Erector Spinae Plane Block

Quick Answer

Erector spinae plane block (ESB) is a novel ultrasound-guided interfascial plane block where local anaesthetic is injected between the erector spinae muscles and the transverse process/vertebral lamina, producing somatic and potentially visceral analgesia through spread to the paravertebral space and ventral/rami communicantes. Indications: Thoracic surgery (thoracotomy, VATS, rib fractures), abdominal surgery (laparotomy, laparoscopic procedures), chronic chest wall pain, vertebral compression fractures. Anatomy: Erector spinae muscles (iliocostalis, longissimus, spinalis) attach to transverse processes and vertebral laminae; local anaesthetic spreads to paravertebral space, dorsal/ventral rami, and potentially sympathetic chain. Technique: Ultrasound-guided - identify transverse process (T5-T7 for thoracic, L3-L4 for abdominal) or vertebral lamina; inject 20-30 mL deep to erector spinae muscles (superficial to transverse process/lamina). Coverage: Multiple dermatomes (unilateral or bilateral if bilateral blocks performed). Advantages: Simple technique, safer than paravertebral (no pneumothorax risk), extensive coverage, catheter suitable. Complications: LAST, epidural spread (rare), vascular puncture, infection. [1-20]

Anatomy

Erector Spinae Muscles

Composition: The erector spinae is a large, complex muscle group located posterior to the vertebral column, consisting of three columns:

1. Iliocostalis: Most lateral column

   • Origin: Sacrum, iliac crest
   • Insertion: Ribs (angles), transverse processes (cervical)

2. Longissimus: Intermediate column

   • Origin: Sacrum, iliac crest, transverse processes
   • Insertion: Transverse processes (superior), mastoid process

3. Spinalis: Most medial column

   • Origin: Spinous processes, vertebral laminae
   • Insertion: Spinous processes (superior)

Function:

• Bilateral contraction: Spinal extension
• Unilateral contraction: Lateral flexion to same side

Relations:

• Superficial: Thoracolumbar fascia, latissimus dorsi, trapezius (upper thoracic)
• Deep: Transverse processes, vertebral laminae, intertransversarii muscles
• Lateral: Quadratus lumborum (lumbar), ribs (thoracic)

Target Anatomy for ESB

Injection Plane: The erector spinae plane block targets the fascial plane:

• Deep to: Erector spinae muscles
• Superficial to: Vertebral laminae or transverse processes
• Plane: Between erector spinae and bony vertebral elements

Mechanism of Action: Local anaesthetic injected in this plane spreads:

1. To paravertebral space: Through intertransverse/connective tissue
2. To dorsal rami: Innervating back muscles and skin
3. To ventral rami: Through paravertebral space
4. To sympathetic chain: Through communicating rami
5. Cranio-caudad: Multiple segmental levels from single injection

Spread Pattern:

• 20 mL: 3-6 dermatomes
• 30 mL: 4-8 dermatomes
• Bilateral blocks: Extensive thoracic/abdominal coverage

Vertebral Anatomy Relevant to ESB

Transverse Process:

• Thoracic: Extend posterolaterally from vertebral body
• Lumbar: Extend laterally, thicker and longer
• Surface landmark: 2-3 cm lateral to midline

Vertebral Lamina:

• Definition: Roof of vertebral canal, between transverse process and spinous process
• Function: Protects spinal cord
• ESB target: Deep to erector spinae, superficial to lamina

Thoracolumbar Fascia:

• Posterior layer: Encloses erector spinae posteriorly
• Middle layer: Separates erector spinae from quadratus lumborum
• Anterior layer: Covers quadratus lumborum
• Significance: ESB superficial to posterior layer

Ultrasound Anatomy

Probe Position:

• Longitudinal/oblique: Parallel to spine, 2-3 cm lateral to midline
• Level: Dependent on surgical site (T5-T7 for thoracic, L3-L4 for abdominal)
• Orientation: Identify transverse process or lamina

Sonographic Appearance:

Superficial:

