Erector Spinae Plane Block

	Insertion site and ultrasound view. (A) The transducer is oriented cephalocaudal and held over the transverse process. The needle insertion may be 1 to 2 cm from the probe. (B) Ultrasound view demonstrating the needle path contacting the posterior surface of the transverse process (From Clin Exp Emerg Med 2024;11(4):379-386 https://doi.org/10.15441/ceem.23.171)
Erector Spinae Plane Block
Indication	Thoracic back pain, cancer-related thoracic pain, chronic thoracic pain
Syringe	10-20 mL syringe
Needle	22 G needle (50 or 100 mm)
Steroid	Dexamethasone 10 mg
Local	1% lidocaine
Volume	10 mL for unilateral, 15-20 mL for bilateral injection

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There is an emerging role for using the Erector Spinae Plane (ESP) block technique to treat thoracic spinal pain conditions as a safer alternative to the more common transforaminal or interlaminar epidural injection approach.^[1]

Anatomy

The Erector Spinae Plane (ESP) Block targets the erector spinae muscle group, which runs parallel to the spine. The injection takes place at the fascial plane, deep to the erector spinae muscles. This interfascial plane technique aims to deliver solution to the soft tissue rather than directly blocking nerves.

Indications and Efficacy

The ESP block has been found effective for both acute and chronic pain management. According to Hochberg et al. (2022), indications include:

Chronic thoracic back pain
Cancer-related thoracic pain
Nociceptive pain (vertebral/rib fractures, kyphosis, scoliosis, myofascial pain, degenerative changes)
Neuropathic pain

In their retrospective study, 53% of patients reported pain reduction of more than 2.5 points on the numerical rating scale (NRS), and 41% reported more than 50% improvement in pain scores. Patients with symptom duration less than 4 months showed better outcomes, supporting early intervention for pain management.

Contraindications

Allergy or hypersensitivity to steroid or amide local anesthetics
Pregnancy
Breastfeeding
Significant motor weakness
Signs or symptoms of myelopathy

Pre-procedural Evaluation

Before performing the ESP block, patients should undergo evaluation including:

Assessment of pain using a numerical rating scale (NRS)
Review of previous conservative treatments (physical therapy, oral analgesics)
Neurological examination to rule out motor weakness or myelopathy
Review of coagulation status and bleeding risk
Informed consent

Equipment

Ultrasound machine
High-frequency linear ultrasound probe (or curvilinear 2-5 MHz probe for obese patients)
22 G needle (50 or 100 mm)
10-20 mL syringe
1% lidocaine
Dexamethasone 10 mg
Sterile field equipment

Technique

The ultrasound guided procedure as described by Hochberg et al. (2022) is performed as follows:

Position the patient prone
Set the ultrasound probe 2.5-3 cm laterally to the spinous process at the desired thoracic vertebral level on a parasagittal plane
Use a high-frequency linear probe (or curvilinear probe for obese patients)
Insert a 22 G needle (50 or 100 mm) under ultrasound guidance in a craniocaudal direction using the in-plane technique
Advance the needle to the fascial plane deeper to the erector spinae muscle group
Inject solution:
1. Unilateral injection: 10 mL of 1% lidocaine with dexamethasone 10 mg
2. Bilateral injection: 15-20 mL of 1% lidocaine with dexamethasone 10 mg

Complications

The ESP block is considered a safe technique with minimal procedure-related complications compared to traditional thoracic neuraxial blocks. No major adverse effects were reported in Hochberg's study of 145 procedures. Minor adverse effects included:

Injection site soreness
Systemic response to steroids (transient increase in blood glucose levels and blood pressure)

The procedure has a low risk for bleeding and is classified by the American Society of Regional Anesthesia (ASRA) as a low-risk procedure for bleeding, similar to musculoskeletal injections and thoracic facet medial branch blocks.

Aftercare

Post-procedure care includes:

Motor function testing, especially following lower thoracic ESP blocks
Observation for any adverse effects
Discharge instructions
Follow-up appointment scheduled 6-8 weeks after the procedure
Evaluation of pain reduction at follow-up
Additional blocks may be considered if needed (maximum of three procedures recommended)

Videos

Resources

ESP Injection for chronic pain - Hochberg 2022.pdf - 242 KB (f)

ESP - Meyer 2024.pdf - 908 KB (f)

References

↑ Hochberg, Uri; Brill, Silviu; Ofir, Dror; Salame, Khalil; Lidar, Zvi; Regev, Gilad; Khashan, Morsi (2022-08-21). "Is the Erector Spinae Plane Block Effective for More than Perioperative Pain? A Retrospective Analysis". Journal of Clinical Medicine (in English). 11 (16): 4902. doi:10.3390/jcm11164902. ISSN 2077-0383.

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,

[1] Hochberg, Uri; Brill, Silviu; Ofir, Dror; Salame, Khalil; Lidar, Zvi; Regev, Gilad; Khashan, Morsi (2022-08-21). "Is the Erector Spinae Plane Block Effective for More than Perioperative Pain? A Retrospective Analysis". Journal of Clinical Medicine (in English). 11 (16): 4902. doi:10.3390/jcm11164902. ISSN 2077-0383.

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