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Erector Spinae Plane Block:

Has the Growth Outpaced the Evidence?
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JEFFREY J. MOJICA, DO
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ERIC S. SCHWENK, MD, FASA

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Sidney Kimmel Medical College

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Thomas Jefferson University Hospital

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Philadelphia
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Member, Anesthesiology News Editorial Advisory Board

(Schwenk)
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The authors reported no relevant financial disclosures.

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F
ew regional anesthesia procedures
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have exploded onto the scene

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with as much enthusiasm as the

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erector spinae plane block.

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Images of ESP blockk at the T5 level courtesy of Jeff Gadsden, MD

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Introduction and Anatomic Studies

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The original report described the ESP block as an

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In 2016, Forero et al1 described a novel regional injection 3 cm lateral to the T5 transverse process
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anesthesia technique that provided satisfactory anal- between the erector spinae muscles and rhomboid
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gesia in two patients with rib pain. At that time, it was major muscle that resulted in anterior displacement
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proposed as a “simple and safe technique for thoracic of the erector spinae muscles. Forero et al found that
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analgesia,” and was dubbed the erector spinae plane cutaneous sensory loss occurred several dermatomes
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(ESP) block. Since then, the popularity of this interfas- above and below the T5 level.1
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cial plane block has exploded, and it has been used for In subsequent studies, however, the ESP block tech-
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a wide variety of clinical indications, from shoulder sur- nique involved the injection of dye or local anesthetic into
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gery2 to hip surgery.3 The wide variety of the block’s
applications (Table) is discussed in this article. Indeed,
a PubMed search using the term “erector spinae plane
block” with no limitations returned 717 articles as of
May 17, 2021, almost all of which were published after
the initial description in 2016.
But do we understand how this block produces anal-
gesia? Are the existing studies consistent in their ana-
tomic findings?
the interfascial plane between the erector spinae muscles
and transverse process (Figure).4,5 Multiple cadaver stud-
ies have investigated the possible mechanisms of action
of this block and have come to different conclusions. In
one of the earliest cadaver studies, Ivanusic et al4 found
that the injection of 20 mL of methylene blue dye at the
T5 transverse process resulted in extensive cephalad, cau-
dad and lateral spread but spared the ventral rami. They
also found that the paravertebral space was not stained.

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 02 1 17
 A cadaver study by Yang et al6 used almost an iden-
tical design, with 20 mL of dye at the T5 level, and
found some paravertebral spread with the ESP injection,
although it was inconsistent, and appeared to result from
spread through the superior costotransverse ligament.
In contrast to the findings of Ivanusic et al, Vidal et
al7 reported that the paravertebral space was stained in
all cadavers they studied, and they found a mean of 4.6
intercostal spaces stained. These results, while inconsis-
tent with those of some others, provide a plausible mech-
anism of analgesia for the ESP block, especially in the
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trials (RCTs) that compared ESP blocks with thoracic
paravertebral blocks for thoracotomy found that hypo-
tension occurred in 6.7% of the ESP patients compared
with 21.7% of the paravertebral block patients.8 This
finding argues against extensive sympathetic chain
blockade with the ESP block, yet analgesia was com-
parable in the two groups.
What is the explanation for these apparently incon-
sistent findings? Despite the consistent use of 20 mL
of dye in all the studies, the injection pressures were
not measured, which could perhaps contribute to the

settings of thoracic and abdominal analgesia that would divergence in results. Injection pressure is not rou-
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involve the ventral rami of the thoracic spinal nerves. tinely measured by most anesthesiologists and would
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Adhikary et al5 also found epidural spread of dye in necessitate a pressure monitor. In addition, cadaver tis-
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three cadavers. Their study went a step further by con- sues and compartments may be affected by embalm-
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firming the dye spread with MRI. Their results suggested ing techniques, and it has been noted that there is no
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that hypotension via sympathetic chain blockade might international standard when it comes to classifying and
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be a concern, yet one of the few randomized controlled describing embalming techniques.9
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Table. Published Applications of the Erector Spinae Plane Block

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Application Highest Level of Evidence Selected References

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Thoracotomy RCT Fang et al8

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Rib fractures Retrospective study Riley et al16

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Adhikary et al17
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Cardiac surgery RCT Krishna et al23

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Video-assisted thoracoscopic surgery RCT Ciftci et al36

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Yao et al37
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Taketa et al38
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Visceral analgesia Case reports Chin et al49

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Mantuani et al51
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Mantuani et al52
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Diwan and Nair53

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Bariatric surgery RCT Mostafa et al54

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Headache disorders Case reports De Haan et al61

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Hernandez et al62
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Modified radical mastectomy RCT Yao et al70

