Introduction

Thoracotomy is one of the most painful procedures, and postoperative pain markedly inhibits pulmonary function and early recovery of the patient if surgical pain is not treated appropriately. Moreover, postoperative pain without adequate analgesia can persist for months or even years after a patient is discharged from hospital. One study reported that 68% of patients experienced pain 3 months after thoracotomy and 11% of them had a pain score of 3 or higher on a 10-point scale [1]. These patients experience a significant reduction in physical activity and vitality [1]. Less invasive approaches, such as video-assisted thoracoscopic surgery (VATS), also require considerable attention regarding postoperative analgesia, although VATS leads to less tissue damage than thoracotomy [2]. In particular, acute postoperative pain is moderate to severe [2].

Complications after thoracic surgery include airway complications, atelectasis, bronchospasm, tracheobronchial disruption, hemorrhage, hemothorax, pneumothorax, pneumonia, respiratory insufficiency, cardiac complications such as arrhythmias, pulmonary hypertension, and post-thoracotomy neuralgia [3]. The incidence of postoperative complications, particularly those involving the lungs, is dependent on effective pain control because successive analgesia can facilitate coughing, deep breathing, and participation in postoperative rehabilitation regimens [4,5]. For several years, many drugs, including systemic opioids, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, acetaminophen, N-methyl-ᴅ-aspartate receptor antagonists, gabapentin, and glucocorticoids, have been used to control pain after thoracic surgery [6]. However, systemic drug therapy often does not provide adequate analgesia. Systemic opioids, commonly used for postoperative analgesia, cause many side effects, such as respiratory depression, postoperative nausea and vomiting, and tolerance development [7]. For early recovery from thoracic surgery, the European Society of Thoracic Surgery suggests multimodal approaches that combine parenteral analgesia with regional anesthetic techniques [8]. Thoracic epidural analgesia (TEA) has become a routine postoperative analgesic technique in thoracic surgery because of its effectiveness and few side effects [9]. However, in practice, acute postoperative pain after thoracic surgery is commonly managed using alternative regional techniques based on efficacy and safety. These include traditional methods such as the thoracic paravertebral block (PVB) and intercostal nerve block (ICB). More recently, ultrasound-guided fascial plane blocks have emerged as promising alternatives for prioritizing safety. Unlike traditional nerve blocks that directly target specific nerves, fascial plane blocks, such as the erector spinae plane block (ESPB), intertransverse process block (ITPB), and serratus anterior plane block (SAPB), involve injecting a local anesthetic into a tissue plane between the fascial layers, relying on volume-dependent spread to reach the target nerves.

Literature search strategy

To ensure a comprehensive overview, we conducted a literature search using electronic databases including PubMed, EMBASE, and the Cochrane Library, covering publications from database inception until September 2025. Key search terms included “thoracic surgery,” “postoperative pain,” “thoracotomy,” “video-assisted thoracoscopic surgery,” and specific regional techniques such as “thoracic epidural analgesia,” “paravertebral block,” “erector spinae plane block,” “intertransverse process block,” “serratus anterior plane block,” and “intercostal nerve block.” We prioritized randomized controlled trials (RCTs), systematic reviews, and meta-analyses published in English. Relevant observational studies and case series were included when high-level evidence was limited, particularly for novel fascial plane blocks.

Pathophysiology of postoperative pain in thoracic surgery

The pathogenesis of postoperative pain after thoracic surgery is a complex phenomenon involving a combination of neurological and inflammatory mechanisms that extend beyond simple tissue damage. Prolonged pain is referred to as post-thoracotomy pain syndrome, which can severely diminish the patient’s quality of life [10].

Acute pain, which occurs immediately after surgery, is primarily caused by several factors. Direct and extensive damage to tissues, such as skin incision, stretch and retraction of muscles and ribs, and injury of costochondral joints by the placement of rib retractors, activates nociceptors [10,11]. During rib spreading, rib fractures or dislocations of the costovertebral joints can occur, leading to severe pain [10,11]. Thoracic surgery is performed through the intercostal space. Therefore, the intercostal nerves can be directly injured by compression from rib retractors, cutting, or suturing. The pleurae are irritated by the surgical incision, drain tube, residual blood, and fluid. In addition, visceral pain is caused by stimulation of the pericardium and bronchi and is transmitted through the vagus and phrenic nerves.

