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Pain Management & Sedation

Erector spinae plane block for intractable, nonsurgical abdominal pain: a scoping review

Ashley Meyer1orcid, Campbell Belisle Haley2orcid, Eisa Razzak3, Amanda Dos Santos2, Kyle Dornhofer2, Edmund Hsu2, Soheil Saadat2, John Christian Fox2, Megan Guy2orcid
Clinical and Experimental Emergency Medicine 2024;11(4):379-386.
Published online: March 15, 2024

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Correspondence to: Megan Guy Department of Emergency Medicine, University of California, Irvine, 3800 W Chapman Ave, Suite 3200 Orange, CA 92868, USA Email: guym@hs.uci.edu
• Received: December 3, 2023   • Revised: February 22, 2024   • Accepted: February 24, 2024

Copyright © 2024 The Korean Society of Emergency Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).

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  • Abdominal pain is one of the most common presenting chief complaints in the emergency department. Erector spinae plane block (ESPB) is an ultrasound-guided nerve block with proven effectiveness in treating visceral and somatic abdominal pain. Despite the increasing popularity of ESPB, its role in the management of nonsurgical abdominal pain has not yet been characterized. Our scoping review aims to synthesize current knowledge on the safety and efficacy of ESPB in the management of patients experiencing intractable, nonsurgical abdominal pain. We searched PubMed and Scopus to evaluate the existing literature on ESPB for nonsurgical abdominal pain. A total of 14 journal articles were included: 12 case-based studies, one systematic review, and one narrative review. All cases described the successful use of ESPB in treating abdominal pain refractory to oral or intravenous analgesic medications, and no complications were reported in any cases. This scoping review provides support for the use of ESPB to manage intractable, nonsurgical abdominal pain. ESPB has demonstrated efficacy in alleviating various conditions such as functional abdominal pain, renal colic, pancreatitis, herpetic pain, and cancer-related pain. Theoretical risks such as pneumothorax, bleeding, and infection are possible, although the studies reviewed did not report such complications.
  • Keywords: Abdominal pain; Erector spinae plane block; Nerve block; Diagnostic imaging; Conduction anesthesia
What is already known
Erector spinae plane block (ESPB) is an ultrasound-guided nerve block that has shown effectiveness in treating visceral and somatic pain.
What is new in the current study
Our review provides support for ESPB in the management of intractable, nonsurgical abdominal pain. ESPB demonstrates efficacy in alleviating various conditions such as functional abdominal pain, renal colic, pancreatitis, herpetic pain, and cancer-related pain.
Abdominal pain is a common presenting chief complaint in the emergency department (ED) and accounts for approximately 5% to 10% of annual ED visits [1]. The ongoing opioid epidemic and serious adverse events related to opioids create additional challenges for physicians when managing both acute and chronic abdominal pain. In recent years, regional anesthesia approaches such as celiac plexus nerve block have been used to manage visceral components of chronic, functional abdominal pain [2]. Erector spinae plane block (ESPB) is an ultrasound-guided nerve block that was introduced in 2016 and shows promise in treating visceral pain as well as somatic abdominal pain [3]. Using an ultrasound probe in the cephalocaudal orientation approximately 3 cm from midline, local anesthetic is injected into the erector spinae facial place which lies between the erector spinae muscles and the posterior surface of the transverse process. (Fig. 1) [4]. Analgesia is achieved with long-acting regional anesthetic injected into the erector spinae fascial plane, either as a bolus or a continuous infusion [5]. Nerve blocks including ESPB are favored due to their efficacy and limited adverse effects compared to pharmacologic agents [5]. The mainstream use of ultrasound to guide the procedure makes ESPB one of the safest peripheral nerve blocks. Despite the increasing popularity of ESPB, its role in the management of intractable, nonsurgical abdominal pain has not yet been fully characterized.
This scoping review aims to provide a better understanding of the safety and efficacy of ESPB in the management of patients experiencing intractable, nonsurgical abdominal pain. We chose to perform a scoping review due to limited prospective, randomized studies on this nerve block. This review includes all studies related to the use of ESPB for intractable, nonsurgical abdominal pain.
PubMed and Scopus were queried to evaluate existing literature on ESPB for intractable, nonsurgical abdominal pain. We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist (Supplementary Material 1) [6].
Eligibility criteria
Articles of all study types published in English prior to July 1, 2023, were considered for inclusion. We included studies evaluating the use of ESPB to manage intractable, nonsurgical abdominal pain in adult patients and excluded studies pertaining to perioperative pain. These indications included but were not limited to pancreatitis, renal colic, herpetic pain, and functional abdominal pain. We defined “intractable” pain as pain that was refractory to at least one dose of oral or intravenous systemic pain medications.
We initially identified 30 published articles using the following search query: (TITLE-ABS-KEY ("erector spinae")) AND (TITLE-ABS-KEY ("plane block" or "nerve block")) AND (TITLE-ABS-KEY ("abdominal pain")).
