Efficacy of erector spinae plane block for postoperative pain management: A meta-analysis and trial sequential analysis of randomized controlled trials

The Takeaway

Erector Spinae Plane Block (ESPB) significantly reduced postop pain up to 48h, decreased postop opioid consumption, lowered postoperative nausea and vomiting (PONV), and without severe adverse events

Study Design

• Meta-analysis of 43 RCTs
• Included 2721 patients
• Efficacy of ESPB was compared with placebo or sham ESPB, both used in addition to conventional multimodal analgesia for surgical patients.

Physiology Refresh

The ESP block is a fascial plane block, meaning we’re not targeting individual nerves directly but instead depositing local anesthetic (LA) in a fascial plane to achieve indirect neural blockade.

1. Anatomical Target

The target is the fascial plane deep to the erector spinae muscle, and superficial to the tips of the transverse processes of the vertebrae. This is typically at the T5–T6 level for thoracic analgesia, but it can be done at various levels for different indications (e.g., lumbar for lower extremity procedures).

• The erector spinae muscle group includes iliocostalis, longissimus, and spinalis muscles.
• You’re placing your LA deep to these muscles, but outside the paravertebral space.

2. Mechanism of Analgesia

Here’s where it gets interesting and a little nuanced:

• Once injected in the correct plane, LA spreads cranio-caudally over multiple vertebral levels.
• It diffuses anteriorly through the connective tissues that link the transverse processes to the paravertebral space.
• This allows LA to reach the dorsal rami (providing posterior somatic sensation) and the ventral rami (which include intercostal nerves, giving anterior thoracic or abdominal sensation).
• Some studies suggest the LA can also reach the epidural space and sympathetic chain, providing visceral analgesia.

This broad, multi-dermatomal spread explains why ESP blocks can be surprisingly effective for:

• Thoracic trauma (rib fractures)
• Post-mastectomy pain
• Abdominal surgery (if performed at lower levels)
• Even lumbar surgery or hip surgery when done at lower thoracic/lumbar levels

3. Clinical Benefits

• It’s a relatively safe block due to the distance from pleura and neurovascular structures.
• Can be used in anticoagulated patients more safely than paravertebral or epidural blocks (though still with caution).
• Good for both somatic and visceral pain, depending on spread.

See NYSORA's ESPB guidance here.

Abstract

Background: Postoperative pain remains a major problem across a wide range of surgical procedures. The efficacy and clinical utility of the Erector Spinae Plane Block (ESPB) in reducing postoperative pain remains uncertain.

Objective: To evaluate the efficacy and safety of the ESPB compared with placebo or sham block in perioperative pain management.

Evidence review: We searched PubMed, Embase, Web of Science, Scopus, and Cochrane CENTRAL for randomized controlled trials (RCTs) comparing ESPB to placebo or sham block in surgical patients. Primary outcomes included postoperative pain at 2 h, 6 h, 24 h, and 48 h, intraoperative and cumulative postoperative opioid consumption (24 h), and postoperative nausea and vomiting, pruritus, and block-related adverse events. Subgroup and sensitivity analyses, as well as meta-regressions, were performed to explore sources of heterogeneity. Trial sequential analysis (TSA) was used to assess the quantitative robustness of the available data. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024583633.

Findings: Forty-three RCTs were included, with 1361 patients randomized to the Erector Spinae Plane Block group. ESPB reduced postoperative pain at 2 h (MD -1.46;95 % CI -1.98 to -0.94;p < 0.001;I² = 91 %), 6 h (MD -1.23;95 % CI -1.64 to -0.83;p < 0.001;I² = 89 %), 24 h (MD -0.47;95 % CI -0.67 to -0.28;p < 0.001;I² = 78 %), and 48 h (MD -0.24;95 % CI -0.39 to -0.09;p = 0.002;I² = 10 %). Also, intraoperative opioid consumption (MD -137.43 μg;95 % CI -208.73 to -66.13;p < 0.001;I² = 100 %), 24 h cumulative opioid consumption (MD -25.62 mg;95 % CI -31.31 to -19.93;p < 0.001;I² = 99 %), and incidence of postoperative nausea and vomiting (RR 0.56;95 % CI 0.44 to 0.72;p < 0.001;I² = 16 %) were significantly lower in patients submitted to ESPB. No significant differences were found in postoperative pruritus (RR 0.62;95 % CI 0.35 to 1.10;p = 0.105;I² = 27 %). Notably, no block-related adverse events were reported in any study. Certainty of evidence was rated as low to moderate for most outcomes. TSA suggested that no further trials are needed to assess ESPB efficacy in the analyzed outcomes, except for postoperative pruritus.

Conclusion: ESPB is a safe and effective regional anesthesia technique that significantly reduces postoperative pain and opioid consumption across various surgical procedures.

Excerpts

The main findings of the pooled analysis were: (1) ESPB significantly reduced postoperative pain at multiple time points, with effects lasting up to 48 h; (2) ESPB decreased intraoperative and cumulative 24-h postoperative opioid consumption; (3) ESPB lowered the incidence of postoperative nausea and vomiting (PONV); (4) there was no significant difference in postoperative pruritus between ESPB and placebo or sham block; and (5) no severe adverse events were reported in either group.

ESPB involves the injection of a local anesthetic into the fascial plane beneath the erector spinae muscles, allowing its spread to adjacent neural structures. This distribution primarily affects the dorsal and ventral rami, providing analgesia for acute somatic pain and, to a lesser extent, visceral pain.

anatomical factors—such as inconsistent spread to the paravertebral space and dorsal root ganglion—and patient-specific variables, including obesity and differences in surgical procedures, may influence the duration and efficacy of the block

For postoperative opioid consumption, our study found a reduction of 25.62 mg of oral morphine equivalents in the first 24 h

existing hypotheses suggesting that opioid-induced nausea and vomiting does not follow a linear dose-response relationship. In fact, higher opioid doses may paradoxically reduce nausea and vomiting. This is probably due to greater penetration of opioids within the blood-brain barrier and the stimulation of the mu receptors in the nucleus tractus solitarius with consequent inhibition of nausea and vomiting, in contrast to stimulation of the mu receptors on the chemoreceptor trigger zone on the area postrema, that induces nausea and vomiting and occur at lower doses due to incomplete blood-brain-barrier.

ESPB as one of the safest nerve blocks available. This is probably due to its shallow and easy-to-visualize under ultrasound endpoint. Furthermore, the transverse process gives the needle a backstop impeding it from advancing past the endpoint and providing a superficial and compressible location preventing important bleedings.

Citation

Gonçalves JPF, Duran ML, Barreto ESR, Antunes Júnior CR, Albuquerque LG, Lins-Kusterer LEF, Azi LMTA, Kraychete DC. Efficacy of erector spinae plane block for postoperative pain management: A meta-analysis and trial sequential analysis of randomized controlled trials. J Clin Anesth. 2025 Apr 7;103:111831. doi: 10.1016/j.jclinane.2025.111831. Epub ahead of print. PMID: 40199030.

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