{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T11:53:25Z","timestamp":1781697205816,"version":"3.54.5"},"reference-count":27,"publisher":"BMJ","funder":[{"name":"Ondokuz Mayis University Scientific Research Projects Coordination Unit","award":["BAP06-2026-6327"],"award-info":[{"award-number":["BAP06-2026-6327"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2026,6,2]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Although widely performed, video-assisted thoracoscopic surgery (VATS) is associated with significant postoperative pain. Thoracic paravertebral block (TPVB) is a guideline-favored regional technique, while intrathecal morphine (ITM) is a technically less demanding and more widely applicable neuraxial alternative. We hypothesized that ITM would provide analgesic efficacy non-inferior to TPVB in terms of 24-hour intravenous morphine milligram equivalents (IV-MME).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This was a prospective, randomized, controlled, observer-blinded non-inferiority trial. Adults undergoing elective VATS were randomized 1:1 to TPVB (0.25% bupivacaine, 0.4\u2009mL\/kg+epinephrine 1:400,000) or ITM (5 mcg\/kg based on ideal body weight). The primary endpoint was 24-hour IV-MME (intraoperative opioids excluded). Secondary endpoints included 12-hour IV-MME, pain (Numeric Rating Scale at rest\/activity), rescue analgesia, time to first opioid demand, 15-item Quality of Recovery, safety (postoperative nausea\/vomiting, pruritus, respiratory depression), and 30-day complications. The prespecified non-inferiority margin was 5.05\u2009mg. Analyses followed intention-to-treat with per-protocol sensitivity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 82 screened, 72 were randomized (ITM n=36; TPVB n=36); 2 TPVB conversions to thoracotomy were excluded from the per-protocol set (n=70). For the primary endpoint, the median difference (ITM\u2013TPVB) in 24-hour IV-MME was 6.5\u2009mg (95%\u2009CI 1 to 17; p=0.009) in intention-to-treat and 9.0\u2009mg (95% CI 2 to 18; p=0.002) in per-protocol; in both analyses, the upper CI bound exceeded 5.05\u2009mg, and non-inferiority was not met. Individual 24-hour and 12-hour IV-MME favored TPVB; rescue analgesia was more frequent with ITM (21\/36 vs 12\/36; p=0.033). Pain outcomes, quality of recovery scores, and time to first opioid demand were similar, with no respiratory depression. Although mild 30-day Clavien-Dindo grade I events differed between groups, no apparent clinically meaningful safety signal was observed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>ITM did not demonstrate non-inferiority to TPVB for 24-hour IV-MME; TPVB was associated with lower systemic opioid use, while pain outcomes were similar.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT07126483\">NCT07126483<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  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