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El Ghamry and Amer71

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Hepatectomy RCT Fu et al72

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Elective lumbar spine surgery RCT Singh et al73

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Yayik et al74
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Hysterectomy RCT Kamel et al75

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Shoulder surgery Case series Diwan and Nair76

Selvi et al77

Chronic low back pain Case series Morais and Martins78

Pelvic and sacral fracture Case report Kilicaslan et al79

RCT, randomized controlled trial

18 A N E ST H E S I O LO GY N E WS .CO M
 However, the most significant question is how these
inconsistent cadaver findings translate to ESP blocks
performed in actual patients. The following sections
discuss the evidence for ESP blocks in multiple clini-
cal settings and surgical procedures, followed by a
summary and thoughts on the future of the ESP block,
including questions for future studies.
Rib Fractures
In the original article by Forero et al,1 the authors
described how a patient with a seven-year history of
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the ESP block has emerged as an alternative regional
anesthetic in this patient population.
The reported success of the ESP block has altered
institutional practices, and some have labeled it the
preferred first-line regional anesthetic technique for rib
fractures.13,14 However, as discussed below, the overall
quality of evidence in rib fractures is weak, and con-
sists mostly of case reports,10,11 a case series15 and sin-
gle-institution retrospective studies.16,17 In contrast, both
TEA and TPVB are supported by RCTs in patients with
rib fractures.18,19

neuropathic pain related to multilevel rib fractures ben- In a large retrospective study of patients with rib
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efited from an ESP block performed at the T5 trans- fractures, variables such as incentive spirometry vol-
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verse process. Since then, several other case reports ume, maximum numerical rating scale pain scores and
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have been published with similar findings for acute rib opioid consumption were compared at various time
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fractures.10,11 points before and after receiving an ESP block.17 A

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Advocates of the technique have argued that the ESP total of 79 patients received either a single-injection
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block is technically easier to perform and safer than (n=18) or continuous ESP block (n=61). Once patients
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traditional techniques such as thoracic epidural anal- received an ESP block, a mean improvement of 545 mL
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gesia (TEA) and thoracic paravertebral block (TPVB).1,12 on incentive spirometry volumes and a reduction in
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Complications and adverse effects associated with TEA, maximum pain scores during the first 24 hours were
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including hypotension, spinal cord injury and epidural observed when compared with their pre-block values.
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hematoma, can theoretically be avoided with an ESP A subgroup analysis found that these benefits were
block. Pneumothorax, which is the most feared compli- present in the continuous block group but not in the
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cation of a TPVB, is unlikely with an ESP block because single-injection group. Opioid consumption was similar
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the transverse process represents a bony backstop before and after ESP blockade. No block-related com-
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that protects against excessive needle advancement plications, including reductions in mean arterial pres-
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and inadvertent pleural puncture. Furthermore, contra- sure, were reported.17

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indications unique to trauma patients, such as hemo- In another retrospective study of patients with rib
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dynamic instability, intracranial bleeding, coagulopathy fractures, the authors compared opioid consumption in
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and the need for ongoing anticoagulation, also may a cohort of patients that received an ESP block (n=33)
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preclude placement of TEA or TPVB. For these reasons, with a matched cohort with comparable demographics
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Figure. Ultrasound images of erector spinae plane block with and without labels.
ESM, erector spinae muscle; TP, transverse process; TPVS, thoracic paravertebral space
Image courtesy of the authors.

