American Society of Regional Anesthesia and Pain Medicine February 2018 - 17

Figure 1: After patients are positioned optimally (sitting or lateral
decubitus), the affected area is identified along with the target transverse
process.

Figure 2: Transverse processes in an in-plane approach are
recognizable as flat, squared-off acoustic shadows with a faint image of
the pleura.

(5-2 MHz) curvilinear probe is useful in more obese patients where
the transverse processes lie at a depth greater than 4 cm. We
prefer to use the catheter-over-needle kit (Pajunk E-Cath, Pajunk
Medical Systems, Norcross, Georgia) because they are more kink
resistant. The block is performed with full aseptic precautions,
and the usual precautions for any regional anesthesia procedures
should be applied.

out. Altered mental status, concomitant injuries, and intubation/
ventilation are considerations primarily with regard to the ability
to position the patient safely and access the paraspinal area to
perform the block. Unlike thoracic epidurals, the ESP block may be
performed in patients with pre-existing thoracic spine disease or
thoracic vertebral (ie, spinous process or lamina) fractures. Pleural
puncture and pneumothorax are not significant concerns, given
that the site of injection is distant from the pleura. We do not view
coagulopathy or the use of anticoagulants or antiplatelet drugs as
absolute contraindications to ESP block because the theoretical
risk of clinically significant hemorrhage or hematoma is very low;
however, an individualized risk-benefit assessment should be
performed for every patient.
Block Equipment and Preparation. In the majority of patients, we
use a high-frequency (10-15 MHz) linear-array transducer because
it provides a higher-resolution image; however, a low-frequency

Scanning Technique. After patients are positioned optimally
(sitting or lateral decubitus), the affected area is identified along
with the target transverse process (Figure 1). Given that local
anesthetic spreads cranially and caudally from the point of
injection, this is usually the transverse process most central to
the affected rib levels. The ultrasound transducer is placed in a
longitudinal parasagittal orientation, about 3 cm lateral to the
spinous processes, allowing for visualization of adjacent transverse
processes (TP) in an in-plane approach. These are recognizable
as flat, squared-off acoustic shadows with only a very faint image
of the pleura visible (Figure 2). If the transducer is too lateral, the
ribs will be visualized instead; these are recognizable as rounded
acoustic shadows with an intervening hyperechoic pleural line
(Figure 3A). If the transducer is too medial, the thoracic laminae
(flat hyperechoic lines) will be visualized (Figure 3B).
After correct TP identification, an 18-gauge echogenic needle
(Pajunk E-Cath, Pajunk Medical Systems) is inserted using an
in-plane, cranial-to-caudad approach to contact the bony shadow
of the TP with the tip deep to the fascial plane of the erector
spinae muscle (Figure 4). The correct location of the needle tip

American Society of Regional Anesthesia and Pain Medicine
2018

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