Erector Spinae Plane Block

Paraspinal fascial plane block, which:

• Involves injecting LA deep to the erector spinae muscle and superficial to the tip of the transverse process
  Distant from the spine, paravertebral space, pleura and vessels.
• Can be performed on anticoagulated patients

Indications

Particularly beneficial in patients where epidural or paravertebral blocks are contraindicated

Thoracic wall analgesia:

• ⩾3 Rib fractures

Contraindications

Anatomy

Landmarks:

• Identify spinous processes midline
• Translate paramedian to identify transverse process and ribs on ultrasound

Layers:

• Skin
• Subcutaneous tissue
• Trapezius
  Present in, absent
• Erector spinae muscle
  Block performed in plane between erector spinae and transverse processes.
• Transverse processes separated by muscles (Multifidus and Rotatores)
  
• Ribs and intercostal muscles
  
• Paravertebral space
• Pleura

Equipment

• High frequency linear transducer
• Needle and catheter kit
  • 18G Tuohy needle
  • 18G Pajunk catheter-over-needle kit
• Local

Technique

Position:

• Sitting
• Lateral decubitus

Probe:

• Place in parasaggital orientation ~3cm lateral to the spinous process
• Identify the transverse processes
  Flat, squared off “tombstone” shadows. Distinguished from the ribs which are:
  • More lateral
  • Deeper
  • Rounded off
  • Separated by hyperechoic pleural line

Needle:

• Insert IP, cranial to caudal
• Contact the bony shadow of the TP with the tip deep to the fascial plane of the erector spinae
  Injection of 0.5-1ml of saline will demonstrate linear fluid spread separating erector spinae from the TP in both cranial and caudal directions.
• Place catheter
• Confirm correct catheter position by bolusing solution down needle sheath

Pump:

• Multiple potential infusion regimens
• Intermittent boluses
  15ml 0.2% ropivacaine Q3H, with 5ml bolus Q1H.
• Continuous infusion 10ml/hr 0.125% bupivacaine.

Complications

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References

1. ASRA News - How I Do It: Erector Spinae Block for Rib Fractures: The Penn State Health Experience - American Society of Regional Anesthesia and Pain Medicine. https://www.asra.com/asra-news/article/39/how-i-do-it-erector-spinae-block-for-rib#r3. Accessed December 29, 2019.
2. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Regional Anesthesia and Pain Medicine. 2016;41(5):621-627. doi:10.1097/AAP.0000000000000451
3. Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. British Journal of Anaesthesia. 2017;118(3):474-475. doi:10.1093/bja/aex013