The Takeaway

"The erector spinae plane block (ESPB) appears to be the preferred option for acute postoperative pain and opioid reduction in adults undergoing laparoscopic cholecystectomy."

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.

Study Design

• Meta-analysis of 5 RCTs including 372 participants
• Comparison of erector spinae plane block (ESPB) vs. oblique subcostal transversus abdominis (OSTAPB) in adult patients undergoing laparoscopic cholecystectomy
• Inclusion criteria: double-arm studies, prospective randomized control trial (RCTs) comparing ESPB with OSTAPB block, (c) adult population going under laparoscopic cholecystectomy, outcomes of post operative pain scores, postoperative opioid consumption at 24 h, intraoperative opioid consumption, postoperative nausea (PON) and vomiting (POV) reported

Abstract

Background: Pain following laparoscopic cholecystectomy plays a pivotal role in determining the quality of patient recovery. Considering the opioid crisis, exploration of alternative approaches, such as regional blocks, including erector spinae plane block (ESPB) and oblique subcostal transversus abdominis plane block (OSTAPB), has garnered considerable attention due to their promising outcomes in clinical trials.

Objective: Our aim is to provide a robust analysis which reflects the most current evidence for the effectiveness and safety of ESPB by comparing it to OSTAPB in adult patients undergoing laparoscopic cholecystectomy.

Methods: An extensive search was performed in the PubMed, Medline, and Cochrane Library databases from inception to June 1st 2023. Mean difference (SMD), and 95% confidence intervals (CIs) were calculated for continuous outcomes, Risk ratios (RR) were calculated for dichotomous outcomes. All statistical analyses were performed using R Statistical Software and meta package v4.17-0.

Results: A total of 5 RCTs including 372 participants were included in this meta-analysis. Pooled analysis of overall postoperative pain scores at 12 and 24 h showed ESPB to be superior to OSTAPB [MD = -0.67; 95% CI: (-0.95 to -0.39); p < 0.001, I² = 72%]. ESPB also showed significantly lesser opioid consumption at 24 h postoperatively [MD = -5.36; 95% CI: (-8.56 to -2.15); p < 0.001, I² = 96%], while intraoperative opioid consumption {MD = -0.46; 95% CI: (-1.27 to -0.36); p = 0.27, I² = 0%} and postoperative nausea and vomiting were not significantly different between the two groups {RR = 0.40, 95% CI (0.10 to 1.56), p = 0.19; I² = 56%}.

Conclusion: In summary, the erector spinae plane block (ESPB) appears to be the preferred option for acute postoperative pain and opioid reduction in adults undergoing laparoscopic cholecystectomy.

Excerpts

Comparative analyses have demonstrated the superiority of nerve blocks over conventional pain management modalities such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, given their targeted blockade of pain pathways at specific sites.

ESPB blocks are a relatively new technique and in particular have shown a remarkable analgesic effect, with the block extending to cover several dermatomes, thereby producing a broader coverage area.

OSTAPB blocks have been shown to target the sensory innervation of the abdominal wall, thereby reducing pain scores in patients undergoing laparoscopic cholecystectomy

Recently, in a meta-analysis by Yang et al. compared ESPB with a control group and other blocks for adults undergoing LC, however for the comparison between ESPB and OSTAPB only a limited number of studies were included

ESPB is a regional anesthesia technique that involves the injection of local anesthetic agents into the erector spinae plane, a plane of tissue located between the transverse process of the vertebrae and the erector spinae muscle

OSTAPB involves the administration of local anesthetics to the nerves that supply the anterior abdominal wall. The technique is performed by injecting local anesthetics into the plane between the internal oblique and transversus abdominis muscles.

The combined analysis of acute postoperative pain scores divided into two subgroups at 12 and 24 h showed ESPB to be superior of the two blocks as the pooled results were statistically significant

While the results were statistically significant, whether this difference meets the minimal clinically important difference (MCID) for postoperative pain relief on pain scale was unassessable.

The presence of intense pain following surgery poses a considerable risk for the emergence of long-term chronic pain as a prior study conducted with patients undergoing laparoscopic cholecystectomy revealed a connection between early visceral pain and the development of chronic pain. In this regard ESPB represents a promising option for perioperative analgesia

OSTAPB only produces sensory blocks in the somatic branches of the spinal nerves. Thus, ESPB may have a potential analgesic mechanism for visceral pain and is expected to provide better analgesia than OSTAPB

postoperative opioid consumption at 24 h was significantly reduced with the intervention of ESPB compared to OSTAPB

Citation

Saleem SZ, Akhtar SMM, Fareed A, Shaik AA, Asghar MS. Redefining pain management: investigating the efficacy and safety of erector spinae plane block and oblique subcostal transversus abdominis plane block in laparoscopic cholecystectomy - a meta analysis of randomized controlled trials. BMC Anesthesiol. 2025 Apr 16;25(1):182. doi: 10.1186/s12871-025-03059-1. PMID: 40240902; PMCID: PMC12001665.

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