Is It Useful and Necessary to Add a T2 Paravertebral Block to the Regional Anesthesia During Proximal Humeral Fracture Surgery in Elderly Patients? A Prospective and Randomized Controlled Trial

Abstract

Objective: This study was designed to investigate whether it is useful and necessary to add a T2 level thoracic paravertebral block (TPVB) based on brachial-cervical plexus block to avoid incomplete anesthesia in elderly patients undergoing deltopectoral approach proximal humeral fracture (PHF) surgery.

Materials and methods: This study involved 80 patients scheduled for PHF surgery who were randomized to receive either IC block (combined interscalene brachial plexus with superficial cervical plexus block) or ICTP block (T2 TPVB supplemented with IC block). The primary outcome was the success rate of regional anesthesia. The patient who experienced incomplete block was administered with intravenous remifentanil for rescue, or conversion to general anesthesia (GA) if remifentanil was still ineffective. Secondary outcomes included requirements of rescue anesthesia, sensory block of the surgical region, the incidence of adverse reactions, and block procedure-related complications.

Results: The success rate of regional anesthesia in the ICTP group was higher compared with the IC group (77.5 vs. 52.5%, p = 0.019). Intravenous remifentanil was required in 32.5% of patients in the IC group and 17.5% in the ICTP group, respectively. Conversion to GA was performed in 15% of patients in the IC group and 5% in the ICTP group. Sensory block at the medial proximal upper arm was achieved in 85% of patients in the ICTP group, whereas 10% in the IC group (p < 0.001). There was no difference between the groups with respect to the incidence of intraoperative adverse reactions. No block-related complications occurred in either group.

Conclusion: Adding a T2 TPVB is helpful to decrease, but not absolutely avoid the occurrence of incomplete regional anesthesia during PHF surgery in elderly patients. However, considering the potential risks, it is not an ideal option while a minor dose of remifentanil can provide a satisfactory rescue effect.

Clinical trial registration: ClinicalTrials.gov, identifier: NCT03919422.

Keywords: brachial plexus block; elderly; proximal humeral fracture; regional anesthesia; thoracic paravertebral block.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Wang, Zhang, Chen, Zhang, Xie, Liao, Jiang and Zhang.

Figures

Figure 1

The CONSORT flow diagram. BMI, body mass index; SCPB, superficial cervical plexus block; GA, general anesthesia; IC, combined ISPB with SCPB; ICTP, IC block combined with T2 TPVB; ISPB, interscalene brachial plexus; ORIF, open reduction and internal fixation; TPVB, thoracic paravertebral block.

Figure 2

Anesthetic effects outcomes. The success rate of surgical anesthesia in the ICTP group was higher compared with the IC group (77.5 vs. 52.5%, p = 0.019). There was no difference in requirement of rescue anesthesia (IV remifentanil or GA) between groups. *p < 0.05 was taken to indicate statistical significance.

Figure 3

Sensory block outcomes. The result was described as three levels: no block (normal sensation), partial block (reduced sensation), and complete block (no sensation at all). The testing region around the deltopectoral incision was divided into 4 sections: A, supraclavicular region; B, deltoid region; C, lateral proximal upper arm; D, medial proximal upper arm. Sensory block at the medial proximal upper arm (including partial and complete block) was achieved in 85% of patients in the ICTP group, whereas only 10% in the IC group (p < 0.001). There was no difference between groups in the other regions. *p < 0.05 was taken to indicate statistical significance.