{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T17:01:22Z","timestamp":1791910882365,"version":"4.3.4"},"reference-count":29,"publisher":"American Medical Association (AMA)","issue":"8","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Surg"],"published-print":{"date-parts":[[2025,8,1]]},"abstract":"<jats:sec><jats:title>Importance<\/jats:title><jats:p>Effective pain control after thoracic surgery is crucial for enhanced recovery. While thoracic epidural analgesia (TEA) traditionally ensures optimal analgesia, its adverse effects conflict with the principles of enhanced recovery after thoracic surgery. High-quality randomized data regarding less invasive alternative locoregional techniques are lacking.<\/jats:p><\/jats:sec><jats:sec><jats:title>Objective<\/jats:title><jats:p>To evaluate the efficacy of continuous paravertebral block (PVB) and a single-shot intercostal nerve block (ICNB) as alternatives to TEA.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design, Setting, and Participants<\/jats:title><jats:p>This randomized clinical trial compared PVB and ICNB vs TEA (1:1:1) in patients undergoing thoracoscopic anatomical lung resection at 11 hospitals in the Netherlands and Belgium, enrolled from March 5, 2021, to September 5, 2023. The study used a noninferiority design for pain and a superiority design for quality of recovery (QoR).<\/jats:p><\/jats:sec><jats:sec><jats:title>Interventions<\/jats:title><jats:p>Continuous PVB and single-shot ICNB.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main Outcomes and Measures<\/jats:title><jats:p>Primary outcomes were pain, defined as mean proportion of pain scores 4 or greater during postoperative days (POD) 0 through 2 (noninferiority margin for the upper limit [UL] 1-sided 98.65% CI, 17.5%), and QoR, assessed with the QoR-15 questionnaire at POD 1 and 2. Secondary measures included opioid consumption, mobilization, complications, and hospitalization.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 450 patients were randomized, with 389 included in the intention-to-treat (ITT) analysis (mean [SD] age, 66 [9] years; 208 female patients [54%] and 181 male [46%]). Of these 389 patients, 131 received TEA, 134 received PVB, and 124 received ICNB. The mean proportions of pain scores 4 or greater were 20.7% (95% CI, 16.5%-24.9%) for TEA, 35.5% (95% CI, 30.1%-40.8%) for PVB, and 29.5% (95% CI, 24.6%-34.4%) for ICNB. While PVB was inferior to TEA regarding pain (ITT: UL, 22.4%; analysis per-protocol [PP]: UL, 23.1%), ICNB was noninferior to TEA (ITT: UL, 16.1%; PP: UL, 17.0%). The mean (SD) QoR-15 scores were similar across groups: 104.96 (20.47) for TEA, 106.06 (17.94; <jats:italic>P<\/jats:italic>\u2009=\u2009.641) for PVB (<jats:italic>P<\/jats:italic>\u2009=\u2009.64 for that comparison), and 106.85 (21.11) for ICNB (<jats:italic>P<\/jats:italic>\u2009=\u2009.47 for that comparison). Both ICNB and PVB significantly reduced opioid consumption and enhanced mobility compared with TEA, with no significant differences in complications. Hospitalization was shorter in the ICNB group.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions and Relevance<\/jats:title><jats:p>After thoracoscopic anatomical lung resection, only ICNB provides noninferior pain relief compared with TEA. ICNB emerges as an alternative to TEA, although risks and benefits should be weighed for optimal personalized pain control.<\/jats:p><\/jats:sec><jats:sec><jats:title>Trial Registration<\/jats:title><jats:p>ClinicalTrials.gov Identifier: <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/study\/NCT05491239\">NCT05491239<\/jats:ext-link><\/jats:p><\/jats:sec>","DOI":"10.1001\/jamasurg.2025.1899","type":"journal-article","created":{"date-parts":[[2025,6,25]],"date-time":"2025-06-25T11:31:09Z","timestamp":1750851069000},"page":"855","source":"Crossref","is-referenced-by-count":25,"title":["Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery"],"prefix":"10.1001","volume":"160","author":[{"given":"Louisa N.","family":"Spaans","sequence":"first","affiliation":[{"name":"Department of Surgery, M\u00e1xima Medical Center, Veldhoven, the Netherlands"},{"name":"Amsterdam UMC location University of Amsterdam, Epidemiology and Data Science, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcel G. W.","family":"Dijkgraaf","sequence":"additional","affiliation":[{"name":"Amsterdam UMC location University of Amsterdam, Epidemiology and Data Science, Amsterdam, the Netherlands"},{"name":"Amsterdam Public Health, Methodology, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denis","family":"Susa","sequence":"additional","affiliation":[{"name":"Department