Thoracic epidural versus paravertebral blockade for reducing chronic post-thoracotomy pain (TOPIC-2): open label, parallel group, superiority, multicentre, randomised controlled trial.
Ben Shelley, Lee Middleton, Rebecca Boyles et al.
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In 30 seconds
This open-label, multicentre, parallel-group superiority randomised trial compared perioperative paravertebral blockade with thoracic epidural in adults undergoing thoracotomy at 15 UK centres. Among 737 patients in the modified intention-to-treat population, chronic post-thoracotomy pain at six months occurred in 22% with paravertebral blockade and 16% with epidural; the adjusted risk ratio was 1.32 (95% CI 0.93 to 1.86; P=0.12). Paravertebral blockade did not significantly reduce chronic pain. Epidural provided slightly better pain relief on postoperative day 1, while several complications differed between groups.
Key findings
- At six months, chronic post-thoracotomy pain occurred in 59 (22%) of 272 paravertebral participants and 47 (16%) of 292 epidural participants; adjusted risk ratio 1.32 (95% CI 0.93 to 1.86), P=0.12.
- On day 1, worst and average pain were greater with paravertebral blockade by 7.7 mm (95% CI 2.8 to 12.5 mm) and 7.0 mm (95% CI 2.7 to 11.2 mm), respectively; pain did not differ on days 2-3.
- Hypotension (12% v 18%) and pruritis (4% v 12%) were less common with paravertebral blockade, while urinary retention was more common (12% v 6%).
Why it matters
The trial addresses whether the choice of regional analgesia for thoracotomy affects persistent pain as well as immediate postoperative outcomes. It found no statistically significant reduction in chronic pain with paravertebral blockade, while acute pain and complication profiles varied. These comparative results help frame the trade-offs between two established techniques without demonstrating superiority for preventing chronic pain.
What to keep in mind
Six-month pain outcomes were available for 272 of 364 participants in the paravertebral group and 292 of 373 in the epidural group. The open-label design may also influence reported pain outcomes.