Erector Spinae Plane Block

Anatomy and Physiology

Erector spinae plane block is most often performed using an in-plane ultrasound-guided technique. This procedure involves a paraspinal fascial plane block, where the needle is placed between the erector spinae muscle and the thoracic transverse processes, and a local anesthetic is administered to block the dorsal and ventral rami of the thoracic and abdominal spinal nerves.[1] This blockage of the dorsal and ventral rami of the spinal nerves helps to achieve a multi-dermatomal sensory block of the anterior, posterior, and lateral thoracic and abdominal walls.

The multi-dermatomal sensory block is hypothesized to result from the spread of the injected local anesthetic both cranially and caudally. This spread is aided by the thoracolumbar fascia, which extends across the posterior thoracic wall and abdomen.[5] Chin et al documented the cadaveric spread of local anesthetic and noted that, radiologically, the local anesthetic spread extended 3 or 4 levels cranially and caudally from the site of injection.[5] The reported mechanism of action is the diffusion of the injected local anesthetic through the connective tissues and toward the spinal nerve roots.[8] A more recent study described the transforaminal and epidural spread of the local anesthetic during erector spinae plane block using magnetic resonance imaging (MRI). The authors noted that the erector spinae plane block may be advantageous to other thoracic interfascial plane blocks due to this spread and the resultant abdominal visceral analgesia.[9]

Indications

The erector spinae plane block can be used to deliver regional analgesia for a wide range of surgical procedures in the anterior, posterior, and lateral thoracic and abdominal areas, as well as for managing acute and chronic pain syndromes. The vast majority of indications for erector spinae plane block have their basis in case reports and anecdotal clinical experience.

Contraindications

Infection at the site of injection in the paraspinal region or patient refusal are absolute contraindications for performing an erector spinae plane block.

Anticoagulation may be a relative contraindication to erector spinae plane block, although there are no specific guidelines. The 2018 ASRA consensus statement does not explicitly address paraspinal blocks or anticoagulation.

Equipment

Equipment involved when performing erector spinae plane blocks includes:

• Chlorhexidine gluconate
• Sterile gloves, mask, and hair cover
• Convex or curvilinear ultrasound probe with sterile probe cover and gel
• Standard epidural catheter tray with a 3-mL syringe with lidocaine 1% on a 25-gauge needle, an 18-gauge Tuohy needle, and an epidural catheter in the case of continuous infusion
• Erector spinae plane block local anesthetic solution (0.25% bupivacaine or 0.5% ropivacaine, 20 to 30 mL)

Personnel

An anesthesiologist with experience in regional anesthesia is preferable when performing an erector spinae plane block. An additional clinician, such as a nurse or physician, should be available to assist.

Preparation

Before performing an erector spinae plane block, obtain informed consent, including the risks and benefits of the procedure. A periprocedural “timeout” should also be performed to confirm the type of procedure, side, and location, and ensure that no contraindications are identified.

Standard patient monitoring should be in place, including continuous electrocardiogram (ECG) monitoring, pulse oximetry, and blood pressure measurements at least every 5 minutes. Intravenous access should be obtained, and resuscitation equipment, including vasopressors/medications for local anesthetic toxicity and intubating equipment, should be nearby.

Patients should undergo prepping with chlorhexidine gluconate, and sterile conditions should be maintained throughout the procedure. Sterile gloves, surgical caps, and masks are necessary. The ultrasound probe should be placed in a sterile ultrasound probe cover for imaging.

Technique or Treatment

Anatomical Landmarks

The erector spinae plane block is most often performed between the T5 and T7 paraspinal levels, but it can also be performed at lower levels. The curvilinear ultrasound transducer should be placed in a cephalocaudal orientation over the midline of the back at the desired level. The probe should then be slowly moved laterally until the transverse process is visible. The transverse process needs to be differentiated from the rib at that level. The transverse process will be more superficial and wider, while the rib will be deeper and thinner. Upon verification of the transverse process, the trapezius muscle, rhomboid major muscle (if performing at T5 level or higher), and erector spinae muscle should be identified superficial to the transverse process.

Erector Spinae Plane Block Technique

The Tuohy needle should be inserted superior to the ultrasound probe, using an in-plane approach, in a cephalad-to-caudal direction. The bevel of the Tuohy needle should point posteriorly and inferiorly and advance under ultrasound guidance through the trapezius muscle, rhomboid major muscle, and erector spinae muscle and towards the transverse process; once the needle tip is below the erector spinae muscle, a small bolus of local anesthetic should be given through the Tuohy needle. The erector spinae muscle should be visualized as it separates from the transverse process. This separation from the transverse process confirms the proper needle position.

The local anesthetic should then be injected in 5-mL increments, with aspiration after every 5 mL to prevent intravascular injection. Between 20 and 30 mL of 0.25% bupivacaine or 0.5% ropivacaine should be used. After injecting 10 to 20 mL of the local anesthetic solution, the catheter can be easily threaded into that space. Threading 5 to 7 cm of the catheter into the space is prudent to avoid inadvertent dislodgement of the catheter. The last 10 to 20 cc can then be injected through the catheter after confirming that the catheter is not intravascular. The ultrasound probe can be moved caudally during injection into the catheter, and often, the local anesthetic can be seen spreading caudally from the catheter.

