Reply to Elsayed and Poullis

We thank Drs Elsayed and Poullis for their reply [1] to our article. In our opinion and in the context of thoracotomy, pain relief, epidural analgesia and paravertebral analgesia several issues have to be addressed and still there is no clear evidence.

1. We agree with the problem of hypotension and urinary retention by using epidural analgesia; fortunately we had no such problems in our series, which may be due to the relatively small number. Anyway your anesthetist should be familiar with epidural analgesia, so you can avoid these side effects.

2. The paravertebral catheter technique is not used in our institution as we see more disadvantages than benefits:

   • the blockade is limited to hours after surgery and additional pain relief, e.g. patient controlled analgesia may be necessary

   • this technique is time consuming and not easy to apply as paravertebral nerves have to be identified (by ultrasound) and blockade/puncture has to be performed over several intercostal spaces

In summary we do believe that all techniques, paravertebral blockade, epidural blockade and intercostal blockade, have specific advantages and disadvantages but can lead to sufficient pain relief and fast tracking patients if properly applied.

The more interesting question in our mind is which is the best technique for patients with reduced pulmonary capacity (FEV1 ≪ 70% of expected value); that is why we conducted a randomized trial that faces this problem (clinicaltrials.gov NCT00530491).

Reference