ESP block

Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.

1. REZA AMINNEJAD; MD.
ASSOCIATE PROFESSOR OF ANESTHESIOLOGY
PAIN SPECIALIST

2. The“erectorspinae”comprisesagroupofmusclesincluding
theiliocostalis,longissimus,andspinalismuscles.
DR. REZA AMINNEJAD

3. Theyrunbilaterallyfromtheskulltothepelvisandsacralregion,and
fromthespinoustothetransverseprocesses,extendingtotheribs.
DR. REZA AMINNEJAD

4. Ligamentsandmusclesaroundtheerectorspinae
plane
DR. REZA AMINNEJAD

5. HISTORICAL ASPECTS
DR. REZA AMINNEJAD
ForeroM,AdhikarySD,LopezH,TsuiC,ChinKJ.TheErectorSpinaePlaneBlock:ANovelAnalgesicTechniquein
ThoracicNeuropathicPain.RegAnesthPainMed.2016Sep-Oct;41(5):621-7.doi:
10.1097/AAP.0000000000000451.PMID:27501016.

6. ThetargetoftheESPblockisbetweenthemostanteriorand
deepestlayeroftheerectorspinaemuscleandthetipofthe
transverseprocess
DR. REZA AMINNEJAD

7. MECHANISM OF ACTION
Theexactmechanism(s)ofactionhasbeenmuchdebated.
❑Neuralblockadeandcentralinhibitionfromdirectspreadoflocalanesthetictothe
paravertebralorepiduralspace(Themostprobable)
❑Analgesiamediatedbyelevatedlocalanestheticplasmaconcentrationsduetosystemic
absorption
❑Immunomodulatoryeffectsoflocalanesthetics
❑Aneffectmediatedthroughthemechanosensorypropertiesofthoracolumbarfascia.
DR. REZA AMINNEJAD

8. SPREAD OF INJECTATE FOLLOWING AN ESP BLOCK
DR. REZA AMINNEJAD

9. DR. REZA AMINNEJAD

10. DR. REZA AMINNEJAD

11. EXTENT OF DISTRIBUTION
❑Theblockhasameanof4.6intercostalspacesstained,withamaximumof
sevenandaminimumofthree.
❑Lateralspreadofdyewasfoundasfaras10cmfromthemidlinenearthe
levelofinjectionbetweenthefifthandthesevenththoracicvertebra.
❑About3.4mLisneededtocoveronedermatome.
DeCassaiA,BonviciniD,CorrealeC,SandeiL,TulgarS,TonettiT.Erectorspinaeplaneblock:a
systematicqualitativereview.MinervaAnestesiol.2019Mar;85(3):308-319.doi:10.23736/S0375-
9393.18.13341-4.Epub2019Jan4.PMID:30621377.
DR. REZA AMINNEJAD

12. DR. REZA AMINNEJAD

13. PATIENT SELECTION AND THE CHOICE OF LEVEL
❑Usually,thelevelchosenforthoracicindicationsisbetweenT2andT5,andforabdominal
pelvicindicationsbetweenT7andT10.
DR. REZA AMINNEJAD

14. LOCAL ANESTHETIC DOSE AND VOLUME
❑MaximumvolumesofLAforunilateralandbilateralblockare35and60mLrespectively.
❑ThevolumeofLAinpediatricpatientsrangesfrom0.2mL/kgto0.5mL/kg.
DeCassaiA,BonviciniD,CorrealeC,SandeiL,TulgarS,TonettiT.Erectorspinaeplaneblock:a
systematicqualitativereview.MinervaAnestesiol.2019Mar;85(3):308-319.doi:10.23736/S0375-
9393.18.13341-4.Epub2019Jan4.PMID:30621377
DR. REZA AMINNEJAD

15. DR. REZA AMINNEJAD

16. DR. REZA AMINNEJAD

17. COMPLICATIONS OF ESP BLOCKS
❑Pneumothorax(aftermid-thoracicESPblock)
❑lowerextremityweakness(afterlowthoracicESPblock)
❑LAsystemictoxicity(LAdosenotspecified)
❑HarlequinSyndrome(duetoipsilateralsympathectomyassociatedwithcompensatory
contralateralflushinganddiaphoresis)
❑Priapism(duetounopposedparasympatheticstimulationsecondarytosympathectomy)
SaadawiM,LayeraS,AlisteJ,BravoD,LeurcharusmeeP,TranQ.Erectorspinaeplaneblock:Anarrativereviewwith
systematicanalysisoftheevidencepertainingtoclinicalindicationsandalternativetruncalblocks.JClinAnesth.2021
Feb;68:110063.doi:10.1016/j.jclinane.2020.110063.Epub2020Oct5.PMID:33032124.
DR. REZA AMINNEJAD

18. ALTERNATIVE TRUNCAL BLOCKS
❑Forthoracicsurgery,alternativestoESPblocksconsistofmidthoracicepiduralblocks,thoracic
paravertebralblocks,midpointtransverseprocesstopleurablocks,andintercostalnerve
blocks.
❑Forbreastsurgery,PECSblockscouldbeusedinlieuofESPblocks.
❑Forabdominalsurgery,thelistofoptionsincludeslowthoracicepiduralblocks,transversus
abdominisplane(TAP)blocks,quadratuslumborumblock,rectussheathblocks,and
ilioinguinal/iliohypogastricnerveblocks.
❑Forlowerlimbsurgery,alternativestolumbarESPblocksconsistoflumbarplexusblocksand
fasciailiacablocks.
SaadawiM,LayeraS,AlisteJ,BravoD,LeurcharusmeeP,TranQ.Erectorspinaeplaneblock:Anarrativereviewwith
systematicanalysisoftheevidencepertainingtoclinicalindicationsandalternativetruncalblocks.JClinAnesth.2021
Feb;68:110063.doi:10.1016/j.jclinane.2020.110063.Epub2020Oct5.PMID:33032124.
DR. REZA AMINNEJAD

19. USGTECHNIQUE
❑Position: Sitting/lateral decubitus/prone; depending on the operator’s and patient’s comfort
❑Probe: Usually a linear probe (7–12 MHz) is sufficient. For high BMI a curvilinear (2–6 MHz)
is advised.
DR. REZA AMINNEJAD

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