Thoracic ESP Block
Indications: Rib fractures, thoracic surgery, cardiac, abdominal, upper and lower extremity, spine (e.g scoliosis repairs with single shot or catheters), even headaches. Basically, if it’s a part of your body, there is a case report someplace describing the ESP block’s efficacy.
Nerve block: ESP is an interfascial plane block of the dorsal rami of spinal nerves. There is considerable debate regarding the mechanism of action, and the extent of local spread, with some sources documenting spread to paravertebral or epidural space, as well as possible bilateral coverage.
Volume: A neonatal cadaver study suggests 0.1mL/kg for each dermatomal level in preterm neonates.
Advantages: Technically simpler (than PVB, QL3). May be safer than TEA and PVB. Multiple dermatomal levels with single injection. No critical structures (blood vessels, pleura) in needle path. Not at increased risk with heparinization.
Complications: May cause hypotension (especially if paravertebral spread with sympathectomy).
Positioning: Lateral vs. prone vs sitting (in awake or lightly sedated patients). We tend to do lateral, as it is generally much easier to do in an intubated patient, though our very own Sam Tafoya routinely does ESP’s prone. Be mindful of the ergonomics and needle directionality if you’re performing catheters. We tend to place the patient in right lateral for catheters, which we thread in a cranial-caudal direction (we are mostly right-handed practitioners).
Technique: Single-shot vs multilevel vs catheter. Transverse or parasagittal. Cervical, thoracic, and lumbar. They’ve all been described. There is also some debate regarding whether injecting cranial-caudal or caudal-cranial matters. At least by using ultrasound, you can have some control over the reliability of spread.
Unlike some of the other blocks where your focus is on visible nerves, or even muscle layers, I tend to think of the ESP block as more of a “bony” block. I really focus most of my initial attention on the bone morphology to discern the correct parasagittal plane. If I’m a bit too medial, I have a retrolaminar block on my hands; too lateral, and I may be doing a rhomboid intercostal and subserratus plane (RISS) block. As such, I typically start fairly lateral from the spine and focus most of my attention on the bone morphology. I want to be able to clearly delineate the transition from rib (round) to rib-transverse process articulation (trapezoidal) to transverse process (tombstone).
Patient Positioning, Probe Orientation, and Ultrasound Imaging
Parasagittal
Scanning from Lateral to Medial
Transverse
IIM: Internal Intercostal Membrane; EIM: External Intercostal Muscle; TP: Transverse Process
Originally described in adults by Forero et al, the ESP has gained considerable popularity in the past few years. So far, much has been limited to case reports (thorax, pyeloplasty), much of that in adults. Only about 10% of papers concern pediatric patients.
One of the first RCT’s looking at ESP in pediatrics was by Aksu et al. Their double-blinded, prospective randomized trial looked at kids ages 1-7 for elective lower abdominal surgery (IH, orchiopexy, hydrocelectomy). 57 patients were included in the final analysis. The ESP block was performed at L1 vs. a standard QL3. They found no significant differences in FLACC scores or time to first rescue analgesic. No child required rescue analgesics while on the ward. The researchers also reported no complications, such as hypotension, arrhythmia or allergic reaction during the intra- or postoperative periods; also, no block-related complications or side-effects were observed postoperatively. Of interest, the authors noted that performing an ESP block may be technically simpler than a QL3.
Another RCT by Kaushal et al evaluated the use of pre-incision, single-shot bilateral ESP blocks vs. control (no block) for patients undergoing CPB via midline sternotomy. 80 patients were included in the final analysis. There were no difference in extubation times or intraoperative narcotic use (though this can fairly standardized and was not directly addressed in the manuscript). The ESP group had a longer time to first rescue analgesic, reduced postoperative narcotic use, lower sedation scores, and reduced ICU stay of approximately 3.5 hours compared to the control group; all were statistically significant (p< 0.0001). No adverse events were reported.
Macaire et al also evaluated the effectiveness of ESP for patients undergoing open cardiac surgery, although using catheters rather than single-shot blocks. Patients were randomized to either a local anesthetic solution or saline intermittently bolused through the ESP catheters postoperatively. Total narcotic use was significantly decreased in the LA group, with the control group requiring over 400% more narcotics in the first 48 hours. The LA group also demonstrated significantly reduced pain scores at extubation, drain removal and during mobilization. There were no difference in extubation times, time to drain removal, time to first active mobilization, length of ICU or hospital stay. One thing to bear in mind is that ICU length of stay varies widely amongst institutions. At my old institution, even simple repairs (e.g. ASD and VSD repairs) were discharged home directly from the ICU. There was no intermediary transfer to a regular floor bed.
Most studies used dilute ropivicaine solutions, though at least one center we know of uses lidocaine. In their retrospective study, lidocaine serum concentrations never reached near-toxic levels, even with lidocaine added to the cardioplegia. The use of lidocaine may have an improved safety profile, and possible systemic analgesic properties.
