Abstract The pain of thoracic surgery is severe which if addressed correctly reduces morbidity and mortality. The pain arises from muscle dissection, rib retraction and intercostal nerve damage. Management is challenged by pre-existing respiratory and co-morbid disease. Thoracic epidural analgesia for thoracotomy is considered ideal, however paravertebral blockade as part of a multimodal approach increasingly offers a comparable solution. Post thoracotomy pain syndrome (PTPS) is a significant issue and preventive analgesia is worthy of consideration.