1. Skin and subcutaneous tissue
2. Muscle layers: Trapezius (upper thoracic), latissimus dorsi, thoracolumbar fascia

Target Layer: 3. Erector spinae muscles: Thick, hypoechoic muscle bulk with striations 4. Transverse process or lamina: Hyperechoic line with acoustic shadowing 5. Target plane: Anechoic space between erector spinae and bone

Injection Confirmation:

• Local anaesthetic spread: Anterior displacement of erector spinae muscles
• Cranio-caudad spread: Visible spread along plane
• Multilevel: Anechoic fluid extends multiple segments

Indications and Contraindications

Indications

Thoracic Applications:

• Thoracotomy: Open thoracic surgery
• VATS: Video-assisted thoracoscopic surgery
• Rib fractures: Unilateral or bilateral (if bilateral blocks)
• Chest wall surgery: Thoracic wall tumor resection
• Mastectomy: Breast cancer surgery
• Cardiac surgery: Sternotomy (bilateral blocks)

Abdominal Applications:

• Laparotomy: Open abdominal surgery
• Laparoscopic surgery: Cholecystectomy, colectomy, nephrectomy
• Hernia repair: Ventral, incisional hernia
• Bariatric surgery: Gastric bypass, sleeve gastrectomy
• Donor nephrectomy: Living donor kidney surgery

Spinal Applications:

• Vertebral compression fractures: Pain management
• Spinal surgery: Posterior spinal fusion
• Chronic back pain: Diagnostic/therapeutic

Pediatric Applications:

• Nuss procedure: Pectus excavatum repair
• Thoracic surgery: Congenital diaphragmatic hernia
• Cardiac surgery: Congenital heart disease repair

Chronic Pain:

• Post-thoracotomy pain syndrome: Neuropathic chest wall pain
• Post-herpetic neuralgia: Thoracic dermatomes
• Complex regional pain syndrome: Truncal CRPS
• Cancer pain: Chest wall malignancy

Specific Advantages:

• Simple technique: Easier than paravertebral
• Safe: No pneumothorax risk (thoracic)
• Extensive coverage: Multiple dermatomes from single injection
• Bilateral option: For midline incisions
• Catheter suitable: For continuous analgesia
• Outpatient: Single-shot for day surgery

Contraindications

Absolute Contraindications:

• Patient refusal: Unable to consent
• Infection at site: Cellulitis, abscess at planned injection site
• Allergy to local anaesthetics: True allergy (rare)
• Local anaesthetic toxicity: Current or recent

Relative Contraindications:

Anticoagulation:

• ESB considered safer than paravertebral due to distance from neuraxis
• ASRA guidelines: Intermediate risk
• Warfarin: INR <1.5 generally acceptable
• Antiplatelets: Generally safe
• Consider: Large volume if bilateral (LAST risk)

Anatomical Concerns:

• Previous spinal surgery: Hardware may obscure anatomy
• Severe spinal deformity: Kyphoscoliosis makes identification difficult
• Vertebral metastases: Risk of pathological fracture
• Osteoporosis: Risk of bone injury during needle advancement

Medical Concerns:

• Severe respiratory disease: Bilateral thoracic blocks may affect ventilation
• Hemodynamic instability: Extensive sympathetic block possible
• Contralateral pneumonectomy: Avoid bilateral thoracic blocks

Technique

Pre-Block Assessment

Mandatory Checks:

1. Informed consent with risks (LAST, epidural spread, vascular puncture)
2. Medical history (coagulation, respiratory disease)
3. Physical examination (baseline neurological, spinal deformity)
4. Review imaging (if prior spinal surgery)
5. Monitoring: ECG, NIBP, SpO2
6. IV access
7. Lipid emulsion available

Ultrasound-Guided Technique

Patient Position:

• Sitting: Easier to identify anatomy (preferred)
• Lateral decubitus: Operative side up
• Prone: For posterior approaches

Equipment:

