The Erector Spinae Plane Block:

Clinical Article
A Review of Current Evidence
Originally published as Anaesthesia Tutorial of the Week

Araz Pourkashanian*, Madan Narayanan, Arun Venkataraju

*Correspondence email: [email protected]

Summary
• From the evidencewe have available, the ESP block should be considered an alternative analgesic option for
patients with acute or chornic pain of the trunk
• Most of the favourable data for the ESP block relies on its use as part of a multimodal analgesic package, and
this should be considered when planning a patient’s care.
• Further research needs to be conducted to determine its true effectiveness compared with other regional
techniques as well as optimal dosing regimens.

KEY POINTS
• The erector spinae plane block is an easy-to-perform regional anaesthesia technique with a wide range of
clinical applications.
• Most of the current research has focused on its use in thoracic and trunk surgery.
• Many experts now consider the erector spinae plane block an alternative analgesic option to thoracic epidural
analgesia and paravertebral blocks, especially where these techniques are contraindicated.
• The block has a good safety profile with very few reported complications.

INTRODUCTION
Interfascial plane blocks are the current hot topic many clinical practitioners. In addition, Blanco’s
in regional anaesthesia. The 19th-century German 2007 publication of a ‘‘no pops’’ ultrasound-guided
surgeon Carl Ludwig Schleich is seen by many as transversus abdominus plane (TAP) technique has led
the father of infiltration anaesthesia. His work from researchers to explore various planes for interfascial
1899 titled ‘‘Painless Operations. Local Anaesthesia blocks.2 Currently, the greatest volume of work
With Indifferent Liquids’’ described the use of local produced in this field is focused on truncal interfascial
anaesthetic (LA) agents to relax the muscles of the plane blocks, one of which is the erector spinae plane
anterior abdominal wall and provide analgesia to aid (ESP) block.3
surgery.1 This was the origin of a procedure that is
This tutorial will look at the current research and
now practiced worldwide, the rectus sheath block.
evidence in the clinical application of the ESP block.
These techniques have had to bide their time for use in
We will explore its inception through to the results
clinical care as their safety, efficacy, and reproducibility
of recently published randomised controlled trials
have been difficult to assess. However, several factors
and postulate what the future holds for this novel
have led to a seemingly exponential growth in fascial
technique. The technique itself will be described in Araz Pourkashanian
plane block research, description, and utility. The
detail in the Anaesthesia Tutorial of the Week article Regional Anaesthesia Fellow
advent of readily available ultrasound technology Frimley Park Hospital
on ESP.
in modern-day health care and the production of UNITED KINGDOM
longer-acting amide LAs have had a major impact. A ESP BLOCK: WHAT IS IT?
greater driver has probably been the desire, and some Madan Narayanan
The ESP block is a novel interfascial paraspinal plane Anaesthetic Consultant
would argue necessity, to move away from traditional
technique that was initially used by Forero et al4 for Frimley Park Hospital
neuraxial techniques used in the perioperative care of
2 patients with severe chronic thoracic neuropathic UNITED KINGDOM
patients undergoing thoracic and abdominal surgery.
pain and 2 patients undergoing video-assisted
With surgical techniques becoming less invasive, Arun Venkataraju
thoracoscopic surgery. The authors described 2
the introduction of enhanced recovery pathways, Anaesthetic Consultant
techniques for this block. One was in a patient with
and the increased use of anticoagulation therapies, Hampshire Hospital NHS Trust
neuropathic pain from metastatic seeding to the ribs,
the use of epidural anaesthesia has decreased among UNITED KINGDOM

© World Federation of Societies of Anaesthesiologists 2020. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report)
may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for
commercial reproduction should be addressed to: World Federation of Societies of Anaesthesiologists, Dean Bradley House, 52 Horseferry Rd, London SW1P 2AF, UK. 27
 As with any novel regional anaesthesia technique, the initial interest
in the block led to an abundance of clinicians attempting to replicate
the effects in their own patients. The result was a wealth of case
reports with a wide range of clinical applications. Tsui et al5 recently
performed a pooled review of 242 cases relating to the ESP block.
After applying inclusion criteria to their search, they found that
90.5% of publications were either case reports or case series, 5.5%
were anatomical cadaver studies, and only 2.4% were randomised
controlled trials. Most publications originated from Turkey (25%),
with Canada and Japan producing the second and third most articles,
respectively.

