Combined Caudal Epidural Analgesia and Surgically Placed Continuous Thoracic Paravertebral Block for Thoracic Neuroblastoma Excision in an Infant: A Case Report

Abstract

Background: Effective opioid-sparing postoperative analgesia following paediatric thoracotomy is essential to reduce respiratory complications and facilitate early recovery. Aim: We report a case demonstrating a combined regional analgesic strategy when conventional neuraxial techniques were not feasible. This case report addresses the complexities of pain management in infants and highlights the role of combined regional analgesia techniques as safer and more effective options. It demonstrates improved postoperative outcomes through reduced dependence on systemic opioids and a lower incidence of opioid-related adverse effects, particularly in thoracic procedures. Case Presentation: A one-year-old male child (7 kg) with infantile neuroblastoma (D2 primary with extension into the left posterior mediastinum) underwent left thoracotomy and tumour excision. Preoperative thoracic epidural catheter placement was not feasible due to the proximity of the surgical incision to the thoracic spine, and anticipated postoperative coagulation concerns precluded epidural placement. After induction of general anaesthesia, a single-shot ultrasound-guided caudal epidural was administered using 9 mL of 0.25% bupivacaine with 1 mg morphine. Following tumour resection and haemostasis, a surgically placed left thoracic paravertebral catheter (T6 level, advanced to T4) was inserted under direct visualisation into the extra-pleural paravertebral space and connected to an elastomeric infusion pump delivering 0.1% bupivacaine at 5 mL/h. Discussion: The combined use of caudal epidural analgesia and continuous thoracic paravertebral block provided effective intraoperative and prolonged postoperative analgesia. Hemodynamic parameters remained stable, FLACC (Face, Legs, Activity, Cry, Consolability) pain scores were consistently low, and no rescue opioid was required for 72 hours. This strategy strengthens the evidence base for multimodal anaesthesia by showcasing an innovative technique that provides targeted, sustained, and balanced analgesia, thereby enhancing overall perioperative care. Additionally, it avoided the risks associated with thoracic epidural analgesia while ensuring adequate pain control, facilitating early chest physiotherapy and recovery. Conclusion: A combined caudal epidural and surgically placed continuous thoracic paravertebral block can provide high-quality opioid-sparing analgesia in paediatric thoracotomy when neuraxial techniques are contraindicated or impractical. This individualised strategy represents a safe and effective alternative in selected cases.