Erector Spinae Plane (ESP) Block

Summary

The Erector Spinae Plane (ESP) block is a versatile and effective technique for pain management, particularly in spine and thoracic surgeries. By injecting local anesthetic near the transverse processes, the ESP block provides analgesia to paraspinal structures, including skin, muscle, and periosteum. It has become a popular alternative to epidural analgesia, offering fewer complications and more flexibility. The block can be performed at various levels, such as T5 for thoracic, T10 for abdominal, and L3 for lumbar surgeries, using ultrasound guidance for accurate placement. Its ease of use, safety profile, and broad applications make the ESP block a valuable tool in modern anesthesia practice.

Takeaways

• 😀 The erector spinae plane (ESP) block is a versatile technique used for various types of surgery and pain management, particularly for spine and abdominal procedures.
• 😀 The ESP block targets the erector spinae muscles, which run along the spine from skull to pelvis, and works by delivering local anesthetic along the fascial plane to block paraspinal structures.
• 😀 Local anesthetic in the ESP block may spread to the paravertebral space, making it effective for a broader range of indications, although there is some controversy about its exact mechanism of action.
• 😀 A typical ESP block uses 30 mL of dilute local anesthetic per side in the thoracic region and about 30–50 mL in the lumbar region to achieve a spread of about four to five levels.
• 😀 ESP blocks are performed at various levels, commonly T5 for thoracic surgery, T10 for abdominal surgery, and L3 for lumbar spine surgery. These can be adjusted based on specific patient needs.
• 😀 ESP blocks can be performed in various patient positions, including sitting, prone, or lateral, making them flexible for different surgical settings.
• 😀 Ultrasound is used to guide needle placement, where the needle aims to contact the transverse process of the spine, allowing for precise delivery of the anesthetic.
• 😀 The ESP block has gained popularity due to its simplicity, effectiveness, and the reduced risk of complications compared to other regional blocks like the epidural or paravertebral blocks.
• 😀 One of the benefits of ESP blocks is that they can be safely performed even in patients on anticoagulants, particularly useful for trauma patients with rib fractures.
• 😀 Despite its popularity, the ESP block is still relatively new, and there are no definitive safety data yet, though it is considered safe due to its shallow position and ease of placement.

Q & A

What is the anatomical basis of the erector spinae plane (ESP) block?

The erector spinae muscle is a group of muscles that runs along the spine from the skull to the pelvis. The ESP block targets the fascia of these muscles, specifically the region just off the midline of the spine, superficial to the laminae and transverse processes, using local anesthetic to block paraspinal structures like skin, muscle, and periosteum.

What is the purpose of the ESP block?

The primary goal of the ESP block is to anesthetize the paraspinal structures, such as the skin, muscle, and periosteum. It may also spread to the paravertebral space, which can provide additional benefits, making it effective for various procedures, including spine surgery and thoracic interventions.

What are the key indications for performing an ESP block?

The ESP block is used for thoracic surgery (e.g., thoracoscopy), rib fracture analgesia, breast surgery, abdominal and pelvic procedures, and spine surgery. It can also be useful for patients undergoing lumbar spine surgery, with specific levels targeted depending on the surgical region.

Why is the ESP block considered an alternative to epidural anesthesia?

The ESP block is considered an alternative to epidural anesthesia due to its safety profile, which avoids issues like arterial hypotension, urinary retention, and other complications common with epidurals. It is also simpler to perform and can be done at the end of the surgery, particularly for patients who are on anticoagulants or have trauma-related conditions.

How do you perform the ESP block in the thoracic region?

In the thoracic region, the ESP block is typically performed at the T5 or T10 levels. The ultrasound transducer is placed in a parasagittal orientation, and the transverse processes are identified. The needle is advanced toward the corner of the transverse process, and after confirming the correct placement with a test injection, local anesthetic is injected to lift the muscle fascia from the bone.

What is the ideal volume of local anesthetic to use for an ESP block?

For the thoracic region, 30 mL of dilute local anesthetic is commonly used, resulting in a spread of approximately four levels up and down. In the lumbar region, the muscle is thicker and less compliant, so 30 mL typically achieves about four to five levels of spread. Volume adjustments can be made depending on the desired extent of anesthesia.

What are the key steps in performing the ESP block in the lumbar region?

In the lumbar region, the ESP block is usually performed at the L3 or L2 levels. The transducer is placed in a parasagittal orientation, and the transverse processes are identified. The needle is advanced in-plane to contact the transverse process, and after confirming the correct fascial plane with a test injection, local anesthetic is injected to spread beneath the muscle.

What are some challenges and precautions when performing the ESP block in the lumbar region?

One challenge in the lumbar region is the greater depth of the target structures, which can make imaging and needle placement more difficult. It’s essential to carefully confirm depth using ultrasound, as the lumbar muscles are thicker and less compliant compared to the thoracic region.

What tips can help improve the success of the ESP block?

Key tips include: 1) Ensuring that the needle is positioned under the erector spinae muscle fascia and not within the muscle itself; 2) Using hydrolocation techniques to confirm proper needle placement; 3) Going slow and being cautious to avoid complications like pneumothorax, especially in the thoracic region.

What are some potential complications or concerns with the ESP block?

Although considered relatively safe, complications such as pneumothorax have been reported. Careful needle placement and hydrolocation are essential to minimize the risk of misplacement. Additionally, more definitive safety data is still needed, as this is a relatively new block.