Paravertebral catheter placement after a failed epidural in a patient with severe scoliosis

A 97 year-old female was admitted to the trauma ICU with left 5-10 rib fractures, left apical pneumothorax and bilateral pleural effusions as a result of a ground-level fall. Her past medical history included osteoporosis, severe scoliosis, post-herpetic neuralgia and mycobacterium avium complex lung infection with subsequent bronchiectasis. The Acute Pain Service (APS) was consulted as the patient’s oxygen saturations were progressively declining and she was unable to breathe deeply, cough or adjust positions. The APS team attempted epidural placement, which proved difficult due to her severe scoliosis. Clear loss of resistance was obtained at two separate interspaces; however the catheter could not be threaded at either level. The procedure was then abandoned as the patient could no longer tolerate positioning. On day two, the patient’s oxygen requirements increased, presumably due to poor respiratory effort and poor pulmonary toilet. Given the previous failure of epidural attempts, the authors decided to place a left paravertebral catheter using ultrasound guidance. The procedure was uncomplicated and the patient received significant analgesia within 20 minutes and was able to change positions and sit upright in bed without pain. She was able to perform pulmonary toilet and was discharged from the ICU that evening. Over the next 5 days the patient reported minimal pain and her catheter infusion was weaned to zero as she transitioned to oral analgesics. She was discharged to a rehabilitation facility without complication. Good analgesia can mean the difference between life and death in certain high-risk groups. This patient’s pre-existing pulmonary disease and advanced age could have very easily led to respiratory failure and severe disability or death if she did not receive adequate analgesia. This case illustrates that a paravertebral catheter placed under ultrasound guidance may be a superior analgesic option when severe scoliosis makes epidural catheter placement difficult.