ESP Block - Where To Inject [2023]

[@DrAmitPawa]

Stunning Video my friend! So happy to see that I am thinking along the same lines as you!

[@TheJezmhill]

Such high value content as always. Thank you

[@alanstedman6716]

Another great video presentation - thank you

[@tobiastemann8295]

Superb, as usual. Thank you!

[@paanmelaka]

thank you

[@akshayuttarwar3240]

How to identify that if we're too lateral on transverse process or medial.. Many a times getting transverse process view itself is challenging if too much muscle bulk or fat is present.. Will it be easy to delineate such structures in curvilinear probe, especially when depth is 4 or more centimetres? Can you please have videos of thoracic ESP block troubleshooting. Although this video do not include lumbar spine ESP, but can you please have videos for lumbar ESP block troubleshooting. I really adore your videos and try to follow your method, it is increasing my understanding and success of block. Thank you.

[@KiJinnChin]

To identify where you are on the transverse process, do one or both of the following: (1) In a parasagittal plane, carefully scan back and forth in a lateral-to-medial direction, looking for the transitions from rib-to-TP-to-lamina. A view of TP shadow closer to the lamina view = more medial part of TP. Closer to rib/pleura view = more lateral part of TP. (2) Start with a transverse scan, obtain a view of the TP shadow arising from the lamina. Centre the part of the TP that you want (e.g. more medial or base) on the screen, then slowly rotate the probe around this central point, into a parasagittal longitudinal orientation, keeping that bony shadow in view the whole time. Curvilinear probe is very helpful for subjects with deeper targets, as you point out, and I use it liberally.

[@akshayuttarwar3240]

@@KiJinnChin thanks a lot for your valuable insight. only problem I feel is that will it give good analgesia for ventral rami of nerves? as ITP block as you say will not work at multiple levels like ESP block.

[@azmiarman]

Seems that tip of block needle is safest in itp space

[@chriswong7075]

Fantastic video. Does the dermatomal spread differ between ESP, ITP & PVB? Is it possible to put a catheter in the ITP?

[@KiJinnChin]

Hi @chriswong7075 - (1) this depends a little bit on how you measure dermatomal spread. If we talk about cutaneous sensory testing over the anterolateral torso, a denser sensory block is likely if more LA reaches the spinal nerve, and so dermatomal spread will be more evident in more segments with a PVB > ITP > ESP across a group of patients. If you are only concerned with posterior torso coverage, the ESP will likely give you the greatest number of levels. (2) I don't have direct experience of catheter insertion into the ITP but it has been described. PVB catheters have traditionally also been described as being tricky to advance and insert (hence the design of helical coil tip catheters - see articles by Luyet C et al), and some of those concerns may apply as well.

[@akeelmerchant7752]

how do you recommend placing erector spinae catheters for rib fractures and thoracic cases? I have found the spread of local anesthetic not as prominent in "creating a space" for catheter insertion when injection is performed below the ESM fascia as opposed to above the ESM fascia. any tips in this situation?

[@KiJinnChin]

I agree that this can be an issue, especially if the needle tip is resting against the surface of the TP - the bone is an obstruction to catheter advancement. I try to skim the "far" corner of the TP I'm aiming for, and I still try initially to open a space with bolus injection well under the deep fascia. If I cannot thread the catheter, then I will pull back slightly, and try again to open up a more obvious pocket while remaining under the muscle fascia. To prevent dislodgement and malpositon of the catheter, I consider it important to thread 4-5cm into the plane under the muscle, so I would make that a priority - over trying to keep the needle tip in the hybrid ESP-ITP zone.

[@doctorbius]

ITP means we block into the muscle?

[@KiJinnChin]

It means being definitively deep to the erector spinae muscle, and within the intertransverse connective tissue complex.

[@akshayuttarwar3240]

@KiJinnchin sir, please do reply