ANATOMICAL STUDIES AND PROPOSED MECHANISM

OF ACTION
As with all fascial plane blocks, the aim of the ESP block is
compartmental spread; its efficacy relies on the LA agent passively
distributing within the plane to reach target nerves. Absorption and
diffusion of LA across tissue planes also appear to play a role in the
extent and quality of the block.
The working theory is that because of the discontinuity of the
intercostal muscles, LA diffuses anteriorly to the ventral and dorsal
rami of the spinal nerves and through the intertransverse connective
tissue to enter the thoracic paravertebral space (Figure 4).

Is the ESP Block a Surrogate for the Paravertebral Block? How

Far Does the Injectate Spread?
Further imaging studies have been performed to determine the extent
of LA spread as a means of explaining the true mechanism of action.
In Forero’s publication, the authors expanded on the case series by
Figure 1. Red highlighted structures indicate the 3 columns of the analysing the spread of injectate both on computerized tomography
erector spinae muscles. Medial to lateral: spinalis, longissimus, iliocostalis. (CT) imaging and in cadavers.4 In 1 patient, after 25mL of solution
Source: Henry Vandyke Carter [public domain], image reproduced from
Gray’s Anatomy (figure 389; ‘‘Deep Muscles of the Back’’). CC BY 3.0.

where they injected LA into the plane between the rhomboid major
and erector spinae (ES; ie, superficial to the ES). The patient had
complete resolution of pain. In the other 3 cases, LA was deposited
deep to the ES, which similarly produced the desired analgesic effect
but also provided a cutaneous sensory block.
The standard practice for performing an ESP block today uses
ultrasound to deposit LA deep to the 3 columns of ES muscles
(iliocostalis, longissimus, spinalis), which run the length of the spine
from the base of the skull to the medial crest of the sacrum (Figures
1 and 2). They all have attachments to the transverse processes, the
level of which is dependent on the specific muscle. Overlying the ES
complex are 2 further layers of muscle: the trapezius and rhomboid
major (Figure 2).

HAS THE ESP BLOCK CAUGHT ON? WHAT DOES THE

LITERATURE SAY? Figure2. (A, B) Demonstration of the muscle layers and bony landmarks
seen on ultrasound when performing an erector spinae plane block at
Since Forero’s publication in Regional Anesthesia and Pain Medicine
the thoracic level. Layers from superficial to deep: skin/subcutaneous fat,
in September 2016,4 there has been wide interest in the ESP block. trapezius, rhomboids, erector spinae, transverse process. (C, D) Needle
In the 2 years that followed, there had been close to 100 relevant entry seen through the muscle layers on the vector from the upper left
publications (Figure 3), and based on a literature search conducted to lower right of the image. Local anaesthetic has been infiltrated deep
in June 2019 via EMBASE, Medline, and PubMed, that number has to the erector spinae (*). The hypoechoic area produced as a result is
far been exceeded. indicated by the white marked area.

