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Evaluating two approaches to the erector spinae plane block: an anatomical study
  1. Monica W Harbell1,
  2. Natalie R Langley2,
  3. David P Seamans1,
  4. Veerandra Koyyalamudi1,
  5. Molly B Kraus1,
  6. Frederick J Carey2 and
  7. Ryan Craner1
  1. 1Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
  2. 2Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
  1. Correspondence to Dr Monica W Harbell, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; Harbell.Monica{at}


Background and objectives Studies show variable spread with thoracic erector spinae plane (ESP) injections. Injection sites vary from lateral end of the transverse process (TP) to 3 cm from the spinous process, with many not describing the precise site of injection. This human cadaveric study examined dye spread of ultrasound-guided thoracic ESP block at two needle locations.

Methods Ultrasound-guided ESP blocks were performed on unembalmed cadavers. Methylene blue (20 mL, 0.1%) was injected in the ESP at the medial TP at level T5 (medial transverse process injection (MED), n=7) and the lateral end of the TP between T4 and T5 (injection between transverse processes (BTWN), n=7). The back muscles were dissected, and the cephalocaudal and medial-lateral dye spread documented.

Results Dye spread cephalocaudally from C4-T12 in the MED group and C5-T11 in the BTWN group, and laterally to the iliocostalis muscle in five MED injections and all BTWN injections. One MED injection reached serratus anterior. Dorsal rami were dyed in five MED and all BTWN injections. Dye spread to the dorsal root ganglion and dorsal root in most injections, though more extensively in the BTWN group. The ventral root was dyed in 4 MED and 6 BTWN injections. Epidural spread in BTWN injections ranged from 3 to 12 levels (median: 5 levels), with contralateral spread in two cases and intrathecal spread in five injections. Epidural spread in MED injections was less extensive (median (range): 1 (0–3) levels); two MED injections did not enter the epidural space.

Conclusion An ESP injection administered between TPs exhibits more extensive spread than a medial TP injection in a human cadaveric model.

  • nerve block
  • ultrasonography
  • regional anesthesia

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @MonicaHarbellMD, @kraus_molly

  • Contributors Study design/planning, data acquisition, analysis, interpretation, writing manuscript, revision, and approval of final manuscript: all authors. MH is the guarantor for this study, who accepts full responsibility for the work and/or conduct of the study, had access to the data, and controlled the decision to publish.

  • 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.

  • Provenance and peer review Not commissioned; externally peer reviewed.