Two reviewers (AM and CBH) independently screened a total of 30 titles and abstracts that met our predefined inclusion and exclusion criteria. Discrepancies between the reviewers were resolved by a third reviewer (SS). Following our initial screening, 35 articles underwent full-text review. We screened the references of all studies meeting our criteria to find additional studies. A total of 14 studies were ultimately included in this review (Fig. 2). Key aspects of each study are summarized in Table 1 [7–20].
A total of 14 journal articles from eight countries between 2018–2023 were selected for scoping review based on their use of ESPB to treat intractable, nonsurgical abdominal pain (Table 1) [7–20]. There were 12 case-based studies, one systematic review, and one narrative review of ESPB for the treatment of intractable, nonsurgical abdominal pain. Of these 14 studies, eight took place in the ED, three involved patients evaluated by an inpatient pain service, two were from outpatient pain clinics, and one study combined multiple settings. There were 181 total described nerve blocks in the studies related to intractable, nonsurgical abdominal pain. No complications were reported in any of these studies.
Both single ESPBs and continuous nerve catheters were described in the included articles, with injections performed at the level T6–T11 thoracic spine levels. Medications used included single anesthetics as well as combinations of long-acting local anesthetics such as bupivacaine, ropivacaine, and levobupivacaine, while others used short-acting agents like lidocaine, corticosteroids, and normal saline for hydrodissection. Bupivicaine was the most frequently used local anesthetic and was often used in conjunction with lidocaine for immediate effect. Ropivacaine and lidocaine were also used alone to achieve analgesia. All studies using lidocaine injected it either as a mixture with a long-acting anesthetic or as a bolus before continuous infusion of a long-acting anesthetic [7–10].
There were 85 cases described in 14 articles that used ESPB for intractable, nonsurgical abdominal pain that was not a result of trauma or burns (Table 1) [7–20]. All the cases described using ESPB to treat abdominal pain refractory to at least one dose of oral or intravenous pain medications (our definition of “intractable” in this study). Six total cases described using ¬ESPB bilaterally to successfully treat refractory cancer-related pain due to colorectal cancer or cholangiocarcinoma [10–13]. Four studies described using ESPB for acute pancreatitis (10 total cases), while another study used ESPB for pain relief in a case of necrotizing pancreatitis [9,14–16]. To summarize, pain control was achieved in 11 pancreatitis cases using ESPB [9,14–17].
One case series of three patients described the successful use of ESPB followed by continuous infusion of 0.187% ropivacaine to treat functional abdominal pain in an outpatient pain clinic, with total resolution of pain at the 6-month follow-up reported for two patients [8]. Two case studies reported the use of ESPB to treat pain from postherpetic neuralgia, with one block performed at the tenth thoracic spine level for abdominal pain and another block used for cervicothoracic and shoulder pain [8,18]. Two prospective studies of ESPB for postherpetic neuralgia were also found: one observational study including 34 patients and one randomized controlled trial with 50 patients (26 randomized to the treatment group) [13]. One case series in the ED used ESPB for renal colic, with an improvement in pain score by an average of 8, using the average visual analog score; furthermore, additional pain medications were not required following these blocks for 8 to 11 hours [7]. A case report demonstrated the usefulness of ESPB in treating abdominal pain from mesenteric ischemia with improvement in pain from 2 out of 3 to 0 out of 3 [19].
This review identified multiple methods of achieving ESPB; injectable anesthetics were combined with corticosteroids in some instances while continuous regional anesthetic infusion was used in others. This resulted in a wide variation in the duration of analgesia. Continuous infusions led to decreased analgesic requirements that lasted throughout catheter placement and in some instances pain relief lasting up to 12 weeks [8,13]. However, continuous infusions were largely performed by inpatient or outpatient pain services [8,9,14,18,19]. In the ED studies (eight total), single blocks were used and demonstrated variable duration. Application of ESPB to treat the pain associated with renal colic resulted in no further oral or intravenous analgesic requirements for 8 to 11 hours [7,20]. A case report of ESPB for pancreatitis reported 24 hours of pain relief, while another described 19 hours of analgesia [15,16]. A case series of ESPB in patients with pancreatitis reported that the median time until the next oral or intravenous analgesic was required was 9 hours [10]. One study performed ESPB using ropivacaine and methylprednisolone for cancer-related pain and reported an improvement in pain score using the numerical rating scale for more than 2 weeks [12].
Review of the literature revealed that ESPB is effective for the treatment of intractable, nonsurgical abdominal pain. While this procedure has clear benefits, there are several concerns that need to be addressed prior to widespread use of ESPB in the ED setting. 
Unlike many other forms of pain relief, ESPB offers multidermatomal analgesia to the thoracic and abdominal walls anteriorly, posteriorly, and laterally [21]. This is achieved by the analgesic spreading along fascial planes throughout multiple vertebral levels, effectively anesthetizing a large area. ESPB provides a targeted approach to administering analgesia, effectively treating both somatic and visceral pain without the systemic side effects seen with oral or intravenous pain medications.
