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To the editor,
There is controversy regarding mechanisms of action of the erector spinae plane block (ESPB). Both cadaveric and clinical imaging studies have shown local anesthesia spread between transverse processes and erector spinae muscles in craniocaudal direction with limited spread anteriorly. It has been shown that local anesthetics can spread to the paravertebral area by extending through the intertransverse ligament.1
Accordingly, increasing the volume of local anesthetic resulted in better clinical effects.2 In a cadaver study by Nielsen et al,3 it was shown that gaps were formed between the superior costotransverse ligament (SCTL) in the thoracic paravertebral area which contained the dorsal rami of the spinal nerves. 3In addition, Nielsen et al demonstrated the passage of injection between the lateral costotransverse ligament and SCTL. On the contrary because of limited spread Ivanusic et al4 stated that that ESPB could not be an alternative to paravertebral block.
In our clinic, to increase the effectiveness of ESPB, we started using a double injectiontechnic. 10 ml of local anesthesia is injected like a traditional ESPB between transverse process and muscle layers.Then, we advance the needle over the intertransverse ligament and inject 15 mL local anesthesia above the SCTL in the area between the two transverse processes (figure 1).
In our modification, although local anesthesia was given above the SCTL, it was seen that the downward orientation of the pleura indicating paravertebral spread. We have seen better clinical results since we started this modification of ESPB.
Contributors All authors contributed.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.