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 02 1 19
and characteristics (n=33) who did not.16 Patients in the
ESP group consumed less oral morphine (35.5±30.0 mg)
compared with the control group (60.8±52.6 mg).16
Overall, the limited body of evidence suggests that
the ESP block may be an effective modality to treat
pain from rib fractures. In the authors’ opinion, the ESP
block should be considered for unilateral fractures or
when contraindications to TEA or TPVB exist.
Cardiac Surgery
Poorly controlled pain after cardiac surgery increases
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morbidity and mortality.20 TEA has been extensively
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studied in cardiac surgery; its potential benefits include
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reduction in postoperative cardiac arrhythmias, pain and
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time to extubation.20 However, these benefits must be
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weighed against the risk for epidural hematoma forma-
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tion in a fully anticoagulated patient. While newer para-
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sternal plane blocks, such as the pecto-intercostal fascial
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plane block and transverse thoracic plane block, avoid
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the risk for epidural hematoma formation, injury to the
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internal thoracic artery (also known as the internal mam-
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mary artery) is possible.21 If these blocks are performed
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before cardiac surgery, damage to the internal thoracic
artery could make it unusable for bypass grafting.21 Fur-
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thermore, although there are reports of parasternal cath-
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eters,22 it is conceivable that cardiothoracic surgeons
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may want to avoid them due to their infectious potential
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and proximity to the surgical incision. Theoretically, the
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ESP block would circumvent these concerns and may
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represent a safer alternative for cardiac surgery.
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One of the first RCTs to evaluate ESP blocks in cardiac
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surgery compared single-injection, bilateral ESP blocks
using 3 mg/kg of 0.375% ropivacaine before induction
of anesthesia and postoperative IV analgesia with 1 g
of paracetamol every six hours and 50 mg of tramadol
every eight hours.23 The times to extubation, ambula-
tion and oral intake as well as total time in the ICU were
reduced in patients receiving bilateral ESP blocks. Total
opioid consumption and total rescue analgesia were also
reduced without any reported complications.23
The most recent American Society of Regional
Anesthesia and Pain Medicine guidelines for regional
anesthesia in patients receiving antithrombotic or
thrombolytic therapy do not directly address the ESP
block.24 However, the relatively superficial location of
the ESP block relative to the intercostal arteries and
epidural vessels as well as other blood vessels provides
some degree of reassurance that devastating hema-
tomas would be unlikely. One small case series of five
patients with altered coagulation reported no bleed-
ing events after five days of close monitoring after ESP
block placement.25 Another case series of five patients
who underwent therapeutic anticoagulation after left
ventricular assist device surgery via a thoracotomy
incision detected no bleeding complications.26 How-
ever, more data are needed before making any defin-
itive statements regarding the safety of the ESP block
in the setting of altered coagulation.
20 A N E ST H E S I O LO GY N E WS .CO M
Thoracic Surgery
Acute post-thoracotomy pain can often be severe.
Aggressive pain management strategies with either
TEA and TPVB are often incorporated into multimodal
analgesic regimens.27 However, the incidence of tech-
nical block failure has been reported to be as high as
32%28 and 10%18 for TEA and TPVB, respectively. In the
case of a failed TEA, Forero et al demonstrated that
an ESP block with 25 mL of 0.5% ropivacaine success-
fully reduced severe acute post-thoracotomy pain from
a pain score of 10/10 to 0/10 within 15 minutes of block
completion.29 Thus, in cases of technical failure with
either TEA or TPVB, the ESP block could be an effec-
tive rescue analgesic.
While TEA and TPVB are considered to be first-line
analgesics for thoracotomy,30 there is no consensus for
the treatment of acute postoperative pain after video-
assisted thoracoscopic surgery (VATS).31 Many tho-
racic surgeons and anesthesiologists consider TEA and
TPVB too invasive for a minimally invasive surgery like
VATS.32,33 Yet, the incidence of persistent postsurgical
pain (PPP) is similar for thoracotomy and VATS proce-
dures,34,35 suggesting there is room for improvement in
postoperative analgesia.
Existing evidence suggests that the ESP block might
be a safe and effective therapy for postoperative pain
after VATS, although most reports have very limited
numbers and were underpowered for most safety out-
comes.36,37 Two RCTs have demonstrated that the ESP
block produced superior analgesia, less opioid con-
sumption and improved patient satisfaction compared
with opioids alone.36,37
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Taketa et al randomized 88 patients to receive a con-
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tinuous infusion of 0.2% levobupivacaine (8 mL per
hour) via either a TPVB or an ESP catheter.38 The study
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concluded that the ESP block provided noninferior
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analgesia to TPVB at 24 hours postoperatively. Both
groups of patients consumed comparable amounts of
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rescue opioids.38
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Breast Cancer Surgery
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PPP is estimated to affect 25% to 60% of patients
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undergoing breast cancer surgery.39 Of these patients,
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an estimated 10% continued to consume opioids three
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months postoperatively.40 Clinical studies indicate that
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attenuation of acute postoperative pain may decrease
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the progression from acute to chronic PPP.41-43 Some
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studies have found that TPVB may reduce PPP, but a
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large multicenter RCT did not find a reduction in PPP
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incidence after breast cancer surgery with TPVB.44,45
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The innervation to the breast is complex and involves
several branches of the C5-T7 spinal nerves.46 Given the
uncertain mechanism by which the ESP block provides
analgesia and the inconsistent spread of local anes-
thetic to the ventral branches of the intercostal nerves
and paravertebral space,4,5,7 it is unlikely that the ESP
block alone could provide adequate analgesia for most
breast surgeries.
 The role of the ESP block was analyzed in two sepa-
rate systematic reviews and meta-analyses. In their anal-
yses, both Leong et al and Hussain et al concluded that
patients receiving an ESP block experienced less pain
and consumed fewer opioids than those who received
systemic analgesia alone in breast surgery.47,48 However,
Hussain et al argued that the reduction in pain and the
opioid-sparing effect, which translates into two 5-mg
tablets of oxycodone over 24 hours, was not clinically
meaningful.47 Yet, in the same review, the authors found
high-quality evidence that the ESP block reduced opi-
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surgery.66,67 The lumbar ESP block has been used as the
primary anesthetic for high-risk older patients undergo-
ing surgical repair of a hip fracture68 and as an analgesic
adjunct for elective hip replacement surgery.69 These
investigations, however, are very preliminary and plau-
sible mechanistic details are lacking.
Future Directions and Conclusions
Few regional anesthesia procedures have exploded
onto the scene with as much enthusiasm as the ESP
block. The large variety of clinical applications in which