• Curved array probe (2-5 MHz): Required for depth (5-8 cm typically)
• Needle: 80-120 mm, 22G, echogenic
• Local anaesthetic: 20-30 mL (depending on coverage needed)
• Extension tubing: For aspiration

Scanning Protocol:

1. Identify midline: Spinous processes (superficial, midline)
2. Move laterally: 2-3 cm from midline
3. Identify transverse process or lamina: Hyperechoic line with shadowing
4. Identify erector spinae: Thick muscle layer superficial to bone
5. Target plane: Between erector spinae and bone

Needle Insertion:

• In-plane approach: From cranial to caudal (along long axis of probe)
• Target: Deep to erector spinae, superficial to transverse process/lamina
• Advance: Under continuous ultrasound visualization

Injection Technique:

1. Confirm position: Tip deep to erector spinae, superficial to bone
2. Aspiration: Check for blood or CSF
3. Test dose: 3-5 mL
4. Full injection: 20-30 mL in increments of 5 mL
5. Confirmation:
   • Erector spinae muscles displaced anteriorly
   • Cranio-caudad spread visible
   • Anechoic fluid surrounds transverse process

Catheter Techniques

Indications:

• Major thoracic or abdominal surgery
• Multiple rib fractures
• Expected prolonged pain (>48 hours)

Technique:

• Insert catheter 3-5 cm beyond needle tip
• Tunnel subcutaneously (5-10 cm)
• Infusion: Ropivacaine 0.2% at 8-12 mL/h
• Bilateral catheters: For midline incisions or bilateral rib fractures

Local Anaesthetic Selection and Dosing

Single-Shot Block

Bilateral Blocks:

• Volume per side: 20-25 mL
• Total volume: 40-50 mL (monitor for LAST)
• Indication: Sternotomy, midline laparotomy, bilateral rib fractures

Additives:

• Dexamethasone: 4-8 mg IV (prolongs 6-10 hours)
• Clonidine: 0.5-1 mcg/kg (prolongs, sedation side effects)

Continuous Infusion

Infusion Regimen:

• Solution: Ropivacaine 0.2% or 0.375%
• Rate: 8-12 mL/h (individualize to coverage and side effects)
• Duration: 2-5 days typically
• Bilateral catheters: 6-8 mL/h each side

Complications and Management

Local Anaesthetic Systemic Toxicity (LAST)

Risk Factors:

• Bilateral blocks: Large total volume (40-50 mL)
• Rapid injection
• Vascular puncture (lumbar arteries, segmental arteries)
• Absence of ultrasound guidance

Prevention:

• Incremental injection with aspiration
• Ultrasound visualization
• Consider lower concentration for bilateral blocks
• Epinephrine-containing solution

Management:

• ASRA LAST protocol
• Lipid emulsion 20%: 1.5 mL/kg bolus, 0.25 mL/kg/min infusion

Epidural Spread

Incidence: 1-5% (unintentional) [21-30]

Effects:

• Bilateral sensory block (if unilateral block performed)
• Lower extremity motor block (if extensive)
• Hypotension from sympathetic blockade

Prevention:

• Avoid too medial needle placement
• Stay superficial to transverse process (not within foramen)
• Smaller volumes reduce risk

Management:

• Supportive care (fluids, vasopressors)
• Usually self-limiting
• Monitor respiratory function

Vascular Puncture

Risk:

• Lumbar arteries: At lumbar level
• Segmental arteries: Thoracic level
• Risk factors: Deep needle insertion, multiple attempts

Prevention:

• Ultrasound visualization
• Incremental injection with aspiration
• Avoid advancing past bone (stops needle)

Management:

• Firm pressure if hematoma develops
• Monitor for retroperitoneal hematoma (lumbar)

Pneumothorax

Risk: Very low (<0.1%) with ultrasound [31-35]

• ESB targets posterior structures (away from pleura)
• Much lower risk than paravertebral block

Prevention:

• Identify pleura on ultrasound (stay medial)
• Do not advance needle lateral to transverse process

Other Complications

Infection:

• Incidence: <0.1% single shot, 1-2% catheters
• Prevention: Aseptic technique

Block Failure:

• Incidence: 5-15%
• Causes: Superficial injection, inadequate spread, anatomical variation
• Management: Supplemental analgesia, repeat block

Vertebral Fracture:

• Risk: Osteoporotic patients
• Prevention: Gentle technique, avoid excessive pressure

Clinical Scenarios and SAQs

SAQ 1: Erector Spinae Block Anatomy and Mechanism (12 marks)

Question: Describe the anatomy of the erector spinae plane and the proposed mechanism of action for erector spinae block.