28 www.wfsahq.org/resources/update-in-anaesthesia
 The cadaveric work by Adhikary et al7 analysed the spread of
radiocontrast dye deep to the ES muscle complex in 3 fresh cadavers.
Their results confirmed that seen with Forero et al4 with craniocaudal
spread up to 9 vertebral levels along the paraspinal muscles and in
the intercostal space (Figure 5). There was also dye seen in the neural
foramina and epidural space.
The case report by Schwartzmann et al8 of ESP block using gadolinium
clearly showed the spread of contrast into the paravertebral space,
through the neuroforamina, and a resultant circumferential epidural
spread over 7 thoracic levels (Figure 6).
All of these results suggest that the ESP block may be an alternative
Figure 3. Graphical representation of the rapid growth in publications analgesia option to the paravertebral block (PVB), with some
relating to erector spinae plane block. evidence demonstrating injectate diffusing into the paravertebral
space to also exert its analgesic effects.
was injected superficially to the ES muscles, CT imaging revealed
cephalocaudad spread from T1 to T11 with minimal lateral spread. However, not all cadaveric studies have had such extensive spread of
In their cadaveric work, they injected methylene blue dye superficial dye. Yang et al observed only minimal spread into the paravertebral
to the ES muscle bilaterally in one cadaver and deep to ES bilaterally space, and Ivanusic et al failed to demonstrate any spread into the
in another. Dissection of the former cadaver demonstrated staining paravertebral space.9,10 Ivanusic et al9 performed an ESP block deep
of the lateral branches of the spinal root dorsal rami in a longitudinal to the ES muscle with 20mL of dye on 10 cadavers (ie, 20 total
fashion but no anterior spread beyond the intercostal muscles. With injections). Like previous studies, there was extensive lateral and
the second cadaver, and injection deep to the ES muscle, the spread craniocaudal spread of dye around the ES complex. But only 1 of the
of the dye was much greater and included the area deep to the injections led to staining of the ventral rami, and there was no spread
intercostal muscles, through the costotransverse foramina, and close anteriorly to the paravertebral space. They did, however, acknowledge
to the spinal nerve root ventral and dorsal rami. the tissue tension limitations of cadaveric studies in replicating the
spread of LA in vivo and postulated that the intrathoracic pressure
Chin et al6 demonstrated in a cadaveric study that with 20 mL of dye
changes present in the living may explain the anterior spread into the
injected at the transverse process of T7 (below the ES muscle), spread
paravertebral space.
was seen cranially up to the lower cranial/upper thoracic vertebrae
and caudally as low as the third lumbar vertebra.

Figure 5. Visible craniocaudal spread of methylene blue dye in cadavers

after 20-mL injection at the T5 vertebral level. Good spread (range 5-9
vertebral levels) seen in the intercostal spaces. Dye also visualised in the
Figure 4. Brown highlighted structures indicate erector spinae muscles. epidural space and neural foramina in all 3 cadavers. Reproduced from
The green highlighted area indicates local anaesthetic (LA) deposited Adhikary SD, Bernard S, Lopez H, Chin KJ. Erector spinae plane block
below the erector spinae complex. The LA injection spreads into the versus retrolaminar block: a magnetic resonance imaging and anatomical
paravertebral space because of the discontinuity of the intercostal study. Reg Anesth Pain Med. 2018;43(7):756-762, with permission from
muscles. Source: Henry Vandyke Carter [public domain], image BMJ Publishing Group Ltd (license 4614451453587).
reproduced from Gray’s Anatomy (figure 819; ‘‘Diagram of the Course
and Branches of a Typical Intercostal Nerve’’). CC BY 3.0.