Inadequate management of acute pain can lead to its transition to chronic pain through processes known as peripheral and central sensitization. Inflammatory mediators are released from damaged tissues and lower the threshold of pain receptors [10-12]. This increases the sensitivity to pain, causing even minor stimuli to be perceived as extremely painful. Repetitive and persistent pain stimuli hypersensitize the neurons in the dorsal horn of the spinal cord. This makes the nervous system more responsive to pain, and structural and functional changes in the pain pathway lead to the amplification of pain signals. Injury to the intercostal nerves can cause ectopic discharge, which leads to neuropathic symptoms such as burning or stabbing sensations, allodynia, and hyperalgesia.

Thoracic epidural analgesia

Among many methods for managing postoperative pain in thoracic surgery, TEA has long been recognized as the “gold standard” of treatment [7]. The fundamental principle of TEA involves inserting a thin catheter into the thoracic epidural space and continuously infusing a local anesthetic and opioid to directly block the spinal nerve roots [9]. TEA is performed using a loss-of-resistance technique [9]. The catheter is typically placed at the spinal level corresponding to the center of the surgical incision [3]. Recently, ultrasound-guided placement has become a new trend for increasing the success rate and safety of the procedure, especially in patients with anatomical variations or obesity [13]. Ultrasound allows preprocedural visualization of the spinal structures to plan the optimal insertion path, predict needle depth, and confirm needle progression in real time [13,14]. Effective pain blockade helps patients breathe deeply and cough smoothly, enabling early mobilization and laying the foundation for accelerated postoperative recovery. According to a previous meta-analysis, TEA can reduce the incidence of atelectasis, pulmonary infections, and hypoxemia [5]. Local anesthetic-based TEA shortens the duration of postoperative ileus and promotes the recovery of gastrointestinal function [5]. This is because TEA blocks sympathetic signals that inhibit gut motility while preserving the function of the parasympathetic nerve that promotes it [5]. Owing to these advantages, TEA has played a pivotal role in post-thoracic surgery pain management for several decades.

TEA consistently demonstrates superior analgesic efficacy compared to opioid intravenous patient-controlled analgesia [3]. However, these benefits are accompanied by tradeoffs. TEA is associated with a higher potential for technical failure and more frequent side effects [6]. The side effects of TEA can be divided into two distinct categories. One comprises relatively common but manageable minor side effects, and the other comprises extremely rare but catastrophic serious neurological events. A large observational study that followed 3,126 patients provided reliable data on the incidence of side effects, including hypotension (4.8%), pruritus (4.4%), motor weakness (2.0%), and postoperative nausea and vomiting (1.8%) [15]. The side effects associated with TEA are predictable based on its pharmacological mechanism and can be managed by adjusting the drug dosage, fluid administration, vasopressor use, and symptomatic treatment [15]. Serious complications associated with TEA include epidural hematoma, direct spinal cord injury, and epidural abscesses. However, such serious complications are very rare. The incidence of epidural hematoma is estimated to be approximately 1:190,000 [16]. In the large-scale study mentioned earlier, no cases of epidural hematoma occurred in 3,126 patients; there was one case of epidural abscess, and there were two cases of subarachnoid block [15]. The overall risk of permanent neurological complications is predicted to be very low [17]. In clinical practice, the extremely rare probability of permanent neurological injury may have a far greater impact on an institution’s practice and a physician’s decision than thousands of successfully managed cases of hypotension, nausea, and vomiting. This “low-incidence, high-impact” risk profile has been a key driver of research into safer alternatives such as PVB.

Thoracic paravertebral block

Thoracic PVB shows equal postoperative analgesic effects to TEA in thoracic surgery but has a lower incidence of adverse effects [5,18]. The thoracic paravertebral space is bound on the back side by the costotransverse ligament, transverse process, and rib, and on the medial side by the vertebral body and intervertebral foramen. Anteriorly, the parietal pleura borders it and laterally, it is continuous with the intercostal space. The dorsal and ventral rami of the spinal nerves, intercostal vasculature, and sympathetic chain are located in the paravertebral space [19,20]. The spinal nerves that emerge from the intervertebral foramina pass into the intercostal space and the back [20]. If a local analgesic drug is administered into the thoracic paravertebral space, nociceptive stimuli originating from the surgery are prevented by blocking the dorsal and ventral rami of the spinal nerve. Local anesthetics can be continuously injected into the paravertebral space using a paravertebral catheter. Continuous PVB showed excellent postoperative analgesic effects in thoracic surgery for several days [14]. The thoracic paravertebral space seems to communicate with the upper and lower paravertebral spaces; thus, an anesthetic drug spreads to multiple dermatomes, depending on the injected volume [20-22].