oid-related adverse effects, such as postoperative nau-

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the block has been used demonstrates the clinical need

sea and vomiting.47 Given the uncertain benefits, it is
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for effective and safe techniques that avoid some of

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evident that additional studies are necessary to eluci-

the complications and side effects of traditional tech-
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date the role of the ESP block in breast surgery.

niques, such as epidural analgesia. However, we do not
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believe the time has come to abandon the epidural. The

Abdominal Surgery
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evidence basis for the ESP block is weak at this point.

Chin et al reported visceral abdominal analgesia with
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While a few randomized studies exist in settings such

an ESP block in a series of three patients undergoing
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as cardiac anesthesia and thoracic anesthesia, most

bariatric surgery.49 The authors hypothesized that local
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reports consist of limited numbers of patients and lack

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anesthetic can anesthetize the visceral sympathetic

comparisons with well-established techniques like TEA
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fibers of the rami communicantes by spreading into the

and TPVB. Chin and El-Boghdadly discussed the vari-
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thoracic paravertebral space.49 As discussed previously,

able findings in a recent review of the ESP block and
cadaver studies have inconsistently demonstrated dye
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suggested that block failure and imprecise cutaneous

spread into the paravertebral space, making the mecha-
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sensory testing could explain the lack of consistent loss

nism of visceral analgesia unclear.50 Nevertheless, relief
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of cutaneous sensation that is observed despite ade-

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of visceral pain also has been reported in patients with

quate analgesia in some patients.50 While thought-pro-
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appendicitis,51 pancreatitis52 and lung cancer.53

voking, these explanations require additional study.
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In the only RCT that evaluated the role of ESP block

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in bariatric patients, a total of 60 patients were ran- The inconsistent blockade of ventral roots of spinal
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domized to receive either a bilateral T7 ESP block with nerves and the paravertebral space observed in cadaver
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studies make conclusions difficult to reach. Alternative

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20 mL of 0.25% bupivacaine or saline.54 Reductions in

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visual analog pain scores and opioid consumption were mechanisms, such as systemic local anesthetic effects
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or epidural spread of local anesthetic, have been pos-

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found in the ESP block group. There was no effect on

tulated but are not supported by all studies.50 Future
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pulmonary function and gastrointestinal or genitouri-

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nary outcomes, such as time to first bowel movement, studies should focus on comparing the ESP block with
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flatus or urinary retention.54 TEA and TPVB and include relevant complications and
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The ESP block also has been reported to benefit side effects. Precise measurement of sensory changes
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patients undergoing other types of major abdominal will add to our knowledge base. Purported safety ben-
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surgeries, including open hysterectomy,55 ventral hernia efits, such as a lower risk for hematoma and decreased
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repair56 and hepatopancreaticobiliary surgery,57 but evi- risk for local anesthetic systemic toxicity, remain specu-
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dence quality is low and consists mostly of case reports lative and are mostly based on very limited uncontrolled
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and a small case series. studies that are underpowered for these outcomes. Pro-
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spective study of these complications would provide

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Miscellaneous Applications the anesthesiology community with greater confidence

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Cervical58 and lumbar59 adaptations of the thoracic that the ESP block is indeed safer than the alternatives.
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ESP block also have been explored. The evidence for The ESP block is a promising option that appears to
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these applications is once again very limited. The ESP be fairly simple to perform, and has been suggested
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block has been performed for relief of chronic shoulder to provide good analgesia for a wide variety of tho-
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pain,60 postdural puncture headaches61 and other head- racic and abdominal procedures as well as nonsurgical
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ache disorders.62 The ESP block has been suggested to
provide analgesia for spine surgery, including for the
cervical63 and lumbosacral regions.64,65 The cervical
ESP block has been explored as a phrenic nerve–spar-
ing alternative to the interscalene block for shoulder
painful states. Caution should be exercised to not over-
state the evidence of safety of the ESP block until addi-
tional studies have been performed. As of today, the
growth and popularity of the ESP block have outpaced
the evidence.

