Lumbar ESP
Indications: Orthopedic hip and proximal femur procedures such as pemberton osteotomy, hip arthroscopy/arthroplasty, and femoral fracture fixation. Iliac crest autograft. Lower quadrant abdominal procedures such as ostomy creation, nephrectomy, inguinal hernia/hydrocele repair, and orchiopexy. Lumbar spine surgery and non-operative pain treatment.
Dose: Please see Local Anesthetic dosing page for recommended dosing guidelines.
Coverage/Distribution: Dermatomal coverage based on the lumbar level(s) of injection. Potential, yet controversial visceral coverage. Unpredictable spread to the lumbar plexus, paravertebral space, and epidural space. Despite the controversy in the extent of the lumbar ESP
Recommended Technique: Probe- Linear; Needle- In-plane
The patient can be positioned sitting, lateral, or prone. In the prone position, a roll placed under the child’s hips helps to minimize an acute needle-entry angle that may be otherwise encountered due to lumbar spine lordosis. The iliac crests are palpated as an initial surface anatomy landmark using the intercristal line (the line joining the superior aspect of the iliac crests posteriorly) as an indicator of L4.
At this level, the ultrasound probe is placed over the spine in longitudinal orientation. The midline spinous processes are easily identified as the most superficial bony structures. The probe is then translated laterally, away from the midline, scanning past the lamina/articular facet joints, and stopping over the transverse processes. Verification of the transverse processes can be achieved by continuing to move the probe laterally until all bony landmarks disappear, then returning medially to the transverse processes.
The needle is driven through the erector spinea muscle group. Our preferred approach is cranial to caudal, yet any in-line approach can be used. Contact with the transverse process and then slight withdrawal is a useful indicator of appropriate depth, though not always necessary. It is critical to see hydrodissection with cephalad and caudad spread of local anesthetic, and obvious elevation of the erector spinea muscle group to ensure a successful block.
Considerations: Accurate lumbar transverse process identification is crucial and can be more challenging than in the thoracic region. In comparison, the transverse processes will lie deeper and more lateral. The articular facet joints in the lumbar region appear more prominent and can be confused for transverse processes. In the thoracic ESP block, the transverse processes take on a marked square-top appearance that is not as pronounced in the lumbar region. Also, the use of the rib-to-transverse process transition point that most providers use as an aid in transverse process identification does not exist at the lumbar levels. Our routine to address these challenges includes dynamic scanning, from the midline moving laterally and returning back medially again, visualizing the bony landmarks in the following in order: spinous processes ⇾ lamina/facet ⇾ transverse process ⇾ no bone ⇾ and then returning to midline just at the point where the transverse process returns into view.
Transverse Bony Anatomy Scan— TP: Transverse Process; AP: Articular Process; SP: Spinous Process
Potential Complications:
Block failure is a realistic consideration if the transverse process is misidentified. This is a significant consideration as compared to ESPB’s performed in the thoracic region, as the transverse process lies deeper, is not as distinctly square-shaped, can be confused with prominent facet joints, and there is no costotransverse joint to aid in identification.
Bleeding at needle insertion site or deeper hematoma (ex. psoas muscle). Accidental injection into underlying deeper structures including unintentional spread to the lumbar plexus, paravertebral, or the epidural space have been reported. Accurate identification of the transverse processes and staying superficial to them will help to mitigate these risks.
Intravascular injection.
With the transverse process as bony endpoint, the overall side effect risk is low as compared to the lumbar plexus block, quadratus lumborum block, and neuraxial injections, making the lumbar ESP an attractive alternative.
Patient Positioning and Probe Orientation
Ultrasound Images
Three main approaches to the pediatric lumbar ESP are well described. The parasagittal in-plane (classic approach) was the first approach described by Tulgar in 2018 for adult hip arthroplasty, and is preferred by the author as it allows for continuous needle visualization while advancing to multiple lumbar levels, if needed to further local anesthetic spread. The transverse approach involves orienting the ultrasound probe in the transverse plane, where the spinous process, facet joint, and transverse process are all visualized at once. For both approaches, either an in-plane or out-of-plane technique can provide excellent visualization of local anesthetic spread, and are based on the preference of the provider. A third approach, the Asku technique (Aksu & Gurkan, 2019), was first described in pediatric patients positioned laterally. The ultrasound probe is oriented transversely, but held over the posterior-lateral flank instead of over the spine itself, and utilizes a “Shamrock” view. Tulgar (2019) added to this approach and his further modification includes additional deposition of local anesthetic at the lumbar plexus. A wonderful review of the multiple possible approaches is provided in Tulgar’s 2020 review article.
The extent of local anesthetic spread is controversial with EPSBs in general. This becomes even more complex in the lumbar region, and is further complicated with the variation in height and weight of pediatric patients. Harbell et al.’s cadaveric study specific to lumbar ESP notes that spread in the lumbar region is limited craniocaudally as compared to spread in the thoracic region. They found coverage of the dorsal rami to be reliable, but saw no spread anteriorly to the paravertebral space nor to the ventral rami. Yet others report, with the use of high volumes of local anesthetic (>20-30mL in adult-sized patients), spread to the lumbar plexus and epidural space may indeed occur leading to unanticipated complete motor block (Karaca 2021).
Holland and Bosenberg’s review of the pediatric-specific ESP literature note the use of local anesthetic dosing at 0.3-0.5mL/kg of 0.25% Bupivacaine in the lumbar region across a multitude of surgery types. Asku and Gurkan’s review of pediatric ESP blockade, not specific to the lumbar region, reports dosing at 0.5ml/kg 0.25% bupivacaine, with a maximum volume of 20mL. We typically use 0.2% Ropivacaine at doses of 0.5-1ml/kg, divided when needed bilaterally, maximum 20mL, and have had excellent duration sensory coverage and have not seen motor blockade.
Tulgar S, Senturk O. Ultrasound guided Erector Spinae Plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty. J Clin Anesth. 2018;44:68.
Aksu C, Gürkan Y. Aksu approach for lumbar erector spinae plane block for pediatric surgeries. J Clin Anesth. 2019;54:74-75.
Tulgar S, Unal OK, Thomas DT, Ozer Z. A novel modification to ultrasound guided lumbar erector spinae plane block: Tulgar approach. J Clin Anesth. 2019;56:30-31.
Tulgar S, Aydin ME, Ahiskalioglu A, De Cassai A, Gurkan Y. Anesthetic techniques: focus on lumbar erector spinae plane block. Local Reg Anesth. 2020;13:121-133.
Karaca Ö. Unexpected motor block after ultrasound-guided lumbar erector spinae plane block. Agri. Published online 2021.
Holland EL, Bosenberg AT. Early experience with erector spinae plane blocks in children. Paediatr Anaesth. 2020;30(2):96-107.
Harbell MW, Seamans DP, Koyyalamudi V, Kraus MB, Craner RC, Langley NR. Evaluating the extent of lumbar erector spinae plane block: an anatomical study. Reg Anesth Pain Med. 2020;45(8):640-644
Aksu C, Gurkan Y. Defining the indications and levels of erector spinae plane block in pediatric patients: a retrospective study of our current experience. Cureus. Published online August 8, 2019.