A recent meta analysis review by Luo et al suggested that the currently available evidence supporting the superiority of an ESP to no block is of low quality. Compared with no block, they found that the ESP block slightly reduced the pain scores at 0 h, postoperatively at rest, but significantly reduced the need for rescue analgesics. Lest you think there is no reason to do ESP given some of these results, bear in mind there is considerable heterogeneity in the included RCT’s (surgery type, background analgesia administration, and varied dosage of local anesthetics), as well as potential bias (selective reporting bias, unclear concealment, and blinding). The studies clearly show children receiving ESPB were approximately 10 times as likely to be free of rescue opioids. Furthermore, they found that compared to no block, ESPB significantly delayed the use of first rescue analgesics.
In summary, the ESP block remains a relatively easy, safe, and extraordinarily versatile block. It has been used for everything from headaches to hips, and everything in between. Most recently, it has even been described for pelvic procedures!
Stondell, C. and Roberto, R., 2022. Erector Spinae Plane Blocks With Liposomal Bupivacaine for Pediatric Scoliosis Surgery. JAAOS Global Research & Reviews, 6(1).
Tsui, B.C., Esfahanian, M., Lin, C., Policy, J. and Vorhies, J., 2020. Moving toward patients being pain-and spasm-free after pediatric scoliosis surgery by using bilateral surgically-placed erector spinae plane catheters. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 67(5), pp.621-622.
Chin, K.J., Dinsmore, M.J., Lewis, S. and Chan, V., 2020. Opioid-sparing multimodal analgesia with bilateral bi-level erector spinae plane blocks in scoliosis surgery: a case report of two patients. European Spine Journal, 29(2), pp.138-144
Forero, M., Adhikary, S.D., Lopez, H., Tsui, C. and Chin, K.J., 2016. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Regional Anesthesia & Pain Medicine, 41(5), pp.621-627.
Schwartzmann A, Peng P, Maciel MA, et al. Mechanism of the erector spinae plane block: insights from a magnetic resonance imaging study. Can J Anaesth. 2018;65:1165-1166.
Tulgar, S., Selvi, O., Ahiskalioglu, A. and Ozer, Z., 2019. Can unilateral erector spinae plane block result in bilateral sensory blockade?. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 66(8), pp.1001-1002.
Altıparmak, B., Toker, M.K. and Uysal, A.İ., 2020. Potential mechanism for bilateral sensory effects after unilateral erector spinae plane blockade in patients undergoing laparoscopic cholecystectomy. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 67(1), pp.161-162.
Tsui, B.C., Fonseca, A., Munshey, F., McFadyen, G. and Caruso, T.J., 2019. The erector spinae plane (ESP) block: a pooled review of 242 cases. Journal of clinical anesthesia, 53, pp.29-34.
Hernandez, M.A., Palazzi, L., Lapalma, J., Forero, M. and Chin, K.J., 2018. Erector spinae plane block for surgery of the posterior thoracic wall in a pediatric patient. Regional Anesthesia & Pain Medicine, 43(2), pp.217-219.
Aksu, C., Şen, M.C., Akay, M.A., Baydemir, C. and Gürkan, Y., 2019. Erector Spinae Plane Block vs Quadratus Lumborum Block for pediatric lower abdominal surgery: A double blinded, prospective, and randomized trial. Journal of clinical anesthesia, 57, pp.24-28.
Govender S, Mohr D, Bosenberg A, et al. A cadaveric study of the erector spinae plane block in a neonatal sample. Reg Anesth Pain Med 2020;45:386–8.
Hagen, J., Devlin, C., Barnett, N., Padover, A., Kars, M. and Bebic, Z., 2019. Erector spinae plane blocks for pediatric cardiothoracic surgeries. Journal of clinical anesthesia, 57, pp.53-54.
Chin, K.J. and Lewis, S., 2019. Opioid-free analgesia for posterior spinal fusion surgery using erector spinae plane (ESP) blocks in a multimodal anesthetic regimen. Spine, 44(6), pp.E379-E383.
Kaushal B, Chauhan S, Magoon R, et al. Efficacy of bilateral erector spinae plane block in management of acute postoperative surgical pain after pediatric cardiac surgeries through a midline sternotomy. J Cardiothorac Vasc Anesth 2020;34:981–6.
Holland EL, Bosenberg AT. Early experience with erector spinae plane blocks in children. Paediatr Anaesth 2020;30:96–107.
Macaire, P., Ho, N., Nguyen, V., Van, H.P., Thien, K.D.N., Bringuier, S. and Capdevila, X., 2020. Bilateral ultrasound-guided thoracic erector spinae plane blocks using a programmed intermittent bolus improve opioid-sparing postoperative analgesia in pediatric patients after open cardiac surgery: a randomized, double-blind, placebo-controlled trial. Regional Anesthesia & Pain Medicine, 45(10), pp.805-812.
De Haan, J.B., Chrisman, O.M., Linden Lee, M.G. and Hernandez, N., 2019. T4 erector spinae plane block relieves postdural puncture headache: a case report. Cureus, 11(11).