Various techniques have been used for thoracic PVB. It can be performed in prone, sitting, and lateral postures. A Tuohy needle should be used to place the catheter if the analgesics are to be delivered continuously. Landmark-based methods use loss of resistance. A needle is inserted 2 to 3 cm lateral to the uppermost portion of the spinous process and advanced vertically to the transverse process of the vertebra. If a transverse process is encountered, the needle walks off the transverse process cranially or caudally. The needle is carefully advanced until a loss of resistance is elicited. This sensation is frequently accompanied by a subtle feeling (a pop) when the superior costotransverse ligament (SCTL) is pierced by the needle [19,20]. Aspiration is usually performed to determine whether the needle is extravascular and has penetrated the lung parenchyma. Inserting a needle into the thoracic paravertebral space using loss of resistance can be difficult because the sensation of loss of resistance is uncertain and different for each person, unlike the perception in an epidural block, which results from passing through the dense ligamentum flavum [23,24]. Because of the difficulty in placing the needle in the paravertebral space, classic percutaneous thoracic PVB has a high failure rate of approximately 10% [6,20,25]. Some authors have suggested a method that measures the pressure while advancing the needle to locate the paravertebral space [24]. The pressure at inspiration is higher than that at expiration while the needle is located in the erector spinae muscle. If the needle enters the paravertebral space, the pressure is lower during inspiration than during expiration [24]. Pressure inversion can be an easy and objective method for identifying the thoracic paravertebral space. Thoracic PVB can be performed under direct visualization using ultrasound guidance. High-resolution ultrasonography can display the anatomical structures of the thoracic paravertebral space, advancement of the needle, and spread of local analgesics [26]. Therefore, ultrasonography is expected to improve the safety and reliability of thoracic PVB. However, it is possible to insert a needle percutaneously by directly visualizing the surgical field during thoracotomy or the image during thoracoscopy [27,28]. Failure of thoracic PVB and injury to the overlying pleurae such as pneumothorax can be avoided because an operator can confirm by eye that the needle is advanced in the correct direction and the catheter is placed in the thoracic paravertebral space.

Several meta-analyses and RCTs have shown that thoracic PVB can provide adequate postoperative analgesia in thoracic surgery compared with TEA [5,29-31]. The former method is especially useful for performing unilateral multi-segmental blocks of the sensory and sympathetic nerves in the thoracic cage [5]. The rare incidence of hypotension is due to the unilateral nature of PVB compared to TEA [6,25]. Other adverse effects such as nausea, vomiting, dural puncture, and urinary retention are also lower with thoracic PVB than with TEA [5,29-31]. Thoracic PVB is easy to manage in patients undergoing anticoagulation therapy because of its wider safety margins. Therefore, PVB is recommended for postoperative pain control during thoracotomy and thoracoscopic surgeries.

The failure rate of thoracic PVB varies across clinical studies, depending on the study design, patient population, operator proficiency, and definition of failure. Although an ultrasound-guided approach produces real visualization of anatomical landmarks and the inserted needle, studies have shown that the application of ultrasound-guided thoracic PVB is unsuccessful in 4% to 7% of cases [32-35]. Potential explanations for these unsuccessful results are improper needle or catheter placement and anatomical variation. Thoracic PVB is a delicate procedure that requires precise injection of a local anesthetic into the narrow paravertebral space adjacent to the spine. Even under ultrasound guidance, potential image loss can occur when the needle tip advances to the adjacent transverse process [32,33]. In patients with anatomical variations, the spread of analgesic drugs is uncertain because the thoracic paravertebral space communicates with the epidural and intercostal spaces, and drugs can reach the epidural, contralateral paravertebral, and intercostal spaces [36]. Therefore, some patients may require multiple thoracic PVB injections for several thoracic segmental blocks [20,21]. The thoracic paravertebral space is bordered on the posterior side by the SCTL. Although the SCTL is the most important landmark for PVB, it is occasionally difficult to identify using ultrasonography. Additionally, the SCTL is very close to the pleura, with a mean separation of only 7 to 8 mm. The posterior intercostal artery and vein are located close to the pleura within the thoracic paravertebral space [37,38]. The anatomy of the thoracic paravertebral space can explain the risks associated with PVB such as pneumothorax, hematoma, and direct trauma to the spinal nerves. Therefore, while thoracic PVB is a very effective method for postoperative pain control, it has certain limitations such as critical complications, technical difficulties, and the possibility of failure.

