Erector Spinae Plane Block

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Take home messages

• The ESPB is a simple and highly effective block for debilitating rib fracture pain
• It's also fabulous for postoperative thoracic pain
• You can expect up to four dermatomes of coverage above and below the level of your block

A Gratifying moment

One of the greatest feelings in anaesthesia is knowing you have absolved a patient of debilitating pain using your knowledge of anatomy and pharmacology, combined with your ninja needle skills.

Whether it's seeing a distraught labouring mother finally fall asleep after her epidural starts to work, or the man with excruciating haemorrhoids finally sit comfortably for the first time in six months, regional anaesthesia is the business when it comes to rapidly (and sometimes completely) removing a patient's pain.

I recently had the absolute pleasure of treating the most fabulously eccentric eighty-five year old librarian and feline connoisseur who had been found having taken a tumble at home and fallen against her rocking chair, snapping multiple ribs down her right side and winding her up in a heap in the emergency department.

Needless to say the fentanyl PCA wasn't quite cutting the mustard, and she lay crumpled and breathless in the bed, unable to cough, with a steadily creeping oxygen requirement.

So we consented her for an erector spinae block and trundled her up to theatre.

Within fifteen minutes of sliding the perineural catheter into her back, she was sat up in recovery, tea in hand, nattering contentedly with the recovery staff.

I asked her to cough, whereupon she took a deep breath in and cleared her chest for the first time in hours.

It was magic.

The Erector Spinae Plane block is a safe, reliable and easy-to-learn technique that can not only relieve a patient of agonising rib fracture pain, but potentially save them from a fatal chest infection, so if you're interested - read on.

A nice halfway house

Before 2016, if you had painful rib fractures that were deemed in need of regional analgesia, you either received a thoracic epidural if they were bilateral or a paravertebral block if they were multiple, or alternatively an intercostal block if there were just a couple.

However each of these have their issues, whether it's increased systemic absorption of local anaesthetic via an intercostal block, or an epidural being contraindicated by anticoagulation.

The erector spinae plane block (ESPB), however provides a nice compromise of avoiding neuraxial blockade with its risks and contraindications, but still providing wide coverage for multiple rib fractures.

We don't really know how it works

Generally speaking, when you perform a nerve block, and see the cross section of the nerve float up on a flood of injectate, it's easy to appreciate that that is where the drug is having its effect.

But with the erector spinae plane block (ESPB) it's rather less clear.

It might be one or both of the following:

• Local anaesthetic spread along the fascial plane and anaesthetising the posterior rami of the spinal nerves
• Diffusion anteriorly into the paravertebral space with a more central action

But either way, it seems to work well.

An unfortunate colleague once sited an erector spinae plane block on the incorrect side after some confusion with the CT report, but the block somehow still worked pretty well, suggesting at least some degree of central diffusion of local anaesthetic.

Where to put your probe, and what to look for

The erector spinae is a group of three muscles that runs from skull to sacrum, lying immediately deep to the thoracolumbar fascia.

It arises from the erector spinae aponeurosis, and it plays a vital role in stabilising the spine and posture.

To find it, simply plonk the probe just off-centre on the thoracic spine, with the probe itself oriented craniocaudally as in the image above.

Positioning options

• Sitting
• Lateral
• Prone

I generally prefer the sitting position, but whatever works, as long as you can get a decent view!

• Slide the probe laterally until you spot nice rounded rib lines, with interspersed hyperechoic pleura
• Then slide medially until these rounded lines turn into square transverse process shadows
• These are usually more superficial and you can no longer see the pleura in between

In plane vs Out of Plane

As with anything in anaesthesia, you can do it your own way, as long as it's safe and clinically justifiable.

You can do blocks in plane or out of plane, however most people seem to stick with the in plane approach.

Your needle can approach from above or below, whichever floats your fascial plane.

This way you can see the entirety of the needle as it approaches the transverse process, right up until it makes contact with the bone.

Then aspirate the needle to ensure you're not in a blood vessel or the pleura, and inject a few millilitres to visualise the spread of your local anaesthetic deep to the erector spinae muscle.

Once you're happy with how the image looks, you can give the whole 20-30mls, and insert the catheter if you're planning on leaving one in situ.

Options for catheters:

• Specific nerve block catheter kit (cannula over needle technique)
• Standard epidural kit (Tuohy needle)

It has other uses too

These clever people reckon it could even act as understudy for the epidural for labour analgesia, when neuraxial blockade is relatively contraindicated:

Useful Tweets and Resources

References and Further Reading

Erector Spinae Plane Nerve Block - NYSORA

The “erector spinae” comprises a group of muscles including the iliocostalis, longissimus, […]

NYSORA

How I Do It: Erector Spinae Block for Rib Fractures: The Penn State Health Experience

The American Society of Regional Anesthesia and Pain Medicine (ASRA)

Erector spinae plane block for pain relief in rib fractures

Editor—We report a case of successful erector spinae plane (ESP) block using a continuous catheter technique for pain relief in a patient with multiple unilater

OUP AcademicD. L. Hamilton

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