of Surgery, Bravis Hospital, Bergen op Zoom, Roosendaal, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erik R.","family":"de Loos","sequence":"additional","affiliation":[{"name":"Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jo M. J.","family":"Mourisse","sequence":"additional","affiliation":[{"name":"Department of Anesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R. Arthur","family":"Bouwman","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Catharina Hospital, Eindhoven, the Netherlands"},{"name":"Department of Electrical Engineering, Signal Processing Systems, Eindhoven Technical University, Eindhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ad F. T. M.","family":"Verhagen","sequence":"additional","affiliation":[{"name":"Department of Cardio-thoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank J. C.","family":"van den Broek","sequence":"additional","affiliation":[{"name":"Department of Surgery, M\u00e1xima Medical Center, Veldhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"OPtriAL Study Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick","family":"Meijer","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology, M\u00e1xima Medical Center, Veldhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marieke","family":"Kuut","sequence":"additional","affiliation":[{"name":"Department of Anesthesia, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nike","family":"Hanneman","sequence":"additional","affiliation":[{"name":"Department of Surgery, Ikazia Hospital, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jelle","family":"Bousema","sequence":"additional","affiliation":[{"name":"Department of Surgery, Ikazia Hospital, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aim\u00e9e","family":"Franssen","sequence":"additional","affiliation":[{"name":"Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hes","family":"Brokx","sequence":"additional","affiliation":[{"name":"Department of Surgery, Bravis Hospital, Bergen op Zoom, Roosendaal, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eino","family":"van Duyn","sequence":"additional","affiliation":[{"name":"Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan-Willem","family":"Potters","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Medisch Spectrum Twente, Enschede, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Renee","family":"van den Broek","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Catharina Hospital, Eindhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"van Brakel","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Herman","family":"Rijna","sequence":"additional","affiliation":[{"name":"Department of Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annemieke","family":"Boom","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Spaarne Gasthuis, Hoofddorp, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valentin","family":"Noyez","sequence":"additional","affiliation":[{"name":"Department of Surgery, Algemeen Ziekenhuis Sint-Maarten, Mechelen, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeroen M. H.","family":"Hendriks","sequence":"additional","affiliation":[{"name":"Department of Vascular and Thoracic Surgery, Antwerp University Hospital, Antwerp, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suresh K.","family":"Yogeswaran","sequence":"additional","affiliation":[{"name":"Department of Vascular and Thoracic Surgery, Antwerp University Hospital, Antwerp, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chris","family":"Dickhoff","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martijn","family":"van Dorp","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"1","key":"soi250032r1","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1093\/ejcts\/ezy301","article-title":"Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS\u00ae) Society and the European Society of Thoracic Surgeons (ESTS).","volume":"55","author":"Batchelor","year":"2019","journal-title":"Eur J Cardiothorac Surg"},{"issue":"6","key":"soi250032r2","doi-asserted-by":"publisher","first-page":"959","DOI":"10.1093\/ejcts\/ezt525","article-title":"Regional analgesia for video-assisted thoracic surgery: a systematic review.","volume":"45","author":"Steinthorsdottir","year":"2014","journal-title":"Eur J Cardiothorac Surg"},{"issue":"3","key":"soi250032r3","doi-asserted-by":"publisher","first-page":"e222","DOI":"10.1016\/j.bja.2021.12.005","article-title":"Variation in postoperative pain management after lung surgery in the Netherlands: a survey of Dutch