Intertransverse process block

ITPB was proposed as a new method for postoperative pain management in thoracic surgery, covering the gap between direct paravertebral injection of the thoracic PVB and the superficial approach of ESPB [39]. The target of ITPB is the tissue complex posterior to the SCTL. It is believed to offer a more direct and reliable pathway to spread into the paravertebral space than ESPB [37]. This suggests that the advantage of ITPB is to combine the efficacy of thoracic PVB with the safety of ESPB [39].

The SCTL connects the inferior border of the transverse process of the vertebra above to the superior border of the rib below [37,38]. It marks the rear boundary of the paravertebral space. The complex region posterior to the SCTL comprises the intertransverse ligament, fatty tissue, and the intertransverse and levatores costarum muscles [40]. Local anesthetic in the intertransverse space behind the SCTL diffuses into the paravertebral space, which is a pattern very similar to that of PVB. Anatomical studies of ITPB have demonstrated that the intertransverse space behind the SCTL directly communicates with the thoracic paravertebral space via the costotransverse foramen and costotransverse space (Fig. 1) [37,38,41]. The costotransverse foramen is an osteoligamentous structure bound superiorly by the inferior margin of the base of the transverse process of the vertebra above, caudally by the crest of the neck of the corresponding rib, medially by the vertebral lamina and facet joint, and laterally by the medial free edge of the SCTL [42]. The costotransverse space is the space between the transverse process and rib and is composed of adipose and loose connective tissues. It is connected to the top and base of the intertransverse space, and its base is incompletely covered by part of the SCTL [41]. Cadaver evaluation revealed that the costotransverse foramen and space provide anatomical pathways for the anterior and intersegmental paravertebral spread of ITPB, respectively [41]. Indeed, anterior displacement of the pleura was commonly visualized on real-time ultrasound imaging during administration of an ITPB [41-43].

ITPB is performed with patients in either a lateral decubitus or prone position, using high-frequency ultrasound and an 80 to 100 mm, 22-gauge echogenic needle. This technique begins by placing the transducer in a transverse orientation, 2 to 3 cm lateral to the spinous process, to identify the hyperechoic transverse process and its acoustic shadow. By moving the probe slightly, an acoustic window is found, revealing the key structures, the parietal pleura anteriorly and the SCTL, with the target being the potential space immediately posterior to this ligament. Using an in-plane lateral-to-medial approach for enhanced safety, the needle is advanced until its tip is positioned in the medial aspect of the space behind the SCTL [44]. Correct placement is confirmed via hydrodissection with 1 to 2 mL of local anesthetic or saline, with the most critical endpoint being ultrasound-verified anterior displacement of the pleura, which confirms that the injectate has reached the paravertebral space [44]. For prolonged analgesia, a long-acting local anesthetic such as ropivacaine or levobupivacaine is used, typically with a single 20 mL injection for broad coverage, or multiple injections of smaller volumes (5 mL per level) for a more precise, targeted block suitable for long incisions, such as those used for thoracotomy [45,46].

On one hand, thoracic PVB has long been the standard management approach and extensive research supports its efficacy and safety. ITPB, on the other hand, is a more recent alternative, and research directly comparing the two procedures is just beginning to emerge. In an RCT comparing ITPB and thoracic PVB in patients who underwent VATS, ITPB showed analgesic effects equivalent to those of PVB 6 hours after surgery [44]. Another RCT in patients who underwent VATS lung resection also confirmed that the analgesic effect of ITPB was non-inferior to that of thoracic PVB for 24 hours after surgery [47]. In contrast, thoracic PVB provided superior analgesia to ITPB in one retrospective study of VATS for lobectomy, in which the ITPB group had significantly higher intraoperative remifentanil consumption (5.2 vs. 2.6 μg/kg/hour) and postoperative 60-minute visual analogue scale score (4.4 vs. 2.2) [48]. These conflicting results suggest that more large-scale RCTs are needed to definitively compare the advantages and disadvantages of the two blocks.