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 02 1 21
References
1. Forero M, Adhikary SD, Lopez H, et al. The erector spinae plane
block: a novel analgesic technique in thoracic neuropathic pain.
Reg Anesth Pain Med. 2016;41(5):621-627.
2. Forero M, Rajarathinam M, Adhikary SD, et al. Erector spinae
plane block for the management of chronic shoulder pain: a case
report. Can J Anaesth. 2018;65(3):288-293.
3. Tulgar S, Selvi O, Senturk O, et al. Clinical experiences of ultra-
sound-guided lumbar erector spinae plane block for hip joint and
proximal femur surgeries. J Clin Anesth. 2018;47:5-6.
4. Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investi-
A
18. Karmakar MK. Thoracic paravertebral block. Anesthesiology.
2001;95(3):771-780.
19. Manion SC, Brennan TJ. Thoracic epidural analgesia and acute
pain management. Anesthesiology. 2011;115(1):181-188.
20. Mazzeffi M, Khelemsky Y. Poststernotomy pain: a clinical review.
J Cardiothorac Vasc Anesth. 2011;25(6):1163-1178.
21. Sepolvere G, Tognù A, Tedesco M, et al. Avoiding the internal
mammary artery during parasternal blocks: ultrasound identifi-
cation and technique considerations. J Cardiothorac Vasc Anesth.
2021;35(6):1594-1602.

gating the mechanism of action of erector spinae blockade. Reg

ll

Anesth Pain Med. 2018;43(6):567-571. 22. Ueshima H, Otake H. Continuous transversus thoracic muscle
rig

Co

plane block is effective for the median sternotomy. J Clin Anesth.

2017;37:174.
ht

5. Adhikary SD, Bernard S, Lopez H, et al. Erector spinae plane block

py

versus retrolaminar block: a magnetic resonance imaging and

s

rig ed.

anatomical study. Reg Anesth Pain Med. 2018;43(7):756-762. 23. Krishna SN, Chauhan S, Bhoi D, et al. Bilateral erector spinae plane
re

block for acute post-surgical pain in adult cardiac surgical patients:

ht
se

6. Yang HM, Choi YJ, Kwon HJ, et al. Comparison of injectate spread a randomized controlled trial. J Cardiothorac Vasc Anesth. 2019;
rv

33(2):368-375.
©

and nerve involvement between retrolaminar and erector spinae

plane blocks in the thoracic region: a cadaveric study. Anaesthe-
20

24. Horlocker TT, Vandermeuelen E, Kopp SL, et al. Regional anes-

sia. 2018;73(10):1244-1250.
thesia in the patient receiving antithrombotic or thrombolytic
21
Re

7. Vidal E, Gimenez H, Forero M, et al. Erector spinae plane block: therapy: American Society of Regional Anesthesia and Pain Med-
M
pr

A cadaver study to determine its mechanism of action. Rev Esp icine evidence-based guidelines (fourth edition). Reg Anesth Pain
Med. 2018;43(3):263-309.
cM
od

Anestesiol Reanim. (Engl Ed). 2018;65(9):514-519.

uc

ah in w

8. Fang B, Wang Z, Huang X. Ultrasound-guided preoperative 25. Galacho J, Veiga M, Ormonde L. Erector spinae plane block and
altered hemostasis: is it a safe option? - a case series. Korean J
tio

single-dose erector spinae plane block provides comparable anal-

on

gesia to thoracic paravertebral block following thoracotomy: a Anesthesiol. 2020;73(5):445-449.

n

single center randomized controlled double-blind study.

Pu

26. Adhikary SD, Prasad A, Soleimani B, et al. Continuous erector spi-

Ann Transl Med. 2019;7(8):174.
nae plane block as an effective analgesic option in anticoagulated
bl

patients after left ventricular assist device implantation: a case

is

9. Balta JY, Cronin M, Cryan JF, et al. Human preservation tech-

ho

series. J Cardiothorac Vasc Anesth. 2019;33(4):1063-1067.

hi

niques in anatomy: A 21st century medical education perspective.

ng
le

Clin Anat. 2015;28(6):725-734.

27. Soto RG, Fu ES. Acute pain management for patients undergoing
or

thoracotomy. Ann Thorac Surg. 2003;75(4):1349-1357.

