A nerve block approach proved superior on some measures to epidural for thoracoscopic anatomical lung surgery, according to a Dutch randomised trial.
In their findings of their OPtriAL study, published in JAMA Surgery, a team led by Frank van den Broek, MD, PhD, of Máxima Medical Centre in Veldhoven, The Netherlands, wrote that a single-shot intercostal nerve block (ICNB) was non-inferior to thoracic epidural analgesia (TEA) for pain control, with 29.5% versus 20.7% of patients having pain scores of 4 or greater on the 0- to 10-point numerical rating scale through postoperative day two.
Continuous paravertebral block (PVB), while one of the most popular locoregional alternatives to epidurals, didn't measure up as a third arm in the trial. It was inferior to TEA for pain control, with 35.5% of patients rating pain at a 4 or more, they noted.
Quality of recovery scores were similar across the analgesia groups.
ICNB and PVB both significantly reduced opioid consumption and enhanced mobility versus TEA, and came out superior to the traditional standard for nausea and vomiting by patient-reported outcomes.
“ICNB emerges as an alternative to TEA, although risks and benefits should be weighed for optimal personalised pain control,” the authors concluded.
An accompanying editorial offered a bolder take: “While the authors are fairly tempered in their conclusions, it would be reasonable, given their level 1 evidence, to suggest that ICNB should be the preferred mode of analgesia for patients undergoing minimally invasive lung resection with a low risk of conversion to thoracotomy,” wrote Joseph Phillips, MD, of Dartmouth-Hitchcock Medical Centre in Lebanon, New Hampshire, USA.
Epidurals make sense with traditional thoracotomy but can be technically challenging and time-consuming in the minimally invasive setting in which “adequate postoperative pain control that minimises time to administration, cost, and resources used and facilitates early mobilisation and appropriate timely discharge is of the utmost importance”, he added.
The trial randomised 450 patients to the three analgesia methods in a 1:1:1 ratio for thoracoscopic anatomical lung resection at 11 hospitals in the Netherlands and Belgium from March 2021 to September 2023.
“While satisfaction seemed to be higher with TEA on the day of surgery, by postoperative days 1 through 3, differences were negligible,” Phillips noted.
Postoperative nausea and vomiting scores averaged higher, at 9, for both minimally invasive analgesia approaches compared with 8 for TEA (both P=0.01) on the 10-point scale from the QoR-15 questionnaire where a higher score represents less nausea and vomiting.
While all three groups had similar time to chest tube removal, there was a numerically higher overall postoperative complication rate with ICNB (27% vs 18% with TEA and 22% with PVB), driven most notably by prolonged air leak (PAL) that required chest tube reinsertion.
“Although we attribute the higher incidence of PAL in the ICNB group to chance, we cannot exclude that improved patient mobility may influence any persistence of air leakage,” the researchers suggested.
The proportion of patients mobilising within the first three days after the procedure was 51% with ICNB and 55% with PVB compared with 38% with the epidural (P=0.002 and P<0.001, respectively). One reason might have been the roughly one-day-longer urinary catheter time with TEA, which likely also contributed to the one-day-longer hospitalisations versus ICNB.
Opioid morphine milligram equivalent came in at a median 25 and 23 for ICNB and PVB, respectively, compared with 195 with TEA on postoperative day 1 and, similarly, 30 and 23 versus 90 at postoperative day 2 –all P<0.001 for comparison.
“The pragmatic nature allowed flexibility of local in-house protocols, not mandating standard administration of opioids in the intervention groups, but only when needed,” the researchers noted, while opioids in the epidural solution is standard of care.
A planned economic analysis will probably further favour ICNB for appropriate analgesia for minimally invasive thoracic surgical procedures, Phillips suggested.
Study details
Intercostal or paravertebral block vs thoracic epidural in lung surgery: a randomised non-inferiority trial
Louisa Spaans, Marcel Dijkgraaf, Denis Susa, et al.
Published in JAMA Surgery on 25 June 2025
Abstract
Importance
Effective pain control after thoracic surgery is crucial for enhanced recovery. While thoracic epidural analgesia (TEA) traditionally ensures optimal analgesia, its adverse effects conflict with the principles of enhanced recovery after thoracic surgery. High-quality randomised data regarding less invasive alternative locoregional techniques are lacking.
Objective
To evaluate the efficacy of continuous paravertebral block (PVB) and a single-shot intercostal nerve block (ICNB) as alternatives to TEA.
Design, Setting, and Participants
This randomised clinical trial compared PVB and ICNB vs TEA (1:1:1) in patients undergoing thoracoscopic anatomical lung resection at 11 hospitals in the Netherlands and Belgium, enrolled from March 5, 2021, to September 5, 2023. The study used a non-inferiority design for pain and a superiority design for quality of recovery (QoR).
Interventions
Continuous PVB and single-shot ICNB.
Main Outcomes and Measures
Primary outcomes were pain, defined as mean proportion of pain scores 4 or greater during postoperative days (POD) 0 through 2 (non-inferiority margin for the upper limit [UL] 1-sided 98.65% CI, 17.5%), and QoR, assessed with the QoR-15 questionnaire at POD 1 and 2. Secondary measures included opioid consumption, mobilisation, complications, and hospitalisation.
Results
A total of 450 patients were randomised, with 389 included in the intention-to-treat (ITT) analysis (mean [SD] age, 66 [9] years; 208 female patients [54%] and 181 male [46%]). Of these 389 patients, 131 received TEA, 134 received PVB, and 124 received ICNB. The mean proportions of pain scores 4 or greater were 20.7% (95% CI, 16.5%-24.9%) for TEA, 35.5% (95% CI, 30.1%-40.8%) for PVB, and 29.5% (95% CI, 24.6%-34.4%) for ICNB. While PVB was inferior to TEA regarding pain (ITT: UL, 22.4%; analysis per-protocol [PP]: UL, 23.1%), ICNB was non-inferior to TEA (ITT: UL, 16.1%; PP: UL, 17.0%). The mean (SD) QoR-15 scores were similar across groups: 104.96 (20.47) for TEA, 106.06 (17.94; P = .641) for PVB (P = .64 for that comparison), and 106.85 (21.11) for ICNB (P = .47 for that comparison). Both ICNB and PVB significantly reduced opioid consumption and enhanced mobility compared with TEA, with no significant differences in complications. Hospitalisation was shorter in the ICNB group.
Conclusions and Relevance
After thoracoscopic anatomical lung resection, only ICNB provides non-inferior pain relief compared with TEA. ICNB emerges as an alternative to TEA, although risks and benefits should be weighed for optimal personalised pain control.
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