Complications

Complications are very rare because the site of injection is far from the pleura, major blood vessels, and the spinal cord. Infection at the needle insertion site, local anesthetic toxicity/allergy, vascular puncture, pleural puncture, pneumothorax, and failed block are the primary complications. Due to the limited published data, more investigations (eg, randomized controlled trials, RCTs) are needed to verify the safety, complication rates, and efficacy of this strategy. 

Clinical Significance

The erector spinae plane block has emerged as a clinically significant regional anesthetic technique due to its broad dermatomal coverage, favorable safety profile, and technical simplicity. It can provide effective analgesia for thoracic, abdominal, and some lower extremity procedures, making it a versatile option in perioperative pain management.[10][11] While much of the early data on erector spinae plane originated from case reports and anecdotal experience, an expanding body of randomized controlled trials now supports its role in improving surgical outcomes. For example, in patients undergoing laparoscopic colon cancer surgery, bilateral erector spinae plane blocks were shown to significantly lower pain scores, reduce intraoperative neuromuscular blocker requirements, promote earlier ambulation and oral intake, and shorten hospital length of stay.[12] In cardiac surgery, erector spinae plane block was found to be superior to intravenous dexmedetomidine in off-pump coronary artery bypass grafting, reducing both pain scores and opioid consumption, prolonging time to first rescue analgesia, and shortening ICU stay.[13]

Comparative studies further underscore the clinical value of erector spinae plane block across diverse surgical settings. Although the Pecs II block was found to provide better analgesia and lower opioid requirements than erector spinae plane block in breast cancer surgery [14], erector spinae plane remains a less invasive and technically simpler alternative in many thoracic procedures. When compared with paravertebral blocks in patients undergoing percutaneous nephrolithotomy, erector spinae plane blocks offered equivalent analgesia but were significantly faster and easier to perform, making them a practical option, especially in resource-constrained or high-throughput environments.[15] 

Similarly, the erector spinae plane block demonstrated superior performance over the intercostal nerve block in patients undergoing minithoracotomy, resulting in lower remifentanil use, fewer analgesic requests, higher patient satisfaction, and better preservation of respiratory muscle strength.[16] Additionally, in thoracotomy patients, erector spinae plane block achieved analgesic efficacy comparable to thoracic epidural analgesia (TEA), while offering greater hemodynamic stability and requiring less opioid supplementation than the serratus anterior plane block. This positioning makes the erector spinae plane a valuable alternative for patients in whom TEA may be contraindicated.[17]

Enhancing Healthcare Team Outcomes

Effective implementation of erector spinae plane blocks relies on the coordinated efforts of an interprofessional healthcare team. Anesthesiologists, anesthesiology residents, and nurse anesthetists typically perform the block in the preoperative holding area, requiring technical skill and familiarity with the procedure’s indications and safety protocols. Perioperative nurses support this process by assisting with patient positioning, conducting the pre-procedure timeout, and continuously monitoring the patient’s vital signs. Accurate verification of the procedure, laterality, and any patient-specific contraindications is essential. The use of sterile technique, along with the availability of resuscitation equipment, is critical to patient safety. Throughout the block, a nurse must remain attentive to the patient’s hemodynamic and respiratory status, ready to intervene should complications arise.

Pharmacists also play a key role by preparing and verifying the appropriate anesthetic agents, ensuring proper dosing, and checking for potential drug interactions. Postoperatively, nurses are responsible for ongoing assessment and care, especially when erector spinae plane block catheters are used for continuous infusion. These catheters, which may resemble epidural lines, require clear labeling and staff education to prevent misidentification and ensure accurate administration. Nurses must be trained to recognize and respond to complications such as local anesthetic systemic toxicity, bleeding, or pneumothorax. Interprofessional communication among all team members—physicians, advanced practitioners, nurses, and pharmacists—is vital to ensuring safe, efficient, and patient-centered care. Through collaboration and shared responsibility, the healthcare team can enhance outcomes, reduce opioid use, and improve overall team performance and patient satisfaction.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses play a vital role in preoperative preparation, block placement, and postoperative management of the catheter. Before placing the block, the nurse should participate in the timeout procedure, which includes verifying the procedure, the side of the procedure, patient allergies, and potential contraindications. During the actual procedure, the nurse should be monitoring the patient’s level of sedation and vital signs. The nurse can also help with patient positioning during the procedure. Post-operatively, the nurse will monitor the analgesia provided by the catheter, as well as watch for potential complications, including bleeding, local anesthetic toxicity, and pneumothorax.

Nursing, Allied Health, and Interprofessional Team Monitoring

The preoperative nurse will monitor the patient during the placement of the erector spinae plane block. Continuous ECG, pulse oximetry, and blood pressure (measured at least every 5 minutes) must be monitored throughout the entire periprocedural period. If sedation is used for the procedure, the preoperative nurse can also help monitor the patient's level of consciousness and breathing. Postoperatively, the post-anesthesia care unit nurse will continue to monitor the patient with continuous ECG, pulse oximetry, and blood pressure (at least every 5 minutes), and also track the patient's postoperative pain scores. If pain is severe, the anesthesiologist can bolus the catheter (if the catheter is placed) with the local anesthetic solution as needed, or the decision can be made to give intravenous medications to manage postoperative pain.