G

10. Hamilton DL, Manickam B. Erector spinae plane block for pain
ro

relief in rib fractures. Br J Anaesth. 2017;118(3):474-475.

in

28. Hermanides J, Hollmann MW, Stevens MF, et al. Failed epidural:

up

causes and management. Br J Anaesth. 2012;109(2):144-154.

pa

11. Nandhakumar A, Nair A, Bharath VK, et al. Erector spinae plane

block may aid weaning from mechanical ventilation in patients
un ou
rt

29. Forero M, Rajarathinam M, Adhikary S, et al. Continuous erector

with multiple rib fractures: Case report of two cases. Indian J
spinae plane block for rescue analgesia in thoracotomy after epi-
w

le

Anaesth. 2018;62(2):139-141.
dural failure: a case report. A A Case Rep. 2017;8(10):254-256.
ith

ss

12. How I Do It: Erector Spinae Block for Rib Fractures: The Penn
ot

30. Yeung JH, Gates S, Naidu BV, et al. Paravertebral block versus tho-
State Health Experience. ASRA Newsletter: American Soci- racic epidural for patients undergoing thoracotomy. Cochrane
he
tp

ety of Regional Anesthesia and Pain Medicine. Accessed May Database Syst Rev. 2016; doi: 10.1002/14651858.cd009121.pub2.
2021.https://www.asra.com/news-publications/asra-newsletter/
rw
er

newsletter-item/asra-news/2020/05/01/how-i-do-it-erector-spi- 31. Yan TD, Cao C, D’Amico TA, et al. Video-assisted thoracoscopic
is
m

nae-block-for-rib-fractures-the-penn-state-health-experience surgery lobectomy at 20 years: a consensus statement. Eur J Car-

e
is

diothorac Surg. 2014;45(4):633-639.

no
si

13. Adhikary SD, Liu WM, Fuller E, et al. The effect of erector spinae
on

plane block on respiratory and analgesic outcomes in multiple rib 32. Kamiyoshihara M, Nagashima T, Ibe T, et al. Is epidural analgesia
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fractures: a retrospective cohort study. Anaesthesia. 2019;74(5): necessary after video-assisted thoracoscopic lobectomy? Asian
d.
is

585-593. Cardiovasc Thorac Ann. 2010;18(5):464-468.

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14. Eng HC, Chin KJ, Adhikary S. How I Do It: Erector Spinae Block 33. Rawal N. Epidural technique for postoperative pain: gold standard
oh

for Rib Fractures. Accessed May 2021. https://www.asra.com/ no more? Reg Anesth Pain Med. 2012;37(3):310-317.
ib

news-publications/asra-newsletter/newsletter-item/asra-news/
2020/05/01/how-i-do-it-erector-spinae-block-for-rib-fractures 34. Bayman EO, Parekh KR, Keech J, et al. A prospective study of
ite

chronic pain after thoracic surgery. Anesthesiology. 2017;126(5):

d.

15. Beh ZY, Lim SM, Lim WL, et al. Erector spinae plane block as anal-
gesic adjunct for traumatic rib fractures in intensive care unit.
Indian J Anaesth. 2020;64(12):1086-1089.
16. Riley B, Malla U, Snels N, et al. Erector spinae blocks for the man-
agement of rib fractures: A pilot matched study. J Clin Anesth.
2020;63:109780.
17. Adhikary SD, Liu WM, Fuller E, et al. The effect of erector spinae
plane block on respiratory and analgesic outcomes in multiple rib
fractures: a retrospective cohort study. Anaesthesia. 2019;74(5):
585-593.
938-951.
35. Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Prevalence of
chronic pain after pulmonary resection by thoracotomy or video-
assisted thoracic surgery. J Thorac Cardiovasc Surg. 1994;107(4):
1079-1085; discussion 1085-1086.
36. Ciftci B, Ekinci M, Celik EC, et al. Efficacy of an ultrasound-
guided erector spinae plane block for postoperative analgesia
management after video-assisted thoracic surgery: a prospec-
tive randomized study. J Cardiothorac Vasc Anesth. 2020;34(2):
444-449.

22 A N E ST H E S I O LO GY N E WS .CO M
37. Yao Y, Fu S, Dai S, et al. Impact of ultrasound-guided erector 54. Mostafa SF, Abdelghany MS, Abu Elyazed MM. Ultrasound-guided
spinae plane block on postoperative quality of recovery in video- erector spinae plane block in patients undergoing laparoscopic
assisted thoracic surgery: A prospective, randomized, controlled bariatric surgery: a prospective randomized controlled trial. Pain
trial. J Clin Anesth. 2020;63:109783. Practice 2021;21(4):445-453.

38. Taketa Y, Irisawa Y, Fujitani T. Comparison of ultrasound-guided
erector spinae plane block and thoracic paravertebral block for
postoperative analgesia after video-assisted thoracic surgery: a
randomized controlled non-inferiority clinical trial. Reg Anesth
Pain Med. 2019. doi:10.1136/rapm-2019-100827.
39. Gärtner R, Jensen M-B, Nielsen J, et al. Prevalence of and factors
associated with persistent pain following breast cancer surgery.
JAMA. 2009;302(18):1985-1992.
A
ll
55. Altinpulluk EY, Ozdilek A, Colakoglu N, et al. Bilateral postop-
erative ultrasound-guided erector spinae plane block in open
abdominal hysterectomy: a case series and cadaveric investiga-
tion. Rom J Anaesth Intensive Care. 2019;26(1):83-88.
56. Chin KJ, Adhikary S, Sarwani N, et al. The analgesic efficacy
of pre-operative bilateral erector spinae plane (ESP) blocks in
patients having ventral hernia repair. Anaesthesia. 2017;72(4):
452-460.