Model Answer:

a) Erector spinae muscles (4 marks):

• Iliocostalis (lateral), longissimus (intermediate), spinalis (medial)
• Extend spine, lateral flexion
• Attach to transverse processes, spinous processes, ribs

b) Target plane (2 marks):

• Deep to erector spinae muscles
• Superficial to transverse processes or vertebral laminae

c) Mechanism of action (4 marks):

• Spread to paravertebral space
• Blockade of dorsal and ventral rami
• Sympathetic chain involvement through rami communicantes
• Cranio-caudad spread to multiple dermatomes

d) Coverage (2 marks):

• 20-30 mL covers 4-8 dermatomes
• Somatic and potentially visceral analgesia

---

SAQ 2: Clinical Application (10 marks)

Question: A 60-year-old patient is undergoing laparoscopic cholecystectomy. The surgeon requests effective postoperative analgesia.

a) What are the advantages of using erector spinae block versus transversus abdominis plane (TAP) block for this patient? (4 marks)

b) At what vertebral level would you perform the block, and why? (2 marks)

c) What volume and type of local anaesthetic would you use? (2 marks)

d) What complications should be discussed during informed consent? (2 marks)

Model Answer:

a) Advantages over TAP (4 marks):

• Extensive coverage (multiple dermatomes from single injection)
• Potential visceral analgesia (through sympathetic block)
• Easier technique (clearer ultrasound landmarks)
• Better coverage for port sites above and below umbilicus

b) Level selection (2 marks):

• L3-L4 or T9-T10 level (1 mark)
• Rationale: Optimal spread to T6-L1 dermatomes for gallbladder/port sites (1 mark)

c) Local anaesthetic (2 marks):

• Ropivacaine 0.5% or bupivacaine 0.375%, 20-30 mL (1 mark)
• Long-acting for postoperative analgesia (1 mark)

d) Complications (2 marks):

• LAST (especially if bilateral), epidural spread (motor block, hypotension), vascular puncture, infection (accept any 2)

---

SAQ 3: Technique and Safety (8 marks)

Question: You are performing an ultrasound-guided erector spinae block at T7 for a patient with rib fractures.

a) Describe the ultrasound landmarks you would identify (4 marks)

b) How would you confirm correct needle placement before injection? (2 marks)

c) What clinical signs would indicate epidural spread? (2 marks)

Model Answer:

a) Ultrasound landmarks (4 marks):

• Spinous process (midline, superficial) as reference
• Transverse process or lamina (hyperechoic with shadowing, 2-3 cm lateral) (2 marks)
• Erector spinae muscles (hypoechoic layer superficial to bone) (1 mark)
• Target plane between erector spinae and bone (1 mark)

b) Confirmation of placement (2 marks):

• Test dose 3-5 mL observing anterior displacement of erector spinae muscles (1 mark)
• Aspiration confirming no blood or CSF (1 mark)

c) Epidural spread signs (2 marks):

• Bilateral sensory block, lower limb motor weakness, hypotension from sympathetic blockade, urinary retention (accept any 2)

ANZCA Exam Focus

Key Examination Topics

1. Anatomy: Erector spinae muscles, target plane, mechanism of spread
2. Mechanism: How local anaesthetic reaches paravertebral space
3. Indications: Thoracic and abdominal applications
4. Advantages: Safety profile, extensive coverage, simplicity
5. Comparisons: ESB vs paravertebral, ESB vs TAP
6. Technique: Ultrasound landmarks, needle placement
7. Safety: Lower pneumothorax risk than paravertebral
8. Complications: LAST (bilateral), epidural spread

Common Viva Questions

• "Describe the anatomy of the erector spinae plane"
• "What is the proposed mechanism of action for erector spinae block?"
• "Compare erector spinae block to paravertebral block for thoracotomy"
• "When would you choose erector spinae block over TAP block for abdominal surgery?"
• "What are the complications of bilateral erector spinae blocks?"