thoracic surgeons.","volume":"128","author":"Spaans","year":"2022","journal-title":"Br J Anaesth"},{"issue":"11","key":"soi250032r4","doi-asserted-by":"publisher","first-page":"4347","DOI":"10.21037\/jtd.2017.09.133","article-title":"Postoperative pain in thoracic surgery: re-evaluating the benefits of VATS when coupled with epidural analgesia.","volume":"9","author":"Obuchi","year":"2017","journal-title":"J Thorac Dis"},{"issue":"3","key":"soi250032r5","doi-asserted-by":"publisher","first-page":"311","DOI":"10.1111\/anae.15609","article-title":"PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations.","volume":"77","author":"Feray","year":"2022","journal-title":"Anaesthesia"},{"issue":"3","key":"soi250032r6","doi-asserted-by":"publisher","first-page":"404","DOI":"10.1093\/icvts\/ivy265","article-title":"Epidural analgesia versus paravertebral block in video-assisted thoracoscopic surgery.","volume":"28","author":"Harky","year":"2019","journal-title":"Interact Cardiovasc Thorac Surg"},{"issue":"1","key":"soi250032r7","doi-asserted-by":"publisher","DOI":"10.1093\/icvts\/ivad003","article-title":"Acute pain management after thoracoscopic lung resection: a systematic review and explorative meta-analysis.","volume":"36","author":"Spaans","year":"2023","journal-title":"Interdiscip Cardiovasc Thorac Surg"},{"issue":"12","key":"soi250032r8","doi-asserted-by":"publisher","first-page":"5012","DOI":"10.21037\/jtd-22-599","article-title":"Regional anesthesia for thoracic surgery: a narrative review of indications and clinical considerations.","volume":"14","author":"Sertcakacilar","year":"2022","journal-title":"J Thorac Dis"},{"key":"soi250032r9","doi-asserted-by":"publisher","DOI":"10.3389\/fmed.2022.842332","article-title":"Regional analgesia in video-assisted thoracic surgery: a bayesian network meta-analysis.","volume":"9","author":"Lin","year":"2022","journal-title":"Front Med (Lausanne)"},{"issue":"1","key":"soi250032r10","doi-asserted-by":"publisher","first-page":"330","DOI":"10.1186\/s12893-022-01765-y","article-title":"Optimal postoperative pain management after VATS lung resection by thoracic epidural analgesia, continuous paravertebral block or single-shot intercostal nerve block (OPtriAL): study protocol of a three-arm multicentre randomised controlled trial.","volume":"22","author":"Spaans","year":"2022","journal-title":"BMC Surg"},{"issue":"4","key":"soi250032r11","doi-asserted-by":"publisher","first-page":"619","DOI":"10.1093\/bja\/aer195","article-title":"Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods.","volume":"107","author":"Gerbershagen","year":"2011","journal-title":"Br J Anaesth"},{"issue":"2","key":"soi250032r12","doi-asserted-by":"publisher","first-page":"205","DOI":"10.1097\/01.sla.0000133083.54934.ae","article-title":"Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.","volume":"240","author":"Dindo","year":"2004","journal-title":"Ann Surg"},{"issue":"1","key":"soi250032r13","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1186\/s13019-019-1003-y","article-title":"Subpleural multilevel intercostal continuous analgesia after thoracoscopic pulmonary resection: a pilot study.","volume":"14","author":"Bousema","year":"2019","journal-title":"J Cardiothorac Surg"},{"issue":"272","key":"soi250032r14","doi-asserted-by":"publisher","first-page":"1096","DOI":"10.1080\/01621459.1955.10501294","article-title":"A multiple comparison procedure for comparing several treatments with a control.","volume":"50","author":"Dunnett","year":"2021","journal-title":"J Am Stat Assoc"},{"issue":"1","key":"soi250032r15","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1097\/ALN.0000000000001158","article-title":"Minimal clinically important difference for three quality of recovery scales.","volume":"125","author":"Myles","year":"2016","journal-title":"Anesthesiology"},{"issue":"2","key":"soi250032r16","doi-asserted-by":"publisher","first-page":"412","DOI":"10.1016\/j.athoracsur.2018.02.074","article-title":"National comparison of hospital performances in lung cancer surgery: the role of case mix adjustment.","volume":"106","author":"Beck","year":"2018","journal-title":"Ann Thorac Surg"},{"issue":"2","key":"soi250032r17","doi-asserted-by":"publisher","first-page":"390","DOI":"10.1016\/j.athoracsur.2018.03.049","article-title":"Dutch lung surgery audit: a national audit comprising lung and thoracic surgery patients.","volume":"106","author":"Ten Berge","year":"2018","journal-title":"Ann Thorac Surg"},{"key":"soi250032r18","doi-asserted-by":"publisher","first-page":"815","DOI":"10.2147\/JPR.S299595","article-title":"The