Erector Spinae Plane Block Levels
For thoracic surgery (VATS), perform the ESP block at T5 level; for breast surgery, use T4 level; and for abdominal surgery, target T7-T9 depending on the surgical site. 1
Thoracic Surgery (VATS)
- T5 is the standard level for video-assisted thoracoscopic surgery, providing effective analgesia with reduced pain scores and opioid consumption during the first 24 hours postoperatively 2, 1
- The block at this level reduces pain scores at rest and during coughing for the first 6-8 hours after surgery 2
- Use 20 ml of bupivacaine 5 mg/ml (0.5%) for single-shot ESP block at T5 2, 1
Breast Surgery
- T4 level is recommended for oncological breast surgery 2, 1
- ESP block at T4 reduces morphine consumption compared to general anesthesia alone, though PECS blocks demonstrate superior pain control after the first postoperative hour 2, 1
- Neither ESP nor PECS blocks reliably provide sufficient analgesia to the axilla (T1 nerve distribution), requiring supplemental local anesthetic wound infiltration for axillary procedures 1
Abdominal Surgery
- T7-T9 levels are appropriate depending on the specific surgical site 1
- The ESP block can be performed at all levels of the spine and provides analgesia to most regions of the body 3
- For lower abdominal procedures, consider more caudal levels within this range 1
Technical Considerations
- Use ultrasound guidance to identify the erector spinae muscle and transverse process at the target level 1
- The recommended volume is 20 ml of bupivacaine 5 mg/ml (0.5%) for single-shot ESP block 2, 1
- Adding dexmedetomidine to ropivacaine results in reduced pain scores, lower rescue analgesia requirements, and shorter hospital stays compared to plain ropivacaine 1
Critical Limitations
- The analgesic effect of single-shot ESP block diminishes after 6-8 hours, requiring supplemental analgesia 1, 4
- Always administer basic analgesia with NSAIDs and paracetamol concurrently with ESP block to optimize pain management 1
- ESP block must be part of a comprehensive multimodal analgesic strategy including paracetamol and NSAIDs or COX-2 selective inhibitors 1
- Opioids should be reserved for rescue analgesia only 1
Continuous Catheter Technique
- For prolonged analgesia beyond 6-8 hours, place a catheter at the target level with continuous infusion of 0.2% ropivacaine 5
- The catheter technique was effective in 83.3% of patients with no reported mortality or major complications 5
- ESP block is particularly indicated when the parietal pleural leaflet is damaged, which would preclude the efficacy of a paravertebral block with catheter 1