on PVVs. Tune in next month to hear the conclusion where we address all the other stuff we haven't even got to yet, including complications, other juicy technical tips, and how to stay out of trouble. And you'll get to hear the whole story behind this bizarre tidbit. Well, you see, you know, yesterday, I bought my first, my first vinyl record, and it was, it was, a disc called sounds wasps make. 

Thanks for tuning in. And until next month, we hope you all block it like it's hot.