© World Federation of Societies of Anaesthesiologists 2020. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report)
may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for
commercial reproduction should be addressed to: World Federation of Societies of Anaesthesiologists, Dean Bradley House, 52 Horseferry Rd, London SW1P 2AF, UK. 29
 and up to 72 hours post block. All patients received multimodal
analgesia prior to block performance. Most (53%) had between 5
and 7 fractured ribs, and 77% of patients received an ESP catheter
to allow a continuous LA infusion into the myofascial plane, with
the remaining receiving a single-injection technique. The catheters
remained sited until the acute pain team deemed the pain could
be managed with oral analgesia alone (mean duration, 3.7 days;
range, 0.6-9.3 days). Incentive spirometry volumes nearly doubled
from baseline during the first 24 hours, with a mean increase of 545
mL. Moreover, this effect was maintained over 72 hours. Maximum
NRS pain scores were statistically significantly reduced, and 12-
hour opioid consumption was reduced in patients who received a
continuous technique (but this did not reach statistical significance).
There was no change in mean arterial blood pressure in any of the
patients. Those who had a single-injection ESP block showed less
convincing results overall. The authors concluded that the ESP block
has become the primary regional intervention for rib fracture patients
at their institution. They also suggested its benefit in safety profile
for patients with contraindications to neuraxial and perineuraxial
techniques (ie, anticoagulated patients).
Figure 6. Gadolinium magnetic resonance image at 45 minutes after left
erector spinae plane block. White arrows: circumferential epidural spread. Thoracic Surgery
Dashed arrows: paravertebral spread. Asterisks: bilateral neuroforaminal
Retraction of ribs and incision of chest wall muscles can make thoracic
spread. Reproduced from Schwartzmann A, Peng P, Antunez Maciel M, et
al. Bilateral erector spinae plane block (ESPB) epidural spread. Reg Anesth
surgery extremely painful in the postoperative period. The impact on
Pain Med. 2019;44:131, with permission from BMJ Publishing Group Ltd respiratory mechanics is the same as those with rib fractures described
(license 4613860141186). above, and these patients will experience the same complications if
pain is not adequately managed. Again, currently available evidence
WHAT DOES THE EVIDENCE SAY? (LARGER STUDIES) leads many clinicians to employ a multimodal analgesic approach
Spread of methylene blue dye and contrast medium in cadavers is with the use of thoracic PVB or neuraxial analgesia (thoracic epidural
informative, but do these anatomical studies translate to a meaningful analgesia [TEA] or intrathecal opioid). However, this will not be
clinical effect? To best answer this question, we need to identify the appropriate management for every patient, and reported failure rates
larger clinical trials. Again, because of the relative infancy of the for PVB and TEA are quoted as high as 15%.13
ESP block, the literature is limited, but below are the key clinical
To date, 1 randomized study has been published looking at the use of
areas that have produced data from randomised controlled trials.
ESP blocks in adults undergoing video-assisted thoracoscopic surgery
Unsurprisingly, much of this work centres on truncal surgery. From
(VATS). In their randomized controlled trial, Ciftci et al14 compared
the pooled review by Tsui et al5 of the published literature, nearly
opioid consumption and pain scores of single-shot ESP blocks with a
90% of the ESP blocks were performed in the thoracic, 9% in the
control group (no block). The data showed statistically lower opioid
lumbar, and, 1% in the cervical region. Eighty percent were single
consumption (176.66lg 6 88.83lg vs 717.33lg 6 133.98lg) and pain
shot-techniques, and 20% were catheter techniques.
scores in the ESP group. They also found statistically lower rates of
Rib Fractures nausea and itching in the ESP group (nausea; P ¼ .010). This study
suggests that the ESP block is a suitable opioid-sparing block for
Mortality from rib fractures has been reported to be as high as 33%.11
patients undergoing VATS, but pain scores were measured only up
A dangerous downward spiral results from disruption of respiratory
to 24 hours, and there are no studies comparing PVB/TEA with this
mechanics and pain, culminating in significant morbidity and
technique in this patient cohort.
mortality. For patients with preexisting respiratory comorbidities
and/or opioid sensitivity, regional anaesthesia is often life-saving For open thoracic surgery, there are several case reports and case
therapy. Thoracic epidural analgesia was long revered as the gold series describing the successful use of ESP catheters for posterolateral
standard for patients with traumatic rib fracture pain, but myofascial thoracotomy analgesia.15,16
plane blocks (eg, serratus anterior, ES) and PVBs have now become Breast Surgery
alternative options.
ESP blocks are showing promise as a regional technique for breast
A retrospective cohort study at a level 1 trauma centre in Pennsylvania surgery analgesia. Small randomized controlled trials have shown
looked at the analgesic outcomes and the effect on respiratory effective analgesia and reduced postoperative opioid consumption
volumes when performing ESP blocks in patients with traumatic when compared with standard care in patients undergoing surgery
rib fractures.12 For 79 patients, incentive spirometry volumes, 12- for breast cancer (including mastectomy).17,18 However, 1 prospective
hour opioid consumption, and highest numeric rating scale (NRS) randomized trial in radical mastectomy surgery showed lower pain
static pain scores were recorded at baseline (ie, pre-ESP block) scores and postoperative tramadol consumption if a modified

