Blok paravertebral Lumbar (LPVB) secara teknis mirip dengan TPVB tetapi

karena perbedaan anatomi antara ruang paravertebra toraks dan lumbar,

kedua teknik paravertebral dijelaskan secara terpisah. LPVB digunakan
paling umum dalam kombinasi dengan TPVB, sebagai blok paravertebral
thoracolumbar, untuk anestesi bedah selama herniorrhaphy inguinalis.

Anatomi
Ruang paravertebral lumbar (LPVS) dibatasi anterolateral oleh otot psoas
mayor; secara medial oleh badan vertebra, cakram intervertebralis, dan
foramen intervertebralis dengan isinya; dan secara posterior oleh proses
transversal dan ligamen yang diselingi antara proses transversal yang
berdampingan. Berbeda dengan TPVS, yang mengandung jaringan
adiposa, LPVS diduduki terutama oleh otot psoas mayor. Otot psoas
mayor terdiri dari bagian anterior berdaging yang membentuk sebagian
besar otot, dan bagian posterior aksesori tipis. Massal utama berasal dari
permukaan anterolateral tubuh vertebral dan bagian aksesori berasal dari
permukaan anterior dari proses transversal. Kedua bagian tersebut berfusi
membentuk otot psoas utama kecuali di dekat tubuh vertebral di mana
kedua bagian tersebut dipisahkan oleh fasia tipis di mana terletak akar
saraf tulang belakang lumbar dan vena lumbalis asenden. Rami ventral
dari akar saraf tulang belakang lumbal memanjang ke lateral dalam
bidang intramuskular yang dibentuk oleh dua bagian otot psoas mayor
dan membentuk pleksus lumbalis di dalam substansi otot psoas mayor.
Otot psoas diselimuti oleh selubung berserat, “selubung psoas,” yang
berlanjut secara lateral saat fasia menutupi otot quadratus lumborum.
Selama LPVB anestesi lokal disuntikkan anterior ke proses transversal ke
dalam ruang segitiga antara dua bagian otot psoas utama yang
mengandung akar saraf tulang belakang lumbar. LPVS berkomunikasi
secara medial dengan ruang epidural.
Serangkaian lengkungan tendon memanjang melintasi bagian-bagian
yang terbatas dari tubuh vertebra lumbar, yang dilalui oleh arteri dan
vena lumbalis dan serat simpatis. Lengkungan tendon ini dapat
memberikan jalur untuk penyebaran anestesi lokal dari LPV ke permukaan
anterolateral tubuh vertebral, ruang prevertebral, dan sisi kontralateral
dan mungkin jalur di mana rantai simpatis lumbar ipsilateral kadang-
kadang dapat terlibat.

Mekanisme Blok dan Distribusi

Anestesi
Injeksi paravertebral lumbal menghasilkan anestesi dermatomal ipsilateral
(Gambar 16) dengan efek langsung anestesi lokal pada saraf tulang
belakang lumbar dan dengan ekstensi medial ke ruang epidural melalui
foramen intervertebralis. Kontribusi penyebaran epidural ke distribusi
anestesi keseluruhan setelah LPVB tidak diketahui tetapi mungkin terjadi
pada sebagian besar pasien dan tergantung pada volume anestesi lokal
yang disuntikkan pada tingkat tertentu.

FIGURE 16. Segmental distribution

of anesthesia with lumbar paravertebral levels.
Ipsilateral sympathetic blockade may also occur due to epidural spread or spread of
local anesthetic anteriorly via the tendinous arches to the rami communicantes or the
lumbar sympathetic chain.

 Technique

Lumbar paravertebral block can be performed with the patient in the sitting, lateral, or
prone position. Surface landmarks must be identified and marked with a skin marker
before block placement. The spinous process of the vertebra at the levels to be blocked
represents the midline, the iliac crest corresponds to the L3-L4 interspace, and the tip of
scapula corresponds to the T7 spinous process. Skin markings are also made 2.5 cm
lateral to the midline at the levels that are to be blocked (Figure 17A) or one can draw a
line 2.5 cm lateral to the midline and perform the injections along this line (Figure
17Band C).