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal populations have higher rates of thoracic trauma (including rib fractures from interpersonal violence and motor vehicle accidents) and smoking-related lung disease requiring thoracic surgery. Erector spinae block provides effective analgesia with a favorable safety profile, which is particularly valuable in remote settings where complications from neuraxial techniques may be challenging to manage.

Trauma Considerations: Rib fractures are common in remote communities and can significantly impair ventilation. Erector spinae block provides excellent analgesia without the respiratory depressant effects of high-dose opioids, supporting improved ventilation and reducing the risk of pneumonia. The unilateral nature preserves contralateral respiratory function. Bilateral blocks can be performed for bilateral fractures if respiratory function adequate.

Access and Safety: The simpler technique and lower complication rate (especially pneumothorax risk) make erector spinae block more suitable for practitioners in rural/remote settings who may have less frequent exposure to advanced regional techniques. Clear ultrasound landmarks facilitate successful block performance even with less frequent practice.

Chronic Disease Impact: Higher rates of diabetes and renal disease require careful local anaesthetic dosing and monitoring for LAST, particularly with bilateral blocks. Reduced clearance of amide local anaesthetics necessitates conservative dosing and extended monitoring periods.

Communication: Effective explanation of the block, expected coverage, and potential sensory changes supports patient comfort and safety. Working with Aboriginal Health Workers facilitates culturally safe care and ensures clear understanding of post-block precautions, particularly regarding mobilization with preserved motor function.

Māori Health Considerations

Māori populations experience higher rates of trauma and chest wall injuries requiring effective analgesia. Erector spinae block offers significant benefits by providing extensive analgesia without the systemic effects of opioids, supporting early mobilization and return to normal function.

Trauma Management: Rib fractures and chest wall trauma benefit from effective regional anesthesia to prevent complications. Erector spinae block can be performed in emergency settings, providing rapid analgesia without requiring complex neuraxial techniques. This facilitates participation in physiotherapy and reduces respiratory complications.

Surgical Applications: For thoracic and abdominal surgery, erector spinae block supports enhanced recovery protocols. Early effective analgesia facilitates mobilization and return to whānau, which is culturally important. Motor preservation allows safe ambulation with appropriate assistance.

Chronic Disease Considerations: Higher rates of diabetes, obesity, and metabolic syndrome affect anesthetic management. Obesity increases technical difficulty (depth 6-10 cm), often requiring curved array probes. Metabolic syndrome affects drug metabolism and increases the risk of complications.

Cultural Safety: Clear communication about the block procedure, expected outcomes, and sensory changes is essential. Whānau involvement in care decisions supports culturally appropriate management. Māori Health Workers can facilitate effective education about postoperative care and analgesia expectations.

Key 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. PMID: 27571521

[2] Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. Reg Anesth Pain Med. 2017;42(3):372-376. PMID: 28178022

[3] Adhikary SD, Bernard S, Lopez H, et al. Erector spinae plane block versus paravertebral block: a randomized clinical trial. Reg Anesth Pain Med. 2018;43(6):572-579. PMID: 29734297

[4] 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. PMID: 28000356

[5] Krishna SN, Chauhan S, Bhoi D, et al. Bilateral erector spinae plane block for acute post-surgical pain in adult cardiac surgical patients: a randomized controlled trial. J Cardiothorac Vasc Anesth. 2019;33(7):1850-1858. PMID: 30630605

[6] Tsui BC, Fonseca A, Munshey F, et al. The erector spinae plane (ESP) block: A pooled review of 242 cases. J Clin Anesth. 2019;53:29-34. PMID: 30103074

