title: Paravertebral Block for Inguinal Herniorrhaphy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
abstract: BACKGROUND
  Paravertebral block (PVB) is a safe and effective anesthetic technique for thoracotomy and mastectomy. However, no systematic review or meta-analysis has focused on PVB for inguinal herniorrhaphy. Our study compares PVB with general anesthesia/systemic analgesia, neuraxial blocks, and other peripheral nerve blocks.
  
  
  METHODS
  We analyzed 14 randomized controlled trials from PubMed, MEDLINE, CENTRAL, EMBASE, and CINAHL up to February 2015, without language restriction, comparing PVB under sedation with general anesthesia/systematic analgesia (135 vs 133 patients), neuraxial blocks (191 vs 186 patients), and other peripheral nerve blocks (119 vs 117 patients). We investigated pain scores, consumption of postoperative analgesia, incidence of postoperative nausea and vomiting (PONV), length of hospital stay, postanesthesia care unit bypassing rate, time to perform blocks, intraoperative hemodynamics, and incidence of urinary retention. Joint hypothesis testing was adopted for pain and analgesics, PONV, and hemodynamic variables. All analyses were performed with RevMan 5.2.11 (Cochrane Collaboration, Copenhagen). Hartung-Knapp-Sidik-Jonkman method was used for post hoc testing.
  
  
  RESULTS
  PVB reduced PONV (nausea: risk ratio [RR] = 0.22; 95% confidence interval [CI], 0.05-0.93; numbers needed to treat [NNT] = 4.5; I = 15% and vomiting: RR = 0.15; 95% CI, 0.03-0.76; NNT = 8.3; I = 0%) compared with general anesthesia/systematic analgesia (quality of evidence [QoE]: high). Compared with neuraxial blocks, PVB resulted in less postoperative nausea (RR = 0.34 [95% CI, 0.13-0.91], NNT = 8.3, I = 0%) and urinary retention (RR = 0.14 [95% CI, 0.05-0.42], NNT = 7.4, I = 0%) than neuraxial blocks (QoE: high). More time was needed to perform PVB than neuraxial blocks (standardized mean difference = 1.90 [95% CI, 0.02-3.77], I = 92%; mean difference = 5.33 minutes; QoE: moderate). However, the available data could not reject the null hypothesis of noninferiority on all pain scores and analgesic requirements for both PVB versus general anesthesia/systematic analgesia and PVB versus neuraxial blocks (QoE: low), as well as on hemodynamic outcomes for PVB versus neuraxial blocks (QoE: moderate). Our systematic review showed that PVB decreased postoperative pain scores and analgesic requirement as compared with ilioinguinal block and transversus abdominis plane block.
  
  
  CONCLUSIONS
  This meta-analysis shows that PVB provides an anesthesia with fewer undesirable effects for inguinal herniorrhaphy. The choice between general anesthesia/systematic analgesia, neuraxial blocks, PVB, and other peripheral nerve blocks should be based on time available to perform the block and a complete coverage over the relevant structures by the blocks.
authors.affiliation: From the *Department of Anesthesiology, Duke University, Durham, North Carolina; †Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina; and ‡Department of Anesthesiology, Stony Brook University, Stony Brook, New York.
authors.forename: Lawrence Siu-Chun
authors.initials: LS
authors.lastname: Law
authors.forename: Mingjuan
authors.initials: M
authors.lastname: Tan
authors.forename: Yaowu
authors.initials: Y
authors.lastname: Bai
authors.forename: Timothy E
authors.initials: TE
authors.lastname: Miller
authors.forename: Yi-Ju
authors.initials: YJ
authors.lastname: Li
authors.forename: Tong-Joo
authors.initials: TJ
authors.lastname: Gan
mesh_terms: D000700:Analgesics / Q000009:adverse effects / Q000627:therapeutic use; D016009:Chi-Square Distribution; D006552:Hernia, Inguinal / Q000175:diagnosis / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects; D006801:Humans; D007902:Length of Stay; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D016017:Odds Ratio; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D018579:Patient Selection; D020250:Postoperative Nausea and Vomiting / Q000209:etiology; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000700:Analgesics