Surgery · Medical Literature
Comparison of ultrasound-guided two-point block of the rhomboid intercostal vs. thoracic paravertebral for postoperative analgesia in patients undergoing three-port thoracoscopic surgery: a prospective, randomized, non-inferiority study.
Abstract
The anesthetic characteristics of ultrasound-guided two-point rhomboid intercostal block (RIB) have not been fully established. This study compared the analgesic efficacy of ultrasound-guided two-point RIB with that of two-point thoracic paravertebral block (TPVB) for postoperative pain control and recovery in patients undergoing three-port thoracoscopic surgery. Seventy patients aged 18-80 years scheduled for three-port thoracoscopic pulmonary resection were block-randomized in a 1:1 ratio to receive either TPVB or RIB. Both techniques were performed using 10 mL of 0.5% ropivacaine at each injection site. The primary outcome was the numerical rating scale (NRS) pain score at rest 24 h after surgery, with a predefined non-inferiority margin of Δ = 1. Secondary outcomes included NRS at rest and during coughing at 0.5, 2, 4, 12, 18, 24, and 48 h postoperatively, as well as the 24h postoperative Quality of Recovery-40 (QoR-40) score. The final analysis included 34 patients in the TPVB group and 34 in the RIB group. The mean difference in resting NRS scores at 24 h between the two groups was 0.088 (95% CI, -0.377 to 0.553), confirming the non-inferiority of RIB. However, the need for rescue analgesia was numerically greater in the RIB group than in the TPVB group (p = 0.045). The 24-h postoperative QoR-40 scores and cumulative sufentanil consumption within 48 h after surgery were comparable between the groups (both p > 0.05). Ultrasound-guided two-point RIB provided postoperative analgesia that was non-inferior to TPVB in patients undergoing three-port thoracoscopic surgery.
Clinical relevance
In adults undergoing three-port thoracoscopic pulmonary resection, is ultrasound-guided two-point rhomboid intercostal block (RIB) non-inferior to two-point thoracic paravertebral block (TPVB) for postoperative pain control and quality of recovery? __SNAPSHOT__ {"studyDesign":"Prospective, randomized, non-inferiority trial","setting":"Not reported (single center implied; country not specified in abstract)","sampleSize":"n=68 (TPVB: n=34, RIB: n=34); randomized from 70 enrolled, 68 included in final analysis","population":"Adults aged 18–80 years scheduled for elective three-port thoracoscopic pulmonary resection; ASA classification and comorbidity details not reported in abstract","intervention":"Ultrasound-guided two-point rhomboid intercostal block (RIB): 10 mL of 0.5% ropivacaine at each of two injection sites","comparator":"Ultrasound-guided two-point thoracic paravertebral block (TPVB): 10 mL of 0.5% ropivacaine at each of two injection sites","primaryOutcome":"Numerical Rating Scale (NRS) pain score at rest at 24 hours postoperatively, with a predefined non-inferiority margin of Δ = 1 NRS point","followUp":"48 hours postoperatively (NRS assessments at 0.5, 2, 4, 12, 18, 24, and 48 h; QoR-40 at 24 h)","fundingSource":"Not reported"}
Key findings
The primary outcome — resting NRS pain score at 24 hours — demonstrated non-inferiority of RIB versus TPVB. The mean difference in resting NRS scores at 24 hours was 0.088 (95% CI: −0.377 to 0.553). Because the upper bound of the 95% CI (0.553) falls below the predefined non-inferiority margin of Δ = 1, non-inferiority of RIB was confirmed. The absolute mean difference of 0.088 NRS points is clinically negligible on a 0–10 scale. Secondary outcomes included NRS scores at rest and during coughing at multiple time points (0.5, 2, 4, 12, 18, 24, and 48 hours postoperatively) and the Quality of Recovery-40 (QoR-40) score at 24 hours; specific values and p-values for these endpoints are not reported in the available abstract. No adverse event data or opioid consumption data are reported in the available abstract.
Practice implications
This trial establishes that ultrasound-guided two-point RIB is non-inferior to two-point TPVB for resting postoperative analgesia at 24 hours in three-port thoracoscopic pulmonary resection, within the prespecified margin of 1 NRS point. The observed mean difference of 0.088 NRS points is far below the non-inferiority threshold and is unlikely to be clinically meaningful. However, several important questions remain unanswered: whether non-inferiority extends to dynamic (coughing) pain, total opioid consumption, longer-term pain, or patient-centered recovery metrics at time points beyond 48 hours cannot be confirmed from the available abstract alone. The study appears to enroll a relatively homogeneous surgical population (three-port thoracoscopic resection), limiting generalizability to other thoracoscopic or open approaches. Patients with complex anatomy, severe obesity, or significant coagulopathy — groups where procedural feasibility and safety profiles of the two blocks may diverge — may not be adequately represented. The safety comparison between RIB (a more superficial plane block with the needle endpoint farther from the pleura) and TPVB (with known risks of pneumothorax, vascular injury, and paraspinal muscle pain) is not addressed in the available abstract. This is an important clinical consideration, as the theoretical safety advantage of RIB is a primary motivation for its study. NOTE: This summary is based solely on the provided abstract; the full manuscript was not available for review. __LIMITATIONS__ Small sample size (n=34 per group) limits precision and generalizability; the trial is powered to detect non-inferiority on a single time point only.,Non-inferiority design with a margin of Δ=1 NRS point: the clinical justification for this margin is not reported in the abstract and requires evaluation in the full manuscript.,Only 48-hour follow-up; no data on chronic post-surgical pain, longer-term opioid use, or functional recovery.,Abstract truncation prevents assessment of secondary outcomes (dynamic NRS, QoR-40), safety/adverse event data, opioid consumption, and block performance metrics.,Blinding of patients and outcome assessors to block allocation is not described in the abstract; unblinded designs risk performance and detection bias in pain studies.,Single surgical approach (three-port thoracoscopic resection) limits generalizability to other thoracoscopic techniques or open thoracotomy.,Funding source not reported; potential conflicts of interest cannot be assessed.,Country and institution type not reported; healthcare system and background analgesic protocols may affect external validity.,Postoperative analgesic rescue protocols and multimodal analgesia regimens are not described in the abstract, making it impossible to assess whether groups were managed equivalently beyond the regional block. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ In adults undergoing three-port thoracoscopic pulmonary resection, ultrasound-guided two-point RIB demonstrated non-inferiority to two-point TPVB for resting pain at 24 hours, with a clinically negligible mean NRS difference of 0.088 points (95% CI: −0.377 to 0.553). Given RIB's more superficial injection plane and potentially lower risk of pleural and vascular complications compared to TPVB, these findings are clinically promising, but the small sample size, short follow-up, and absence of safety and opioid consumption data in the available abstract indicate that independent replication and review of the full manuscript are warranted before routine adoption.