FIGURE 17. A: Surface landmarks and needle insertion sites for lumbar paravertebral
block. B and C: Needle insertion.
A standard regional anesthesia tray is prepared; strict asepsis should be maintained
during block placement. An 8-cm, 22-gauge, Tuohy tip needle (see Figure 1–8) is used
for LPVB. Similarly to the recommendations for TPVB, the use of needles with depth
markings on the shaft of the needle or a guard indicating the depth (see Figure 1–8) is
recommended. Advancing the needle by a fixed predetermined distance (1.5–2.0 cm)
beyond the transverse process, without eliciting paresthesia, is the method most
commonly used to perform LPVB. The block needle is inserted perpendicular to the skin
until the transverse process is contacted. The depth at which the transverse process is
contacted is variable (4–6 cm) and depends on the build of the patient. Once the
transverse process is identified, the marking on the needle is noted or the depth marker
is adjusted so that it is 1.5–2.0 cm beyond the skin–transverse process depth. The
needle is then withdrawn to the subcutaneous tissue and reinserted at a 10- to 15-
degree superior or inferior angle so that it slides off the superior or inferior edge of the
transverse process, similarly to the technique in thoracic paravertebral block (see Figure
11). The needle is advanced by a further 1.5–2.0 cm beyond the contact with the
transverse process or until the depth marker is reached. After negative aspiration for
blood or cerebrospinal fluid (CSF), the local anesthetic is injected. Since spread of local
anesthetic after a single large-volume lumbar paravertebral injection is unpredictable,
the multiple-injection technique in which 4–5 mL of local anesthetic is injected at each
level is more commonly used.

Choice of Local Anesthetic

As for TPVB, long-acting local anesthetic agents such as bupivacaine 0.5%, ropivacaine
0.5%, or levobupivacaine 0.5% are commonly used for LPVB. During a multiple injection
LPVB, 4–5 mL of the local anesthetic is injected at each level. Anesthesia develops in
about 15–30 minutes and lasts for 3–6 h. Analgesia is also long-lasting (12–18 h) and
generally outlasts the duration of anesthesia. There are no data on the pharmacokinetics
of local anesthetic after LPVB. Nevertheless, the addition of epinephrine (2.5–5.0
mcg/mL) to the local anesthetic may reduce systemic absorption and reduce the
potential for toxicity.

Indications and Contraindications

LPVB is commonly used in combination with TPVB (T10 through L2) for surgical
anesthesia during inguinal herniorrhaphy. It can be also effective for rescue in patients
with severe pain after total hip replacement. It can also be used for diagnostic purpose
during evaluation of groin or genital pain, such as that following nerve entrapment
syndrome after inguinal herniorrhaphy.

Contraindications for LPVB are similar to TPVB, but caution should be exercised in
patients who are anticoagulated or are receiving prophylactic anticoagulants since psoas
hematoma with lumbar plexopathy has been reported.

Complications and How to Avoid Them

Published data suggest that complication is rare after LPVB. Nevertheless, it is possible
to inadvertently inject local anesthetic into the intravascular, epidural, or intrathecal
spaces during LPVB, and this may be more common if the needle is directed medially.
Therefore, the direction of the block needle should be maintained perpendicular to the
skin during insertion, and medial angulation should be avoided. Intraperitoneal injection
or visceral injury (renal) may also occur, although this can occur only as a result of gross
technical error. Motor weakness involving the ipsilateral quadriceps muscle may result if
the L2 spinal nerve is blocked (femoral nerve L2–L4).
SUMMARY

Proper training is necessary to acquire stereotactic techniques required to ensure a high

success rate. Thoracic paravertebral block produces unilateral somatic and sympathetic
nerve blockade that is adequate for surgical anesthesia during breast surgery and for
analgesia when pain is of unilateral origin from the chest or abdomen. It has been also
described as a rescue analgesic therapy in patients with rib fractures and respiratory
compromise. Lumbar paravertebral block is less commonly used in clinical practice. As a
thoracolumbar paravertebral block, it is effective for surgical anesthesia during inguinal
herniorrhaphy.

Hemodynamic stability is usually maintained after a paravertebral block due to the

unilateral nature of sympathetic blockade. Bladder and lower limb motor function are
also preserved, and no additional nursing vigilance is required during the postoperative
period. Successful clinical applications of a bilateral paravertebral block have also been
reported.

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