The primary advantage of ITPB is its enhanced safety profile compared to thoracic PVB, which, despite a low overall complication rate of <5%, carries the risk of serious events such as hypotension (approximately 4.6%), vascular puncture (approximately 3.8%), and pneumothorax (approximately 0.5%) [49]. The fundamental safety of ITPB derives from its anatomical safeguard, as the needle tip remains posterior to the SCTL, which acts as a physical barrier protecting the pleura and neurovascular structures, in contrast to thoracic PVB, which requires intentional penetration of this ligament [39,50]. The latter approach practically reduces the risk of pleural puncture and pneumothorax, making ITPB a more attractive option for patients at high risk with severe chronic obstructive pulmonary disease, or for less experienced practitioners [39]. A retrospective study supported this finding, with no cases of pleural puncture in the ITPB group versus two in the thoracic PVB group [51]. In addition, ITPB provides greater hemodynamic stability. The same study demonstrated that the rate of >20% decrease in mean arterial pressure was significantly lower in the ITPB group (5%) than in the thoracic PVB group (25%), likely due to the slower spread of the local anesthetic to the sympathetic ganglia [51]. This stability is clinically beneficial, as it reduces the risk of intraoperative hypotension and the need for vasopressors, which are independent risk factors for adverse outcomes such as postoperative myocardial or acute kidney injury [52].

ITPB is a novel PVB with a superior safety profile compared with classical thoracic PVB. However, because it is a newly developed method, large-scale multicenter RCTs evaluating its efficacy for postoperative pain management after thoracic surgery are lacking.

Erector spinae plane block

ESPB is defined as an injection into the fascial plane located between the erector spinae muscles and the underlying transverse process of a vertebra [53]. This technique is considered simpler and safer than traditional PVB because the injection site is more superficial and farther from the pleura and major neurovascular structures.

The erector spinae muscle is not a single muscle but a functional group of muscles responsible for spinal extension and maintaining posture. It is composed of three muscle columns: the spinalis, located closest to the spine; the longissimus, lateral to it; and the iliocostalis, the most lateral of the three [54]. This erector spinae muscle complex runs the length of the spine from the base of the skull to the sacrum, with each muscle attached to the transverse processes of its respective vertebral segments [54]. The most critical anatomical target for ESPB is the fascial plane located deep to the erector spinae muscle and superficial to the tip of the vertebral transverse process (Fig. 2) [53].

ESPB, performed under ultrasound guidance, can be administered to patients in prone, lateral, or sitting positions [53]. The procedure begins by using a high-frequency linear transducer to locate the transverse process approximately 2 to 3 cm lateral to the midline and visualizing the erector spinae, rhomboid major, and trapezius muscles above it [54]. Subsequently, a block needle is inserted using an in-plane approach toward the transverse process, which serves as a crucial “bony backstop,” preventing the needle from advancing too deeply and significantly reducing the risk of serious complications, such as pleural puncture. Once the needle tip is confirmed to be in contact with the transverse process, aspiration is performed to rule out intravascular placement, and 20 to 30 mL of local anesthetic is injected [55,56]. Successful injection is confirmed on the ultrasound image by the characteristic finding of the erector spinae muscle lifting off the transverse process as the local anesthetic spreads between them [55]. ESPB can be performed as a single-shot injection, or for continuous pain control, a catheter can be placed for continuous infusion of local anesthetic [53].

Approximately 5 to 6 years after ESPB introduction, a substantial number of RCTs have investigated its analgesic efficacy across nearly all types of surgical procedures on the human torso. Cumulatively, the evidence shows that ESPB provides superior analgesia and lowers opioid consumption following various surgeries, such as breast surgery, laparoscopic cholecystectomy, and thoracotomy, in comparison to sham or no-block groups [53,54,57-61]. However, whether ESPB can serve as a viable alternative to conventional PVB remains unclear. Although thoracic PVB has demonstrated superior analgesic efficacy after thoracic surgery [62], ESPB offers a more favorable safety profile [53]. Thoracic PVB inherently carries the risk of serious complications because the needle tip is close to the pleura, major blood vessels, and the neuroaxis. In contrast, ESPB utilizes the hard bony structure of the transverse process as a safety backstop. Once the needle touches the surface of the transverse process, it cannot advance further, eliminating the risk of damage to the pleura or lungs. Additionally, the injection site is far from the neuroaxis and major blood vessels, which significantly lowers the risk of hematoma or nerve injury. Therefore, ESPB may not be the first-choice technique for postoperative pain control in thoracic surgery, but it can be an effective alternative when thoracic PVB or TEA is contraindicated because of coagulopathy or anticoagulant treatment [63,64].