40. Marcusa DP, Mann RA, Cron DC, et al. Prescription opioid use 57. Nair S, Mcguinness S, Masood F, et al. Erector spinae plane
rig

Co

among opioid-naive women undergoing immediate breast recon- blocks in major hepatopancreaticobiliary surgery: a case series.
struction. Plast Reconstr Surg. 2017;140(6):1081-1090. A A Pract. 2019;13(9):332-334.
ht

py
s

rig ed.

41. Richebe P, Capdevila X, Rivat C. Persistent postsurgical pain: 58. Elsharkawy H, Ince I, Hamadnalla H, et al. Cervical erector spinae
re

pathophysiology and preventative pharmacologic considerations. plane block: a cadaver study. Reg Anesth Pain Med. 2020;45(7):
ht
se

Anesthesiology. 2018;129(3):590-607. 552-556.

rv

42. Ilfeld BM, Madison SJ, Suresh PJ, et al. Treatment of postmas- 59. Harbell MW, Seamans DP, Koyyalamudi V, et al. Evaluating the
20

tectomy pain with ambulatory continuous paravertebral nerve extent of lumbar erector spinae plane block: an anatomical study.
21

blocks: a randomized, triple-masked, placebo-controlled study.

Re

Reg Anesth Pain Med. 2020;45(8):640-644.

Reg Anesth Pain Med. 2014;39(2):89-96.
M
pr

60. Forero M, Rajarathinam M, Adhikary SD, et al. Erector spinae

cM

43. Ilfeld BM, Madison SJ, Suresh PJ, et al. Persistent postmastectomy
od

plane block for the management of chronic shoulder pain: a case

pain and pain-related physical and emotional functioning with report. Can J Anaesth. 2018;65(3):288-293.
uc

ah in w

and without a continuous paravertebral nerve block: a prospec-

tio

tive 1-year follow-up assessment of a randomized, triple-masked,

on

61. De Haan JB, Chrisman OM, Lee L, et al. T4 erector spinae plane
placebo-controlled study. Ann Surg Oncol. 2015;22(6):2017-2025. block relieves postdural puncture headache: a case report. Cureus.
n

Pu

2019;11(11):e6237.
44. Kairaluoma PM, Bachmann MS, Rosenberg PH, et al. Preincisional
bl

paravertebral block reduces the prevalence of chronic pain after

62. Hernandez N, Guvernator G, Ansoanuur G, et al. Relief of second-
is

breast surgery. Anesth Analg. 2006;103(3):703-708.

ho

ary headaches with high thoracic erector spinae plane block. Loc
hi

Reg Anesth. 2020;13:49-55.

ng
le

45. Sessler DI, Pei L, Huang Y, et al. Recurrence of breast cancer after
regional or general anaesthesia: a randomised controlled trial.
or

63. Goyal A, Kamath S, Kalgudi P, et al. Perioperative analgesia with

G

Lancet. 2019;394(10211):1807-1815.
erector spinae plane block for cervical spine instrumentation sur-
ro
in

gery. Saudi J Anaesth. 2020;14(2):263-264.

up

46. Woodworth GE, Ivie RMJ, Nelson SM, et al. Perioperative breast
pa

analgesia: a qualitative review of anatomy and regional tech-

64. Melvin JP, Schrot RJ, Chu GM, et al. Low thoracic erector spinae
un ou
rt

niques. Reg Anesth Pain Med. 2017;42(5):609-631.

plane block for perioperative analgesia in lumbosacral spine sur-
w

le

47. Hussain N, Brull R, Noble J, et al. Statistically significant but clin- gery: a case series. Can J Anaesth. 2018;65(9):1057-1065.
ith

ss

ically unimportant: a systematic review and meta-analysis of the

65. Brandao J, Graca R, Sa M, et al. Lumbar erector spinae plane block:
ot

analgesic benefits of erector spinae plane block following breast

cancer surgery. Reg Anesth Pain Med. 2021;46(1):3-12. Successful control of acute pain after lumbar spine surgery - A
he
tp

clinical report. Rev Esp Anestesiol Reanim. (Engl Ed). 2019;66(3):

rw

48. Leong RW, Tan ESJ, Wong SN, et al. Efficacy of erector spinae 167-171.
er

plane block for analgesia in breast surgery: a systematic review

is
m

and meta-analysis. Anaesthesia. 2021;76(3):404-413. 66. Hamadnalla H, Elsharkawy H, Shimada T, et al. Cervical erector
e
is

spinae plane block catheter for shoulder disarticulation surgery.

