REZA AMINNEJAD; MD.

ASSOCIATE PROFESSOR OF ANESTHESIOLOGY

PAIN SPECIALIST
The “erector spinae” comprises a group of muscles including
the iliocostalis, longissimus, and spinalis muscles.

DR. REZA AMINNEJAD

They run bilaterally from the skull to the pelvis and sacral region, and
from the spinous to the transverse processes, extending to the ribs.

DR. REZA AMINNEJAD

Ligaments and muscles around the erector spinae
plane

DR. REZA AMINNEJAD

HISTORICAL ASPECTS

Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in
Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016 Sep-Oct;41(5):621-7. doi:
10.1097/AAP.0000000000000451. PMID: 27501016.

DR. REZA AMINNEJAD

The target of the ESP block is between the most anterior and
deepest layer of the erector spinae muscle and the tip of the
transverse process

DR. REZA AMINNEJAD

MECHANISM OF ACTION
The exact mechanism(s) of action has been much debated.
❑Neural blockade and central inhibition from direct spread of local anesthetic to the
paravertebral or epidural space (The most probable)
❑Analgesia mediated by elevated local anesthetic plasma concentrations due to systemic
absorption
❑Immunomodulatory effects of local anesthetics
❑An effect mediated through the mechanosensory properties of thoracolumbar fascia.

DR. REZA AMINNEJAD

SPREAD OF INJECTATE FOLLOWING AN ESP BLOCK

DR. REZA AMINNEJAD

DR. REZA AMINNEJAD
DR. REZA AMINNEJAD
EXTENT OF DISTRIBUTION

❑The block has a mean of 4.6 intercostal spaces stained, with a maximum of
seven and a minimum of three.
❑Lateral spread of dye was found as far as 10 cm from the midline near the
level of injection between the fifth and the seventh thoracic vertebra.
❑About 3.4 mL is needed to cover one dermatome.

De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T. Erector spinae plane block: a
systematic qualitative review. Minerva Anestesiol. 2019 Mar;85(3):308-319. doi: 10.23736/S0375-
9393.18.13341-4. Epub 2019 Jan 4. PMID: 30621377.

DR. REZA AMINNEJAD

DR. REZA AMINNEJAD
PATIENT SELECTION AND THE CHOICE OF LEVEL
❑Usually, the level chosen for thoracic indications is between T2 and T5, and for abdominal
pelvic indications between T7 and T10.

DR. REZA AMINNEJAD

LOCAL ANESTHETIC DOSE AND VOLUME
❑Maximum volumes of LA for unilateral and bilateral block are 35 and 60 mL respectively.
❑The volume of LA in pediatric patients ranges from 0.2 mL/kg to 0.5 mL/kg.

De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T. Erector spinae plane block: a
systematic qualitative review. Minerva Anestesiol. 2019 Mar;85(3):308-319. doi: 10.23736/S0375-
9393.18.13341-4. Epub 2019 Jan 4. PMID: 30621377

DR. REZA AMINNEJAD

DR. REZA AMINNEJAD
DR. REZA AMINNEJAD
COMPLICATIONS OF ESP BLOCKS
❑Pneumothorax (after mid-thoracic ESP block)
❑lower extremity weakness (after low thoracic ESP block)
❑LA systemic toxicity (LA dose not specified)
❑Harlequin Syndrome (due to ipsilateral sympathectomy associated with compensatory
contralateral flushing and diaphoresis)
❑Priapism (due to unopposed parasympathetic stimulation secondary to sympathectomy)

Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with
systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2021
Feb;68:110063. doi: 10.1016/j.jclinane.2020.110063. Epub 2020 Oct 5. PMID: 33032124.

DR. REZA AMINNEJAD

ALTERNATIVE TRUNCAL BLOCKS
❑For thoracic surgery, alternatives to ESP blocks consist of midthoracic epidural blocks, thoracic
paravertebral blocks, midpoint transverse process to pleura blocks, and intercostal nerve
blocks.
❑For breast surgery, PECS blocks could be used in lieu of ESP blocks.
❑For abdominal surgery, the list of options includes low thoracic epidural blocks, transversus
abdominis plane (TAP) blocks, quadratus lumborum block, rectus sheath blocks, and
ilioinguinal/iliohypogastric nerve blocks.
❑For lower limb surgery, alternatives to lumbar ESP blocks consist of lumbar plexus blocks and
fascia iliaca blocks.
Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with
systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2021
Feb;68:110063. doi: 10.1016/j.jclinane.2020.110063. Epub 2020 Oct 5. PMID: 33032124.

DR. REZA AMINNEJAD

USG TECHNIQUE
❑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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