Although the clinical efficacy of ESPB is known, its precise mechanism of action remains a major topic of academic debate. The analgesic mechanisms of ESPB are multifaceted. The primary effect is the direct blockade of the dorsal rami of the spinal nerves, which innervate the spine and paravertebral tissues [65]. The local anesthetic spreads extensively in a craniocaudal direction within the injected fascial plane, blocking the dorsal rami of multiple segments and providing potent analgesia for the back. This explains how the block can effectively control dorsal pain even if the anterior spread into the paravertebral space is insufficient. In addition to this direct action, the injected local anesthetic spread anteriorly to reach the paravertebral space [55,66]. According to this hypothesis, the local anesthetic injected into the deep erector spinae plane gradually seeps through the fenestrations in the intertransverse connective tissue complex to enter the paravertebral space. Once in this space, the local anesthetic blocks both the ventral ramus (intercostal nerve) and dorsal ramus of the spinal nerve, resulting in an extensive somatic sensory blockade covering the anterior, lateral, and posterior aspects of the thoracic wall [53]. Furthermore, in some cases, the anesthetic may spread through the neural foramina into the epidural space, providing additional analgesic effects [53].

The introduction of ultrasound has led to the development of various fascial plane blocks such as ESPB. In this technique, a local anesthetic is injected into a plane between the two layers of the fascia, often at a site remote from the intended target area [67]. The anesthetic then spreads along this plane to block the target nerves. Therefore, ESPB differs from traditional nerve blocks that target a single specific nerve, resulting in variability in its analgesic effects. Fascial plane blocks such as ESPB generally require a large volume of local anesthetic to increase success rates [68]. However, the safety profile of local anesthetics for ESPB remains inadequately defined, as systematic evaluations based on serum concentrations are lacking. This uncertainty is further complicated by the variable distribution of the injectate, which makes it difficult to predict its spread into the anterior thoracic paravertebral space versus into the posterior musculofascial layer. A cadaver study showed that simply increasing the injection volume did not necessarily correlate with greater paravertebral spread [69]. Therefore, there is a need for continued research to identify the optimal dose-volume regimens that maximize the efficacy of the ESP block while ensuring patient safety.

Serratus anterior plane block

SAPB is performed by injecting the drug into the plane between the serratus anterior and latissimus dorsi muscles (superficial SAPB) or between the serratus anterior and intercostal muscles (deep SAPB) in the midaxillary line rather than directly around a specific nerve.

The dorsal and ventral rami are spinal nerves that exit the intervertebral foramen. The dorsal rami pass through the costotransverse foramen and control the somatosensory sensation of the back. The ventral rami run laterally as intercostal nerves that divide into the anterior and lateral cutaneous branches, which supply cutaneous innervation to the anterior and lateral chest wall [70]. The analgesic effect of SAPB is achieved by blocking the lateral cutaneous branches of the thoracic intercostal nerves, which pierce the intercostal and serratus anterior muscles at the midaxillary line.

SAPB is performed under ultrasound guidance. A high-frequency linear transducer is placed in transverse orientation on the patient’s midaxillary line at the level of the fifth rib [71]. The operator should clearly identify key structures on the ultrasound screen, including the latissimus dorsi, serratus anterior, and external intercostal muscles, as well as the ribs and pleura [71]. The procedure is performed using an in-plane technique that allows real-time visualization of the entire needle shaft and tip as it advances toward the target [72,73]. Before injecting the full volume of local anesthetic, a small amount of saline or local anesthetic (1–3 mL) is often injected to hydrodissect the target fascial plane and confirm correct placement of the needle tip, thereby increasing procedural accuracy. Local anesthetics can be injected into one of two different planes with respect to the serratus anterior muscle: superficial (between the latissimus dorsi and serratus anterior muscles) or deep (between the serratus anterior and ribs/external intercostal muscles) (Fig. 3) [73]. A recent meta-analysis of seven RCTs found no statistically significant differences between the superficial and deep approaches in terms of 24-hour postoperative opioid consumption, pain scores, or time to first analgesic request [72]. This suggests that both approaches provide similar degrees of postoperative pain relief. For patients in whom prolonged postoperative pain is anticipated, a continuous SAPB technique is highly recommended [73]. This method involves placing a catheter within the serratus anterior plane after an initial bolus, allowing continuous infusion of local anesthetics [73].

