Erector spinae plane block

KEY POINTS

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The erector spinae plane block (ESPB) is actually used for acute and chronic thoracoabdominal pain syndromes, although its indication has been described for the treatment of pain in other locations.
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It is advisable to use a high frequency transducer (7–12 MHz).
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Clear identification of the transverse process is mandatory prior to infiltration or catheter insertion.
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Injection volumes ranging from 20–40 mL of a long-lasting local anesthetic are commonly used.
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Local anesthetic injected over the transverse process and beneath the erector spinae muscle spreads cranial and caudal to achieve multiple vertebral levels and reaches the paravertebral space.

Perspective

The ESPB was first described by Forero et al in 2017, and was initially applied in the management of thoracic neuropathic pain. Actually, there are more than 100 reports published, most of which demonstrated efficacy for acute and chronic thoracoabdominal pain syndromes.

The ESPB is an interfacial plane block whereby local anesthetic is injected within a plane beneath the erector spinae muscle, to achieve multimodal analgesia for thoracic or abdominal surgery. Its analgesic effect appears to be the result of local anesthetic diffusion into the paravertebral space, affecting both the dorsal and ventral ramus of the thoracic spinal nerves.

Clinical results indicate that local anesthetic injected over the transverse process and beneath the erector spinae muscle spreads cranial and caudal to achieve multiple vertebral levels and reaches the paravertebral space to anesthetize dorsal and ventral ramus as well as the rami communicantes, which supply the sympathetic chain. The exact pathway by which the local anesthetic reaches the spinal nerves is still undefined. Between the erector spinae plane and paravertebral space, we can find a series of anatomical structures that conceptually are given the name of “intertransverse connective tissue complex”. This complex is a layer composed of multiple separate structures (intertransverse and costotransverse ligaments, levator costarum, rotator costarum, external intercostal muscles, and fat). As such, there may well be perforations that allow local anesthetic to diffuse through into the paravertebral space.

Indications

Spine region	Indications
High Thoracic T2 or T3	Chronic shoulder pain syndrome Postsurgical shoulder pain
Mid Thoracic T4 to T6	Rib fracture (midpoint of level of ribs fracture)
	Open thoracotomy and VATS lobectomy (T5)
	Rescue after TE failure for thoracic surgery (T5)
	Cardiac surgery-sternotomy (T5)
	Breast surgery with axillary lymph node dissections (T3)
	Chronic postherpetic neuralgia (level of segment involved)
	Chronic postthoracotomy pain (level of segments involved)
	Metastatic ribs cancer (level of segments involved)
Low Thoracic T7 to T12	Nephrectomies (T8)
	Hysterectomies (T10)
	Laparoscopic ventral hernia repair with mesh (T7)
	Laparotomies ( T7)
	Chronic postherpetic neuralgia (level of segment involved)
	Chronic abdominal pain syndrome (T7 to T10)
	Chronic pelvic pain syndrome (T10)
Lumbar (L4)	Vertebral surgery (midpoint of levels involved)
Lumbar (L4)	Postsurgical hip replacement pain management (L4)