Erector Spinae Plane Block

The Erector Spinae Plane Block (ESPB) is a technically simple and safe form of regional anaesthesia that can provide effective analgesia for 12 hours in patients with acute posterior rib fractures

  • ESPB achieves a block of the posterior, lateral, and anterior thoracic wall
  • Retrospective cohort studies have demonstrated increased respiratory function, reduced pain scores, and reduced opioid consumption when administered to patients with multiple posterior rib fractures. No complications were demonstrated

Anatomy
  • The “erector spinae” is a group of muscles that run bilaterally from the skull to pelvis/sacral region, and from spinous to transverse processes, extending to the rib
  • The aim to inject local anaesthetic (LA) into the fascial plane that runs between the muscle and the transverse process
CT axial section demonstrating anatomy: Erector spinae muscle group shown in blue, injection site in red
  • LA spreads anteriorly to the paravertebral space and laterally to reach intercostal nerves, and spreads along the plane in a craniocaudal manner, covering 3-4 levels above and below

Indications
  • Two or more acute posterior, posterolateral, or lateral rib fractures
  • Opioid analgesia and/or oxygen requirement

Contraindications
  • Absolute:
    • LA allergy
    • Risk of LA toxicity (e.g. if other regional anaesthesia such as femoral nerve block already performed)
    • Localised infection att site
  • Relative:
    • Inadequate assessment of sonoanatomy (e.g. obese patient)

In patients with isolated anterior or anterolateral rib fractures, a serratus anterior plane block (SAPB) may be more appropriate.


Preparation
  • Patients must be cardiac monitored in a resuscitation bay with IV access
  • Preferred position is the patient sitting on the edge of the bed leaning forwards, with the machine on the opposite side of the bed in line of sight
  • Prepare the thoracic wall with 2% chlorhexidine solution
  • Dilute 20ml of 0.75% ropivacaine (150mg) with 20ml normal saline for a total volume solution of 40ml (alternatively 40ml of 0.25% levobupivacaine, adhering to safe weight-based LA dosing)
  • STOP before you block – confirm correct side of block

Sonoanatomy
  • High frequency linear probe (musculoskeletal preset) is placed in a parasagittal longitudinal position, around 3cm from the midline
  • Identify the ribs and adjacent pleural line, and set your depth such that the pleural line and lung are in the bottom third of your image
  • Move the probe medially — transverse processes will appear more square-like, and the pleural line with disappear

Technique
  • Using an in-line cephalic approach, aim to contact the corner of the transverse process to “lift off” the fascia
  • After contact, inject 40ml of LA in 5-10ml increments. You should visualise the erector spinae muscle “peeling” off the top of the transverse process
  • You can follow the spread of injectate with your needle tip during or after administration

ULTRASOUND LIBRARY

POCUS

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

MBChB, PGCert (Public Health), PGDip (Medical Ultrasound). UK Emergency Registrar gone walkabout in Melbourne, Australia. Interests include point-of-care ultrasound, critical care, #FOAMed and coffee. Twitter: @NishCherian

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