From the Guidelines
The recommended technique for placing an erector spinae block involves positioning the patient in a sitting or lateral position with the target side up, using ultrasound guidance to identify the transverse process at the desired vertebral level, and injecting 20-30mL of local anesthetic into the fascial plane deep to the erector spinae muscle. This technique is supported by recent studies, including those published in 2022 1, which demonstrate the effectiveness of erector spinae plane blocks in reducing postoperative pain and opioid consumption.
Key Steps for Placement
- Position the patient in a sitting or lateral position with the target side up
- Use ultrasound guidance to identify the transverse process at the desired vertebral level (typically T5-T7 for thoracic procedures or L2-L4 for abdominal procedures)
- Place a high-frequency linear probe in a parasagittal orientation 2-3 cm lateral to the spinous processes
- Advance a 22G, 80-100mm echogenic needle in-plane from caudal to cranial direction until the needle tip contacts the transverse process
- After negative aspiration, inject 20-30mL of local anesthetic (typically 0.25% bupivacaine or 0.2% ropivacaine) into the fascial plane deep to the erector spinae muscle
Mechanism and Outcomes
The erector spinae block works by diffusion of local anesthetic into the paravertebral space, affecting the dorsal and ventral rami of spinal nerves. Onset typically occurs within 15-30 minutes, with duration of 12-24 hours depending on the local anesthetic used, though adding dexamethasone (4-8mg) can prolong the effect 1. Studies have shown that this block can reduce pain scores, opioid consumption, and postoperative nausea and vomiting, while also improving patient satisfaction and reducing length of stay 1.
Comparison to Other Techniques
While paravertebral blocks are also effective for postoperative pain management, the erector spinae block has been shown to be a valuable alternative, with some studies suggesting similar or improved outcomes 1. However, the choice of technique ultimately depends on the specific clinical context and patient needs.
From the Research
Assessment for Placement of an Erector Spinae Block
To assess for the placement of an erector spinae block, the following techniques can be considered:
- Fluoroscopic guidance: This method has been shown to improve the efficiency and accessibility of the erector spinae plane block (ESPB) for spine surgeons, reducing dependence on anesthesiology personnel trained in administering the block 2.
- Ultrasound guidance: This technique is commonly used for ESPB and has been shown to be effective in providing postoperative analgesia when part of a multimodal analgesia plan 3, 4, 5.
- Intraoperative three-dimensional (3D) imaging: This method can be used to visualize the spread of the anesthetic and confirm the correct placement of the block 2.
Recommended Technique
The recommended technique for placing an erector spinae block involves:
- Identifying the correct level for the block, which can be determined by the location of the surgery or the area of pain 3, 4, 5.
- Using fluoroscopic or ultrasound guidance to insert the spinal needle and localize the erector spinae plane 2, 3, 4.
- Injecting the anesthetic, such as liposomal bupivacaine, into the erector spinae plane to provide prolonged analgesia 6.
- Confirming the correct placement of the block using intraoperative 3D imaging or other methods 2.
Key Considerations
When assessing for the placement of an erector spinae block, the following key considerations should be taken into account:
- The patient's anatomy and the location of the surgery or area of pain 3, 4, 5.
- The type and dose of anesthetic used, which can affect the efficacy and safety of the block 3, 6.
- The potential risks and complications of the block, such as infection, bleeding, or nerve damage 5.
- The need for multimodal analgesia and the potential benefits of combining ESPB with other analgesic techniques 3, 5, 6.