Various studies have shown that SAPB can be safe and effective for postoperative analgesia of breast surgery, rib fracture, thoracoscopic surgery, and minimally invasive thoracotomy [17,74-78]. Although thoracoscopic surgery is used to decrease mortality and postoperative pulmonary complications because it is a minimally invasive technique, its postoperative pain is distinct and can cause pulmonary complications and lengthen hospital stays [79]. SAPB has better postoperative analgesic effects on rehabilitation exercises and diminishes the amount of systemic analgesics compared to intravenous and oral analgesic drugs [75]. Other studies have shown that SAPB is an equally effective, simple, and safe method for postoperative pain control in thoracoscopic surgery compared with thoracic PVB [80]. However, the limitations of SAPB must be considered. The dorsal rami and anterior cutaneous branches of the ventral rami of the spinal nerves are spared from SAPB; consequently, noxious stimuli from the anterior chest wall, posterior spinal muscles, and costovertebral area are not blocked. SAPB may be inadequate for postoperative pain control in open thoracotomy because of the wide skin incision, cutting and retraction of the chest wall muscles, and dislocation of the costovertebral and costochondral joints. In a previous study, SAPB did not provide adequate postoperative analgesia for thoracotomy compared to thoracic PVB [81].

Intercostal nerve block

ICB is one of the oldest and most fundamental regional anesthesia techniques used for pain management after thoracic surgery. The intercostal nerves originate from the ventral rami of the thoracic spinal nerves and run along the subcostal groove along with the intercostal arteries and veins between the internal and innermost intercostal muscles [82]. The lateral cutaneous branches of the intercostal nerves divide at the posterior axillary line. To block the lateral chest wall, ICB should be performed medially to the posterior axillary line. This block can be easily performed under ultrasound guidance or by eye when the chest is open. In the percutaneous technique, a needle is inserted at the angle of the rib proximal to the midaxillary line, 6 to 8 cm laterally from the spinous process, before a lateral cutaneous branch emerges from the intercostal nerve [6]. The needle is inserted below the inferior border of the rib, is advanced cephalad to the subcostal groove, and 3 to 5 mL of local anesthetic is injected. Two intercostal nerves of the upper and lower dermatomes should be blocked for adequate postoperative analgesia at the thoracotomy incision site [6].

A large-scale meta-analysis showed that ICB provides a clinically and statistically significant analgesic benefit during the first 24 hours after surgery compared to systemic analgesia alone in thoracic surgery [83]. However, some limitations must be considered. ICB cannot provide effective analgesia for posterolateral thoracotomy because the dorsal rami, which innervate the back, pierce the costotransverse ligaments close to the vertebrae. It should also be remembered that the rapid systemic uptake of local anesthetics by the highly vascular intercostal space can cause a toxic reaction, and repeated ICB is required because the half-life of the local anesthetic is shortened by high absorption [6]. However, as the number of needle insertions increases, the risk of complications, such as pneumothorax, vascular puncture, and local anesthetic systemic toxicity, also increases.

Continuous wound instillation

Continuous wound instillation (CWI) is an analgesic technique in which a specially designed catheter is placed within or near the tissue layers of the surgical wound at the time of closure, through which a local anesthetic is continuously infused for a defined period [84]. The anesthetic diffuses into the damaged tissue surrounding the surgical incision and reversibly blocks voltage-gated sodium channels located on the cell membranes of the peripheral nerve fibers [85]. When these sodium channels are blocked, the influx of sodium ions across the nerve cell membrane is inhibited, rendering the generation and conduction of action potentials impossible. As a result, noxious afferent signals originating from damaged tissues are prevented from being transmitted to the spinal cord and brain, producing a potent analgesic effect. Recent studies have suggested that CWI involves additional mechanisms beyond simple nerve blockade. The direct instillation of a local anesthetic into the wound site has also been shown to mitigate local inflammatory responses to tissue injury [86].