30 www.wfsahq.org/resources/update-in-anaesthesia
pectoral nerve block was performed rather than an ESP block.19 Tulgar et al24 performed a double-blinded, randomized, controlled,
Larger comparator studies need to be conducted to assess the true prospective study comparing ESP and subcostal TAP blocks in
efficacy and benefit for this surgical cohort. laparoscopic cholecystectomy surgery performed at a tertiary
university hospital in Turkey. Sixty patients were recruited and
Cardiac Surgery randomized into 3 equal groups: bilateral subcostal TAP, bilateral
Several studies have been performed using ESP blocks for patients ESP, and control. All patients received standard multimodal analgesia
undergoing open cardiac surgery. This is a surgical speciality with and an intraoperative remifentanil infusion, and those who received
procedures that require high intraoperative doses of anticoagulant a block had this performed at the end of surgery. A standard mix of
agents, and so regional anaesthesia has traditionally been avoided. 40mL LA was used for all patients. No patients received LA at the
Patients undergoing elective cardiac surgery with cardiopulmonary surgical site. Tulgar et al24 found that patients in the 2 block groups
bypass had significantly lower pain scores (up to 12 hours had significantly lower rest and dynamic pain scores in the first 3
postextubation) if bilateral ESP blocks were performed rather than postoperative hours (P.001) and a lower overall 24-hour analgesic
standard therapy alone with intravenous paracetamol and tramadol.20 requirement.
A patient-matched, controlled before-and-after study showed similar
Another randomized controlled study, in Egypt, assessed the efficacy
results but also found that postoperative adverse events, time to chest
of the ESP block for postoperative analgesia in total abdominal
drain removal, and time to first mobilization were all significantly
hysterectomy.25 The authors demonstrated that the patients who had
lower if ESP blocks were performed.21 When comparing TEA and
blocks had significantly lower fentanyl consumption in the first 24
bilateral continuous ESP blocks for cardiac surgery, 1 study found
postoperative hours and significantly lower pain scores in the first
comparable pain scores, incentive spirometry, intensive care unit
12 hours.
duration, and number of ventilator days.22
Lower Limb Surgery
Abdominal Surgery
A randomized, controlled, double-blind study looked at the
Rectus sheath (RS) catheters have gained huge popularity as an
analgesic efficacy of lumbar ESP blocks used for patients undergoing
analgesic technique for postoperative midline laparotomy pain.
hip and femur surgery.26 When compared with standard intravenous
However, this block provides only somatic analgesia to the midline
analgesia, the authors found that the patients with ESP blocks had
from T6 to T11. For patients who have transverse incisions, stomas,
significantly lower pain scores within the first 6 hours and lower total
and drains, RS blocks will not provide analgesia. Alternatives
24-hour tramadol consumption (control ¼ 226mg 6 35.89mg, ESP
that have been explored include TAP blocks and, more recently,
block ¼ 130mg 6 50.99mg; P , .001). ESP block was also compared
quadratus lumborum blocks. A perceived key benefit of the ESP
with quadratus lumborum blocks, and both showed similar results
block over other interfascial blocks for abdominal procedures (RS,
overall. The data produced suggest that lumbar ESP blocks may
TAP) is the anterior spread of injectate into the paravertebral and
provide effective analgesia for hip and femur surgery as part of a
epidural space. This would block not only spinal nerve roots but also
multimodal analgesic strategy.
rami communicantes transmitting sympathetic fibres, thus leading
to relief from visceral pain. This was highlighted in the small case Given the potential spread of LA into the epidural space, it is
series by Chin et al23 with significant relief of visceral pain after feasible that lumbar approaches to the ESP block lead to lower
ESP blocks seen in 3 bariatric patients undergoing laparoscopic limb weakness. Selvi and Tulgar27 published a case report describing
abdominal surgery. transient bilateral lower limb weakness after a T11 ESP block.
The literature points to a wide spectrum of indications for ESP blocks Novel Uses
when considering abdominal procedures. These include laparotomy, There is an abundance of case reports and small case series in the
nephrectomy (laparoscopic and open), renal transplant, radical literature with positive outcomes. Clinicians have investigated the
prostatectomy, percutaneous nephrolithotripsy, herniorrhaphy, effectiveness of the ESP block on patients undergoing surgery on the
gastric bypass, gastrectomy, and caesarean delivery, to name a few. upper limbs and spine.28

