Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial

Spaans, LN; Dijkgraaf, MGW; Susa, D; de Loos, ER; Mourisse, JMJ; Bouwman, RA; Verhagen, AFTM; van den Broek, FJC; OPtriAL Study Group; Meijer, P; Kuut, M; Hanneman, N; Bousema, J; Franssen, A; Brokx, H; van Duyn, E; Potters, JW; van den Broek, R; van Brakel, T; Rijna, H; Boom, A; Noyez, V; Hendriks, JMH; Yogeswaran, SK; Dickhoff, C; van Dorp, M

doi:10.1001/jamasurg.2025.1899

Cardiothoracic & vascular anaesthesia

Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial

JAMA SurgPublished 1 Aug 2025Randomised controlled trial

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Authors' conclusion

After thoracoscopic anatomical lung resection, only ICNB provides noninferior pain relief compared with TEA.

Study context

Population: Patients undergoing thoracoscopic anatomical lung resection at 11 hospitals in the Netherlands and Belgium389 in ITT analysis
Participants: 450 patients

Comparison: Continuous paravertebral block (PVB) and single-shot intercostal nerve block (ICNB) vs thoracic epidural analgesia (TEA)
TEAn = 131reference
PVBn = 134
ICNBn = 124
Primary endpoint: Pain: mean proportion of pain scores 4 or greater during POD 0–2 (non-inferiority margin for UL of 1-sided 98.65% CI, 17.5%); and QoR-15 at POD 1 and 2
Follow-up: POD 0 through 2

Methodological detailsmulticentre, non-inferiority (pain), superiority (quality of recovery (QoR)), 1:1:1, Enrolled March 5, 2021, to September 5, 2023

Multicentre
Non-inferiority (pain)
Superiority (QoR)
1:1:1
Enrolled March 5, 2021, to September 5, 2023

Primary result

As reported in the abstract

Mean proportion of pain scores ≥4, POD 0–2

TEA20.7%mean · 95% CI 16.5%–24.9%

PVB35.5%mean · 95% CI 30.1%–40.8%

ICNB29.5%mean · 95% CI 24.6%–34.4%

UL of 1-sided 98.65% CI (ITT)

22.4%

PVB · inferior; PP: UL, 23.1%

UL of 1-sided 98.65% CI (ITT)

16.1%

ICNB · noninferior; PP: UL, 17.0%

Further findings

Mean

Outcome	TEA	PVB	ICNB	P value
QoR-15 score (co-primary) · POD 1 and 2PVB vs TEA · also printed as P = .641	104.96 (SD 20.47)	106.06 (SD 17.94)	106.85 (SD 21.11)	P = 0.64
QoR-15 score (co-primary) · POD 1 and 2ICNB vs TEA				P = 0.47

QoR-15 score (co-primary) · postoperative days (POD) 1 and 2

Similar across groups

Opioid consumption and mobility

Both ICNB and PVB significantly reduced opioid consumption and enhanced mobility vs TEA

Hospitalization

Shorter in the ICNB group

Safety

No significant differences in complications

Reference

Authors: Spaans LN, Dijkgraaf MGW, Susa D, de Loos ER, Mourisse JMJ, Bouwman RA, et al.
All 26 authors
Spaans LN, Dijkgraaf MGW, Susa D, de Loos ER, Mourisse JMJ, Bouwman RA, Verhagen AFTM, van den Broek FJC, OPtriAL Study Group, Meijer P, Kuut M, Hanneman N, Bousema J, Franssen A, Brokx H, van Duyn E, Potters JW, van den Broek R, van Brakel T, Rijna H, Boom A, Noyez V, Hendriks JMH, Yogeswaran SK, Dickhoff C, van Dorp M
Journal: JAMA Surgery
Published: 1 Aug 2025
DOI: 10.1001/jamasurg.2025.1899
PubMed: 40560556
Registration: NCT05491239

Topic: Cardiothoracic & vascular anaesthesia
Also indexed: Regional anaesthesia

Intervention details

TEA: thoracic epidural analgesia
PVB: continuous paravertebral block
ICNB: single-shot intercostal nerve block

Key notes

Non-inferiority margin 17.5%
Intention-to-treat and per-protocol

Original publication

Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial. JAMA Surg. Published 1 August 2025. doi:10.1001/jamasurg.2025.1899

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