Erector spinae plane block: Anatomical landmark-guided technique.

Sir,

Interfascial plane blocks have revolutionized the management of acute perioperative and chronic pain. After the first description of ultrasound-guided erector spinae plane block (ESPB) in 2016 by Forero et al., it has been reported to provide analgesia for various indications.[1] However, not all hospitals are equipped with ultrasound machines in the operation theatre and/or trained anesthesiologists, even in the developed world.[2] We are describing a novel anatomical landmark-guided technique of ESPB which can be performed for acute pain relief.

Landmark-guided ESPB can be performed with the patient in prone, lateral, or sitting position. The sitting position allows easy identification of landmarks and greater comfort to the patient. Our aim is to deposit local anaesthetic (LA) into the fascial plane deep to erector spinae muscle which blocks the dorsal and ventral rami of the spinal nerve depending on the level of injection and the amount of local anesthetic injected [Figure 1]. The spinous process of the vertebra and a point 3 cm lateral to it are marked at the appropriate level before performing the block. Under aseptic precautions, the needle (22-gauge, 8–10 cm short bevelled needle or a Tuohy needle) is inserted and advanced perpendicular to the skin in all planes to contact the transverse process of the vertebra [Figure 2a]. The transverse process of the thoracic vertebra lies at a variable depth of 2–4 cm from the skin depending on the build of the individual.[3] At this point, the needle tip lies between the erector spinae muscle and transverse process. After negative aspiration, local anesthetic is injected in 3–5 ml aliquots. A volume of 20–25 ml of 0.25% (levo) bupivacaine or 0.2% ropivacaine with or without adjuvants can be used for analgesia on each side depending upon the surgery and requirements. The drug injected in this plane spreads in the longitudinal axis to both cephalad and caudal direction over several levels as the erector spinae fascia extends from nuchal fascia to the sacrum [Figure 2b]. Although it is simple and easy to perform, a randomized controlled trial is required to validate its efficacy, safety, and reliability compared to fluoroscopy or ultrasound-guided techniques.

Figure 1

Scematic diagram of landmark guided Erector Spinae Plane Block. TM=Trapezius Muscle, RMM=Rhomboid Muscle, ESM=Erector Spinae Muscle, TP=Transverse Process of vertebra, LA=Local Anaesthetic

Figure 2

(a) Point of needle entry for the block. (b) Post block Ultrasound scan confirms the drug spread

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.