The CWI procedure consists of three components: a catheter, an infusion pump, and a local anesthetic solution. CWI typically employs a flexible, multi-holed catheter, also known as a “soaker catheter,” which is designed to allow the local anesthetic to seep out uniformly along the entire length of the incision, rather than from a single point [86]. Various types of pumps are used to continuously infuse local anesthetics, with the most common being portable disposable elastomeric pumps. These pumps infuse the drug at a constant rate by utilizing the contraction force of the internal elastic membrane, requiring no external power. This simplicity is a major advantage as it reduces the management burden on ward nursing staff [87]. The most used drugs in clinical studies are bupivacaine and ropivacaine, with concentrations ranging from 0.2% to 0.5%, although this can vary among studies [87].

An RCT involving patients who underwent muscle-sparing thoracotomy revealed that the CWI group had significantly lower pain scores both at rest and during coughing than the placebo (saline infusion) group [86]. This suggests that CWI is effective in controlling not only persistent baseline pain but also acute pain experienced during activities essential for pulmonary rehabilitation. However, despite the increasing clinical adoption of CWI, a major RCT indicated that for post-thoracotomy pain management, the thoracic PVB group demonstrated markedly better outcomes than the CWI group [88]. The thoracic PVB group demonstrated superior analgesic efficacy to the CWI group, as the former experienced significantly lower pain scores both at rest and during coughing and required considerably less supplemental opioid medication. This suggests that thoracic PVB provides sufficient analgesia on its own, thus reducing opioid dependence. In contrast, the CWI group showed no significant difference in pain scores or morphine consumption compared with the group receiving only systemic analgesia, implying that CWI does not offer additional analgesic benefit, at least in major surgeries such as thoracotomy.

Conclusion

Effective postoperative analgesia for thoracic surgery is critical for reducing severe postoperative complications and preventing the transition to chronic pain. For thoracic surgery, most patients are best managed with a combination of regional analgesia and opioids, sometimes supplemented with non-opioid analgesics. While TEA remains the historical gold standard owing to its potent analgesic effects, its profile of rare but severe neurological risks and common side effects such as hypotension has spurred the development of alternatives. Thoracic PVB offers comparable efficacy with greater hemodynamic stability but is hampered by technical challenges and a non-trivial failure rate. This efficacy-safety trade-off has driven the evolution of newer fascial plane blocks, such as ESPB, which offers an enhanced safety profile at the potential cost of reduced analgesic potency, and ITPB, which aims to combine the efficacy of PVB with superior safety, although its comparative effectiveness requires further validation. Other regional techniques such as SAPB, ICB, and CWI have demonstrated utility in less invasive procedures but are generally insufficient for the comprehensive somatic and visceral pain of open thoracotomy. Therefore, the selection of a primary regional technique for postoperative pain control after thoracic surgery is a carefully considered decision that balances proven efficacy against procedural risk and is tailored to institutional resources, practitioner skills, and individual patient factors.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Investigation, Resources, Software, Supervision, Validation: SJP; Visualization: SJP, EKC; Writing-original draft: SJP, EKC; Writing-review & editing: SJP, EKC.

Fig. 1.

Sagittal-sectional image of the intertransverse process region. The arrowheads indicate the superior costotransverse ligament. The asterisk indicates the costotransverse space between the rib (R) and transverse process (TP). The red dotted lines indicate the erector spinae fascial plane. PVB, paravertebral block; ESP, erector spinae plane block; ITP, intertransverse process block; P, pleura. Reproduced from Kim [37] under the Creative Commons BY-NC 4.0 license.

Fig. 2.

Ultrasound anatomy of erector spinae block at the T5 level. TP, transverse process; T, trapezius; RM, rhomboid major; ESP, erector spinae; Pl, pleura. *Needle tip position. Reproduced from Kot et al. [53] under the Creative Commons License BY-NC 4.0 license.

Fig. 3.

Ultrasound image obtained during a superficial and deep serratus anterior plane block. Reproduced from Chen et al. [73] under the Creative Commons License BY-NC 4.0 license.

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