analgesic effects of thoracic paravertebral block versus thoracic epidural anesthesia after thoracoscopic surgery: a meta-analysis.","volume":"14","author":"Liang","year":"2021","journal-title":"J Pain Res"},{"issue":"12","key":"soi250032r19","doi-asserted-by":"publisher","first-page":"1255","DOI":"10.1001\/jamasurg.2023.5228","article-title":"Effectiveness of surgeon-performed paravertebral block analgesia for minimally invasive thoracic surgery: a randomized clinical trial.","volume":"158","author":"Chenesseau","year":"2023","journal-title":"JAMA Surg"},{"issue":"5","key":"soi250032r20","doi-asserted-by":"publisher","first-page":"394","DOI":"10.4097\/kja.20065","article-title":"Paravertebral block: anatomy and relevant safety issues.","volume":"73","author":"Ardon","year":"2020","journal-title":"Korean J Anesthesiol"},{"key":"soi250032r21","doi-asserted-by":"publisher","first-page":"1106","DOI":"10.1097\/ALN.0b013e318289465f","article-title":"Magnetic resonance imaging analysis of the spread of local anesthetic solution after ultrasound-guided lateral thoracic paraverterbal blockade.","volume":"118","author":"Marhofer","year":"2013","journal-title":"Anesthesiology"},{"issue":"5","key":"soi250032r22","doi-asserted-by":"publisher","first-page":"297","DOI":"10.5761\/atcs.oa.20-00283","article-title":"Continuous paravertebral analgesia versus continuous epidural analgesia after video-assisted thoracoscopic lobectomy for lung cancer: a randomized controlled trial.","volume":"27","author":"Lai","year":"2021","journal-title":"Ann Thorac Cardiovasc Surg"},{"issue":"12","key":"soi250032r23","doi-asserted-by":"publisher","first-page":"1321","DOI":"10.1111\/j.1365-2044.2012.07234.x","article-title":"The location of paravertebral catheters placed using the landmark technique.","volume":"67","author":"Luyet","year":"2012","journal-title":"Anaesthesia"},{"issue":"1","key":"soi250032r24","doi-asserted-by":"publisher","first-page":"406","DOI":"10.1186\/s13019-024-02877-7","article-title":"Comparative analysis of the analgesic effects of intercostal nerve block, ultrasound-guided paravertebral nerve block, and epidural block following single-port thoracoscopic lung surgery.","volume":"19","author":"Shen","year":"2024","journal-title":"J Cardiothorac Surg"},{"issue":"11","key":"soi250032r25","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2021.33394","article-title":"Assessment of intercostal nerve block analgesia for thoracic surgery: a systematic review and meta-analysis.","volume":"4","author":"Guerra-Londono","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"4","key":"soi250032r26","doi-asserted-by":"publisher","first-page":"705","DOI":"10.1016\/j.bja.2017.12.037","article-title":"Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfort.","volume":"120","author":"Myles","year":"2018","journal-title":"Br J Anaesth"},{"issue":"1","key":"soi250032r27","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1136\/rapm-2023-105047","article-title":"Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracoscopic surgery: a prospective randomized open-label non-inferiority trial.","volume":"50","author":"van den Broek","year":"2025","journal-title":"Reg Anesth Pain Med"},{"issue":"9","key":"soi250032r28","doi-asserted-by":"publisher","first-page":"1744","DOI":"10.1053\/j.jvca.2023.05.003","article-title":"Impact of regional anesthesia on subjective quality of recovery in patients undergoing thoracic surgery: a systematic review and meta-analysis.","volume":"37","author":"Xu","year":"2023","journal-title":"J Cardiothorac Vasc Anesth"},{"issue":"4","key":"soi250032r29","doi-asserted-by":"publisher","first-page":"1843","DOI":"10.1016\/j.jtcvs.2017.10.151","article-title":"The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer.","volume":"155","author":"Rogers","year":"2018","journal-title":"J Thorac Cardiovasc Surg"}],"container-title":["JAMA Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/articlepdf\/2835787\/jamasurgery_spaans_2025_oi_250032_1754331660.90719.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,13]],"date-time":"2025-08-13T15:00:40Z","timestamp":1755097240000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/fullarticle\/2835787"}},"subtitle":["A Randomized Noninferiority Trial"],"short-title":[],"issued":{"date-parts":[[2025,8,1]]},"references-count":29,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2025,8,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamasurg.2025.1899","relation":{},"ISSN":["2168-6254"],"issn-type":[{"value":"2168-6254","type":"print"}],"subject":[],"published":{"date-parts":[[2025,8,1]]}}}