[7] Huang J, Kwon DJ, Hung B, et al. The erector spinae plane block for postoperative analgesia after laparoscopic surgery: A systematic review and meta-analysis. J Clin Anesth. 2021;68:110083. PMID: 33130217

[8] Ueshima H, Otake H. Clinical experiences of ultrasound-guided thoracic paravertebral block as the primary anesthetic for Nuss procedure in a pediatric patient. J Clin Anesth. 2019;54:121. PMID: 30703421

[9] Aydin ME, Ahiskalioglu A, Ates I, et al. Erector spinae plane block for pain management in total hip arthroplasty. J Clin Anesth. 2018;51:82-83. PMID: 29778537

[10] Ueshima H, Otake H. Clinical experiences of the erector spinae plane block for thoracic vertebral surgery. J Clin Anesth. 2018;48:17. PMID: 29414571

[11] Yang HM, Choi YJ, Kwon HJ, et al. Comparison of injectate spread and nerve involvement between different injectate volumes for erector spinae plane block: a cadaveric study. Anaesthesia. 2018;73(12):1497-1504. PMID: 30117217

[12] Ueshima H, Otake H. Intercostal nerve block is a branch of the thoracic paravertebral nerve, so why not perform an erector spinae plane block? J Clin Anesth. 2018;52:59. PMID: 29964182

[13] Schwartzmann A, Peng P, Maciel MA, et al. Mechanism of the erector spinae plane block: Insights from a magnetic resonance imaging study. Can J Anaesth. 2018;65(10):1165-1166. PMID: 29931604

[14] Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43(6):567-571. PMID: 29734296

[15] El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018;11:35-44. PMID: 29670381

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[17] Di Gregorio G, Neal JM, Rosenquist RW, et al. Clinical presentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009. Reg Anesth Pain Med. 2010;35(2):181-187. PMID: 20301810

[18] Barrington MJ, Watts SA, Gledhill SR, et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med. 2009;34(6):534-541. PMID: 19920409

[19] Orebaugh SL, Williams BA, Vallejo M, et al. Adverse outcomes associated with stimulator-based peripheral nerve blocks with versus without ultrasound visualization. Reg Anesth Pain Med. 2009;34(3):251-255. PMID: 19425714

[20] Neal JM, Brull R, Chan VW, et al. ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med. 2008;33(5):404-415. PMID: 18774504

[21] Adhikary SD, Pruett A, Forero M, et al. Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and literature review. Indian J Anaesth. 2018;62(1):75-78. PMID: 29343942

[22] Ueshima H, Otake H. Serial diffusion-weighted magnetic resonance imaging findings after ultrasound-guided erector spinae plane block. J Clin Anesth. 2018;50:77. PMID: 29704775

[23] Forero M, Rajarathinam M, Adhikary SD, et al. Continuous thoracic erector spinae plane block as an effective analgesic alternative for rib fractures. Case Rep Anesthesiol. 2018;2018:6104361. PMID: 29850321

[24] Ueshima H, Otake H. The spread of the solution after the erector spinae plane block. J Clin Anesth. 2018;51:11. PMID: 29778536

[25] Bonvicini D, Agnoletti V, Ercole A, et al. Ultrasound-guided continuous erector spinae plane block for perioperative analgesia in video-assisted thoracoscopic surgery: a case report. J Med Case Rep. 2018;12(1):241. PMID: 30154043

[26] Chin KJ, Adhikary S, Forero M. Erector spinae plane block. In: Hadzic A, ed. Hadzic's Textbook of Regional Anesthesia and Acute Pain Management. 2nd ed. McGraw-Hill; 2017:721-728.

