Preemptive Intercostal Nerve Block as an Alternative to Epidural Analgesia

Abstract

Background: The necessity of thoracic epidural analgesia (TEA) during minimally invasive surgery (MIS) remains unclear. We investigated TEA efficacy in MIS versus thoracotomy and the noninferiority of a preemptive intercostal nerve block (ICNB) to TEA in MIS.

Methods: We investigated 393 patients who underwent lung resection, with and without TEA, between 2014 and 2019 (242 MIS, 151 thoracotomy) and 93 patients who underwent MIS with ICNB between 2019 and 2020. To address selection bias 70 TEA and 70 ICNB patients were propensity score matched. Endpoints were pain score during hospitalization, postoperative complications, duration of operating room use, analgesia-related adverse effects, and use of supplemental pain medication.

Results: One-third of patients with MIS discontinued TEA on postoperative day 1 or earlier; those with early TEA discontinuation reported worse pain the next day. TEA was associated with lower pain scores compared with non-TEA, regardless of surgical invasiveness, and a lower complication risk in patients with thoracotomy but not MIS. For MIS, ICNB was associated with an equivalent pain score on postoperative day 1, lower average pain score during hospitalization, shorter duration of operation room use, less frequent use of supplemental pain medication, and similar risk of postoperative complication and analgesia-related adverse effects compared with TEA after matching.

Conclusions: Given early TEA discontinuation after MIS and ICNB's noninferior pain relief, preemptive ICNB can be an alternative for TEA in patients undergoing MIS.