Erector spinae plane block: New block with great expectations.

The practice of regional anaesthesia is constantly evolving and shifting to minimally invasive techniques that provide maximum safety. Erector spinae plane (ESP) block was first described by Forero et al.[1] for thoracic analgesia but since then it has been used for many different indications where paravertebral block (PVB) and epidural anaesthesia are currently the main regional techniques.[23] There are a few randomized controlled trials but there are many case reports/editorials about its use.[45] However there is still significant work to be done both for finding out the real indications and limits of this promising new method.

In this issue of the Saudi Journal of Anaesthesia, with the case report of De Cassai et al,[6] ESP has been highlighted as a rescue analgesia method. As stated by authors, the exact mechanism of action is not that clear. Forero et al.[1] reported that the local anaesthetic spread involved both the ventral and dorsal rami of spinal nerves while Ueshima and Hiroshi[7] suggested a paravertebral spread. However, very recently published cadaveric study of Ivanusic et al.[8] showed no spread to both paravertebral space and ventral rami. On the other hand, a recently published magnetic resonance imaging and anatomical study has reported epidural and intercostal spread.[9]

Many controversial results as above can be found in the literature. One way or another ESP block has found to be effective in a wide range of indications both in paediatric and adult patients. Especially in paediatrics, quality of analgesia provided by ESP block has shown to be highly satisfying. While Tulgar et al.[3] reported rescue analgesic usage in adult patients after laparoscopic cholecystectomy; Aksu and Gürkan[4] showed that there was no need for any additional analgesic in paediatric patients. Other reports on the use of ESP block in paediatric patients also support these findings.[5]

Although it is much more common practice to perform nerve blocks for upper and lower extremity surgeries; today anaesthesiologists have a large armamentarium of different interfascial plane blocks to cover abdominal and thoracic surgeries. As part of multimodal analgesia technique, we think that almost every patient undergoing surgery can benefit from one or other block. Ultrasound guidance makes regional anaesthesia technically easier and safer. Opioid sparing effects of regional anaesthesia has been known and recommended by current enhanced recovery after surgery (ERAS) protocols.

ESP, in these case reports have been used as a rescue block after surgeries yet we strongly recommend that regional anaesthesia techniques should be performed preoperatively whenever possible. Due to a well-known fact that unrelieved acute pain could lead to chronic pain, regional anaesthesia techniques should be used as a part of the multimodal analgesia methods.