Comparison of Paravertebral Block by Anatomic Landmark Technique to Ultrasound-Guided Paravertebral Block for Breast Surgery Anesthesia A Randomized Controlled Trial Rupali Patnaik, MD,* Anjolie Chhabra, MD,* Rajeshwari Subramaniam, MD,* Mahesh K. Arora, MD,* Devalina Goswami, MD,* Anurag Srivastava, MS,† Vuthaluru Seenu, MS,† and Anita Dhar, MS† Background and Objectives: Paravertebral block (PVB) is an estab- lished technique for providing anesthesia for breast surgery. The primary objective was to compare anatomical landmark technique (ALT) to the ultrasound-guided (USG) PVB block for providing surgical anesthesia. Secondary objectives included comparison of perioperative analgesia and complications. Methods: This randomized, controlled, observer-blinded study included 72 females, aged 18 to 65 years, American Society of Anesthesiologists physical status I or II, undergoing elective unilateral breast surgery. Study participants were randomized to the ALT group or USG group. Ipsilateral PVB was performed with the respective technique from T1 to T6. Five mil- liliters of local anesthetic mixture (0.5% ropivacaine, 5 μg/mL adrenaline, 1 μg/kg clonidine) was administered at each level. Paravertebral catheter was inserted at T4/T3 level. After confirming sensory loss, patients were taken up for surgery with propofol sedation (20–50 μg/kg per minute). Results: More patients in the USG group (34/36 [94.44%]) had a success- ful block as compared with the ALT group (26/36 [72.22%]) (P = 0.024). Difference in proportion was 18.1 (95% confidence interval, 0.15–36.0) (P = 0.024) after adjustment for age. More dermatomes were blocked in the USG group (P = 0.0018) with less sparing of upper T2 and T3 derma- tomes (P = 0.003, P = 0.006, respectively). Median time to first postoper- ative analgesic requirement was 502.5 minutes (range, 195–1440 minutes) in the USG group versus 377.5 minutes (range, 215–1440 minutes) in the ALT group. Pain at rest and movement 2 and 4 hours postoperatively and number of catheter top-ups in 24 hours postoperatively were lesser in the USG group (P = 0.012). Complications were comparable. Conclusions: Ultrasound-guided PVB provided better anesthesia and perioperative analgesia than the landmark technique for breast surgery. Clinical Trial Registration: The trial was registered retrospectively at the Clinical Trial Registry of India, CTRI/2015/05/005774. (Reg Anesth Pain Med 2018;43: 00–00) T horacic paravertebral block (PVB) is an established technique for breast surgery for providing either analgesia 1–5 or anesthesia. 6–11 The use of the block is associated with good perioperative analge- sia, reduced need for opioids, and improved quality of recovery, although heterogeneity in results exists. 11,12 Major advantages of PVB anesthesia include preservation of physiological homeo- stasis and immunity, making it an ideal anesthetic technique for high-risk patients and those undergoing breast cancer surgery. 13,14 The anatomical landmark technique (ALT) and nerve- stimulated PVB techniques depend on the ability to blindly sound the transverse process (TP) using a needle, which at times may be difficult, especially in obese patients. 8,9,15 In the last decade, var- ious approaches of ultrasound-guided (USG) PVB block have been described that involve visualizing the hyperechoeic TP, the underlying hypoechoic PVB space, and anterior displacement of the pleura on local anesthetic (LA) deposition. 16–20 However, the USG PVB is technically challenging as compared with the landmark PVB block, which requires no sophisticated gadgets, and is relatively simple but has a failure rate of 10% to 15%. 9,12 This may not be acceptable in high-risk patients. On literature re- view, we found no randomized controlled trial comparing the USG with the landmark technique of PVB for surgical anesthesia in patients undergoing breast surgery. The primary aim of this prospective randomized trial was to compare the success rate of anesthesia with either PVB tech- nique in adult female patients undergoing unilateral breast sur- gery. The secondary objectives included comparison of the segments blocked, perioperative pain, need for supplemental an- algesia, time to first postoperative analgesic request, and compli- cations with either technique. METHODS After obtaining institutional, ethics committee approval, this randomized, controlled, observer-blinded study was conducted from June 2014 to January 2016 at the All India Institute of Med- ical Sciences, New Delhi, India. Participants were 72 females aged 18 to 65 years undergoing unilateral breast surgery (American So- ciety of Anesthesiologists physical status I or II) (Table 1). The trial was retrospectively registered with Clinical Trial Registry of India (CTRI/2015/05/005774) on May 14, 2015. We excluded patients who refused consent, those with body mass index (BMI) 30 kg/m 2 or greater, and those with standard contraindications for regional blocks (eg, infection at block site, severe chest wall deformity, coagulopathy/anticoagulants, LA al- lergy). Written consent was obtained on the evening prior to sur- gery from patients included in the study. They were instructed on use of a 0- to 100-mm visual analog scale (VAS), with 0 (green) corresponding to no pain and 100 (red) being the worst imaginable pain possible. On day of surgery, patients were transferred to the anesthesia room, 120 minutes before surgery; baseline vitals were noted; premedication (1–1.5 mg midazolam and 25 μg fentanyl intra- venously [IV]) and oxygen by face mask were administered. From the Departments of *Anesthesiology and †Surgery, All India Institute of Medical Sciences, New Delhi, India. Accepted for publication October 22, 2017. Address correspondence to: Anjolie Chhabra, MD, House No. 13, Road No. 61, W Punjabi Bagh, New Delhi 110026, India (e‐mail: anjolie5@hotmail.com). Resources used were from the All India Institute of Medical Sciences, New Delhi, India. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000746 REGIONAL ANESTHESIA AND ACUTE PAIN ORIGINAL ARTICLE Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018 1 Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.