(Kiosk 5) Alleviating Periscapular Pain in the Clinic with Paravertebral Block: A Case Report

Case Diagnosis: Chronic bilateral periscapular neuropathic pain treated with ultrasound guided Thoracic (T7) Paravertebral Block (TPB).

Case Description or Program Description: Patient is a 71 year-old female with diffuse back pain, worse along the thoracic spine, periscapular region bilaterally. Pain began insidiously 4 years prior without acute inciting event. Patient denies radicular symptoms and physical exam was negative for focal neurologic deficits. Imaging of the spine was unremarkable. She was diagnosed with likely neuropathic periscapular pain. She previously failed conservative management including physical therapy, pharmacotherapy and trigger point injections. The decision was made to perform outpatient TPB.

Setting: Outpatient pain medicine department of tri-state academic medical center.

Assessment/Results: Bilateral T7 TPBs were performed using a longitudinal, out-of-plane approach via ultrasound guidance. The ribs, parietal pleura and intercostal spaces were identified, followed by medial translation of the transducer to identify the transverse process. A 22-gauge 3.5-inch spinal needle was used to contact the transverse process, followed by hydrodissection to identify the erector spinae fascial plane. Negative aspiration was performed and injectate was applied with good spread in the paravertebral space. Symptomatic relief was immediate, without complications, lasting at 6-week follow-up.

Discussion (relevance): TPB inject local anesthetic near spinal nerves where they emerge from intervertebral foramina, with dermatomal blocking of sympathetic and somatic nerves. TPB are commonly used for thoracic surgery to reduce post-op unilateral chest and abdominal pain. Here we show an uncommon outpatient setting with uncommon indications - no thoracic surgery and pain both bilateral and periscapular.

Conclusions: The growing use of ultrasound guided interventions for pain has increased options available to treat chronic pain in the outpatient setting. TPBs can broaden past the post-operative pain realm and onto managing chronic pain effectively in the outpatient setting. While this patient had pain relief at 6 weeks follow-up, more studies are required to identify if this outcome would be generalizable to larger populations.