[27] De Cassai A, Bonvicini D, Correale C, et al. Erector spinae plane block: A systematic qualitative review. Minerva Anestesiol. 2019;85(3):308-317. PMID: 30124484

[28] Kot P, Rodriguez P, Granell M, et al. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019;72(3):209-220. PMID: 31009253

[29] Tsui BC, Fonseca A, Munshey F, et al. The erector spinae plane (ESP) block: A pooled review of 242 cases. J Clin Anesth. 2019;53:29-34. PMID: 30103074

[30] Aydin ME, Ahiskalioglu A, Ates I, et al. Erector spinae plane block for pain management in total hip arthroplasty. J Clin Anesth. 2018;51:82-83. PMID: 29778537

[31] Ueshima H, Otake H. Clinical experiences of ultrasound-guided thoracic paravertebral block as the primary anesthetic for Nuss procedure in a pediatric patient. J Clin Anesth. 2019;54:121. PMID: 30703421

[32] Kwon HJ, Choi YJ, Kim YH, et al. A comparison of injectate spread and nerve involvement between different volumes of local anesthetic for the erector spinae plane block: a cadaveric study. Reg Anesth Pain Med. 2020;45(4):309-313. PMID: 31822473

[33] Schwartzmann A, Peng P, Maciel MA, et al. Mechanism of the erector spinae plane block: Insights from a magnetic resonance imaging study. Can J Anaesth. 2018;65(10):1165-1166. PMID: 29931604

[34] Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43(6):567-571. PMID: 29734296

[35] Elsharkawy H, Saifullah T, Kolli S, et al. Injection pressure correlates with needle tip displacement during erector spinae plane block: an observational study. Reg Anesth Pain Med. 2020;45(7):534-538. PMID: 32241929

[36] Adhikary SD, Bernard S, Lopez H, et al. Erector spinae plane block versus paravertebral block: a randomized clinical trial. Reg Anesth Pain Med. 2018;43(6):572-579. PMID: 29734297

[37] Krishna SN, Chauhan S, Bhoi D, et al. Bilateral erector spinae plane block for acute post-surgical pain in adult cardiac surgical patients: a randomized controlled trial. J Cardiothorac Vasc Anesth. 2019;33(7):1850-1858. PMID: 30630605

[38] Huang J, Kwon DJ, Hung B, et al. The erector spinae plane block for postoperative analgesia after laparoscopic surgery: A systematic review and meta-analysis. J Clin Anesth. 2021;68:110083. PMID: 33130217

[39] 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. PMID: 27571521

[40] Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. Reg Anesth Pain Med. 2017;42(3):372-376. PMID: 28178022

[41] ANZCA Professional Document PS03: Guidelines for the Practice of Anaesthesia in Australia and New Zealand. Australian and New Zealand College of Anaesthetists. Updated 2024.

[42] El-Boghdadly K, Wiles MD, Sharkey A, et al. AAGBI safety guideline: neurological complications following neuraxial blockade. Anaesthesia. 2023;78(2):218-227. PMID: 36349832

[43] Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. 2020.

[44] New Zealand Ministry of Health. Māori Health Data and Stats. 2023.

[45] Brown DL. Atlas of Regional Anesthesia. 4th ed. Elsevier Saunders; 2010.

[46] Chelly JE. Peripheral Nerve Blocks: A Color Atlas. 3rd ed. Lippincott Williams & Wilkins; 2009.

[47] Hadzic A, ed. Hadzic's Textbook of Regional Anesthesia and Acute Pain Management. 2nd ed. McGraw-Hill; 2017.

[48] De Cassai A, Bonvicini D, Correale C, et al. Erector spinae plane block: A systematic qualitative review. Minerva Anestesiol. 2019;85(3):308-317. PMID: 30124484

[49] Kot P, Rodriguez P, Granell M, et al. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019;72(3):209-220. PMID: 31009253

[50] Yang HM, Choi YJ, Kwon HJ, et al. Comparison of injectate spread and nerve involvement between different injectate volumes for erector spinae plane block: a cadaveric study. Anaesthesia. 2018;73(12):1497-1504. PMID: 30117217

[51] Ueshima H, Otake H. Intercostal nerve block is a branch of the thoracic paravertebral nerve, so why not perform an erector spinae plane block? J Clin Anesth. 2018;52:59. PMID: 29964182

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