Erector Spinae Plane Block
The erector spinae consists of a group of muscles and tendons which run the length of the spine just lateral to the vertebral column bilaterally. At the T5 level (midscapula) the erector spinae can be found immediately superficial to the transverse process of the spine. The rhomboid and trapezius muscles are found superficial to the erector spinae muscle at the same level. The paravertebral space and pleura is located between and deep to the transverse processes. Analgesia for the ESP block occurs form the diffusion of local anesthesia anteriorly to the ventral and dorsal rami of the spinal nerves.
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The erector spinae plane block is performed with the patient in the sitting position. The ultrasound probe is placed in the cranial caudal orientation. The transverse process should be identified at the T5 level (midscapula). Lateral to the transverse process the ribs may be identified as rounded hyperechoic structures by ultrasound. The rib may be followed medially giving rise to the transverse process which is identified as a square hyperechoic structure. The erector spinae, rhomboid and trapezius muscles are identified superficial to the transverse process respectively. The block needle is inserted using the in plane cranial to caudad approach. The transverse process may be used as a target for the block needle to minimized the chance of entering the paravertebral space which would increase chances for a pneumothorax. After the block needle meets the transverse process the needle may be withdrawn slightly to allow injection of 20-40ml of local anesthetic just deep to the erector spinae.. The local anesthetic will spread in the cranial caudal directions allowing for coverage of multiple dermatomes of the back and chest.