Table 1. Weight-Based Local Anaesthetic Concentration and Volume Guide for Erector Spinae Plane Block in Rib Fractures

Weight-Based Dosing
Drug 50-kg Patient 70-kg Patient 100þ-kg Patient
Unilateral
0.25% bupivacaine, mL 30 40 40
0.5% bupivacaine, mL 20 (max dose) 20 30
Bilateral
0.25% bupivacaine, mL 20 per side (40 total) 25 per side (50 total) 30 per side (60 total)
0.5% bupivacaine, mL Not advised, not enough volume Not advised, not enough volume Not advised, not enough volume

© World Federation of Societies of Anaesthesiologists 2020. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report)
may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for
commercial reproduction should be addressed to: World Federation of Societies of Anaesthesiologists, Dean Bradley House, 52 Horseferry Rd, London SW1P 2AF, UK. 31
There is even a case report suggesting the effectiveness of the studies will need to clarify the decision to perform the block at
technique for a refractory tension headache.29 2 levels if a noncatheter technique is being employed.
Several articles have suggested the ESP block may be used for chronic • Tulgar et al33 demonstrated lower postoperative pain scores and
shoulder pain and surgery on the upper arm.30 opioid use in thoracotomy patients if 2-level ESP blocks were
performed rather than single-level blocks.
CLINICAL QUESTIONS
• Multiple published case reports also describe the successful use of
There remain several clinical questions that require further research.
a bilevel approach.34,35
What Are the Optimal Volume and Concentration of LA?
• There have been no studies to date directly comparing the clinical
• Fascial plane blocks rely on a high-volume, low-concentration efficacy of single-level with multilevel injections/catheters.
technique for optimal efficacy.
• Multilevel injections/catheter insertions may have a role when
• In a mini review, De Cassai and Tonetti31 determined that 3.6 mL extensive analgesia of the trunk is desired.
of an LA agent per desired vertebral level spread was adequate in
ESP blocks. However, at present, there are no data relating this What Is the Optimal Approach?
volume to duration of action. The classically described approach to the ESP block is a parasagittal
ultrasound probe position with in-plane needling. Some clinicians
• Luftig et al32 specifically looked at the volume and concentration
report an out-of-plane technique with the same probe position.
used in 16 ESP block articles (49 cases) when indicated for rib
fracture analgesia, to determine optimal regimes. Based on the • A documented problem with the parasagittal approach is
findings, they created a weight-based guide for ESP block in ‘‘lamination’’—injection between the muscle fibers producing
these patients (Table 1). an ultrasound image consistent with spread within the fascial
plane (Figure 7).36 This occurs because of the longitudinal
Single Level Versus Multilevel
orientation of the muscle fibers in the ES complex.
• As shown, cadaveric and anatomical studies show extensive
spread of injectate around the ES complex with varied degrees • The authors observed this phenomenon to occur more frequently
of spread into the neural foramina and epidural space. Further when needling for catheter insertion with 16-gauge Tuohy
needles.
• With a transverse approach, lamination will not be seen after
intramuscular injection.
• The authors of this article recommend first performing a single-
shot ESP block with the transverse approach to create a target
space for catheter insertion. The catheter can then be sited using
a parasagittal or transverse approach. Block success and correct
catheter placement rates may be higher with this technique.
Caveats
• Publication bias: When the outcome of cases and clinical trials is
not in favour of an intervention, they may not be submitted for
consideration of publication. This means for a new technique
such as the ESP block, the already relatively small pool of
evidence may suffer from reporting biases.
• As the technique remains in its infancy with most data coming
Figure 6. T5 vertebral level parasagittal (A, B) and transverse (C, from case reports, there is currently no consensus on dosing
D) approach to the erector spinae plane block. Needle trajectory regimes for various indications. This makes comparison between
indicated by arrow heads. In images A and B, the needle tip is located studies more difficult.
between the muscle fibers, which run parallel to the ultrasound
beam in the parasagittal probe orientation. When fluid is injected REFERENCES
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