Thoracic Paravertebral Nerve Block as the Sole Anesthetic for an Open Biopsy of a Large Anterior Mediastinal Mass

compressed the left bronchial tree. The tumor completely surrounded large blood vessels and the heart, as confirmed by echocardiography. The systolic function of the heart was preserved. Flexible fiberoptic bronchoscopy (FFB) under sedation determined that the lumen of the left bronchial tree was narrowed to one-third of its normal size due to external compression. The type of the tumor was not determined by transtracheal and ultrasound-guided transthoracic puncture, and the patient presented for biopsy. The patient was ASA class IV due to position and extension of the tumor. The high risk of the procedure including TPVB was explained to the patient, and she signed an informed consent for both surgery and the nerve block. Methylprednisolone, pantoprazole, cefazolin, and 5 mg of oral diazepam were administered preoperatively. It was elected to use TPVB repeated at each dermatome level. With the patient in a sitting position, 8 mL of 2% lidocaine was administered subcutaneously. Using a 10-cm long 22-gauge Tuohy spinal needle and a loss of resistance technique, single punctures of the 4 left paravertebral spaces from T2-T5 were performed. After careful aspiration, 5 mL of 0.5% bupivacaine per segment was administered. 10-13 The onset of sensory loss occurred approximately 25 minutes after the injections. Before starting the incision, 0.05 mg of alfentanil and 1 mg of midazolam were administered intravenously, and 100 mg of 2% lidocaine was injected under the skin. The patient was lying on her back but in the right semilateral position, and the surgical access was an anterior mediastinotomy carried out through the third left intercostal space. A 5-cm transverse parasternal skin incision, just lateral to the sternal border, removing the underlying costal cartilage, was used. Electrocautery was used to divide intercostal muscles, and after removing costal cartilage, the internal mammary vessels were ligated. Abundant biopsy specimens were taken. Excellent analgesic effect was achieved. During the operation, the patient was awake, did not experience pain, and was hemodynamically stable and spontaneously breathing. After surgery, she was observed for 24 hours. The pathohistologic examination was unable to determine the precise type of the tumor, and the procedure was repeated 5 days later. Under TPVB, the wound was reopened, and several large biopsy specimens were taken. The postoperative course was uneventful after both procedures. The pathologic diagnosis was eosinophilic granuloma.