no
si

49. Chin KJ, Malhas L, Perlas A. The erector spinae plane block pro- Can J Anaesth. 2019;66(9):1129-1131.
on

te

vides visceral abdominal analgesia in bariatric surgery: a report of

67. Ma W, Sun L, Ngai L, et al. Motor-sparing high-thoracic erec-
d.

3 cases. Reg Anesth Pain Med. 2017;42(3):372-376.

is

tor spinae plane block for proximal humerus surgery and total
pr

50. Chin KJ, El-Boghdadly K. Mechanisms of action of the erector spi- shoulder arthroplasty surgery: clinical evidence for differential
oh

nae plane (ESP) block: a narrative review. Can J Anaesth. 2021 peripheral nerve block? Can J Anaesth. 2019;66(10):1274-1275.
;68(3):387-408.
ib

68. Ahiskalioglu A, Tulgar S, Celik M, et al. Lumbar erector spinae

ite

51. Mantuani D, Luftig J, Herring A, et al. A novel technique to reduce plane block as a main anesthetic method for hip surgery in high
risk elderly patients: initial experience with a magnetic resonance
d.

reliance on opioids for analgesia from acute appendicitis: the

ultrasound-guided erector spinae plane block. Clin Pract Cases imaging. Eurasian J Med. 2020;52(1):16-20.
Emerg Med. 2019;3(3):248-251.
69. Abdelnasser A, Zoheir H, Rady A, et al. Effectiveness of ultra-
52. Mantuani D, Josh Luftig PA, Herring A, et al. Successful emer- sound-guided erector spinae plane block for postoperative pain
gency pain control for acute pancreatitis with ultrasound guided control in hip replacement surgeries; A pilot study. J Clin Anesth.
erector spinae plane blocks. Am J Emerg Med. 2020;38(6):1298. 2020;62:109732.
e5-1298.e7.
70. Yao Y, Li H, He Q, et al. Efficacy of ultrasound-guided erector
53. Diwan S, Nair A. Is paravertebral-epidural spread the underlying spinae plane block on postoperative quality of recovery and anal-
mechanism of action of erector spinae plane block? Turk J Anaes- gesia after modified radical mastectomy: randomized controlled
thesiol Reanim. 2020;48(1):86-87. trial. Reg Anesth Pain Med. 2019; doi:10.1136/rapm-2019-100983

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 02 1 23
71. El Ghamry MR, Amer AF. Role of erector spinae plane block ver- 75. Kamel AAF, Amin OAI, Ibrahem MAM. Bilateral ultrasound-guided
sus paravertebral block in pain control after modified radical erector spinae plane block versus transversus abdominis plane
mastectomy. A prospective randomised trial. Indian J Anaesth. block on postoperative analgesia after total abdominal hysterec-
2019;63(12):1008-1014. tomy. Pain Physician. 2020;23(4):375-382.

72. Fu J, Zhang G, Qiu Y. Erector spinae plane block for postoperative
pain and recovery in hepatectomy: A randomized controlled trial.
Medicine (Baltimore). 2020;99(41):e22251.
73. Singh S, Choudhary NK, Lalin D, et al. Bilateral ultrasound-guided
erector spinae plane block for postoperative analgesia in lumbar
spine surgery: a randomized control trial. J Neurosurg Anesthesiol.
2020;32(4):330-334.
A
76. Diwan S, Nair A. Erector spinae plane block for proximal shoul-
der surgery: a phrenic nerve sparing block! Turk J Anaesthesiol
Reanim. 2020;48(4):331-333.
77. Selvi O, Tulgar S, Ozer Z. Case report presentation of ultrasound-
guided erector spinae plane block in shoulder surgery: three
patients and two different results. Cureus. 2018;10(11):e3538.
doi:10.7759/cureus.3538
78. Goncalves Morais I, Barreira Martins A. Erector spinae plane block

for chronic low back pain analgesia: A case series. Rev Esp Anes-
ll

tesiol Reanim (Engl Ed). 2020; doi:10.1016/j.redar.2020.06.018.

rig

Co

74. Yayik AM, Cesur S, Ozturk F, et al. Postoperative analgesic effi-

ht

cacy of the ultrasound-guided erector spinae plane block in 79. Kilicaslan A, Aydin A, Kekec AF, et al. Sacral erector spinae plane
py

patients undergoing lumbar spinal decompression surgery: a ran- block provides effective postoperative analgesia for pelvic and
s

rig ed.

domized controlled study. World Neurosurg. 2019;126:e779-e785. sacral fracture surgery. J Clin Anesth. 2020;61:109674.
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