ESPB can serve as an opioid-sparing alternative to improve abdominal pain, including cancer-related pain [22]. Similarly, for chronic noncancer pain, evidence suggests that while opioids significantly improve pain, the magnitude of such improvement is small [23]. ESPB can be used to address this discrepancy. Moreover, while opioids may reduce pain, they may also have numerous adverse effects including nausea, vomiting, constipation, hyperalgesia, bradycardia, dizziness, syncope, delirium, and dependence [23,24]. Through our literature search, we identified numerous studies of patients on high doses of opioids who were able to reduce their opioid dosage after receiving ESPB.
ESPB and other regional nerve blocks also facilitate avoidance of nonopioid medication-related adverse effects. Common effects of nonsteroidal anti-inflammatory drugs include renal injury, gastritis/peptic ulcer disease, and gastrointestinal bleeding [25].  Additionally, muscle relaxants and neuropathic pain medications such as anticonvulsants and antidepressants can cause dizziness, drowsiness, and somnolence [26,27]. These systemic side effects are especially important to consider in the elderly who are most at risk for these adverse medication reactions. Using ESPB in the elderly for the treatment of abdominal pain could be an effective and safe alternative to systemic pain medications.
Finally, ESPB has been performed in multiple EDs in different countries, in addition to inpatient pain services and pain clinics. ESPB appears to be safe and effective when used by emergency physicians. With ubiquitous access to ultrasound machines and increasing emergency physician proficiency in ultrasound-guided procedures, there is significant potential for expanding the use of this regional nerve block in the ED.
While ESPB has broad utility, some adjustments to the ED workflow may be required for the block to be feasible. Nerve block kits that contain the equipment necessary for the procedure such as the local anesthetic, nerve block needle, syringe, extension tubing, sterile gel, ultrasound probe cover, and ChloraPrep will help facilitate the procedure for busy emergency physicians. The time to pain control may be delayed by the time it takes to obtain consent and prepare for the procedure; therefore, decreasing the time required to acquire the materials is important. Additionally, physicians without adequate point-of-care-ultrasound training may be hesitant to conduct regional nerve blocks; this could be mitigated by departmental training. It would be beneficial for emergency medicine residents and attendings to receive training on performing ESPB under ultrasound guidance to increase physician comfortability performing the block. Finally, many of the studies described continuous infusions via nerve catheters by pain specialists, which is not feasible in the emergency setting. Thus, while ESPB may be useful for short-term pain relief of up to 24 hours, additional pain management may be required after the anesthetic wears off, and appropriate follow-up is necessary.
Despite the various benefits of ESPB, there are several risks that require consideration. While this is rare under ultrasound guidance, it is possible to cause a pneumothorax while performing this nerve block, although there were no reported pneumothoraces in any of the reviewed studies. A pneumothorax may occur as the result of poor hand-eye coordination or miscalculation of the proper injection site if the provider loses visualization of the needle tip under ultrasound guidance [28]. Additionally, as with any injection, there is the risk of infection if sterility is broken, and a risk of bleeding if the provider penetrates a blood vessel or if the patient is prone to bleeding. Furthermore, while there are theoretical complications such as local anesthetic systemic toxicity and neurovascular injury, these are extremely rare and none of these complications were reported in the studies we reviewed.
While the effectiveness and safety of ESPB have been demonstrated, the time required to perform the procedure may decrease provider willingness, and the pain associated with receiving an injection may decrease patient willingness. Additionally, depending on the ED length of stay, a patient may require multiple nerve blocks once the anesthetic wears off, which can be time-consuming for both the physician and the patient. While the overall benefits of EPSB may outweigh these negative aspects, patient and provider preferences and treatment goals should be taken into consideration.
An important limitation of this scoping review is the lack of data and randomized controlled trials on ESPB. Over a 5-year period, 14 journal articles were found that met the inclusion criteria. As such, our findings suggest several potential uses of this nerve block but there is not a large body of evidence to support these uses. Prospective studies are needed to provide further evidence supporting the feasibility and safety of ESPB. Additionally, given that our criteria involved only articles published in English, there is the possibility that we missed supporting evidence from non-English articles; this limitation should be addressed in future studies. 
In summary, the current literature illustrates the potential benefits of ESPB in patients experiencing intractable, nonsurgical abdominal pain. Additional research will enhance our understanding of the advantages and limitations of ESPB. Based on the current literature, ESPB is a promising alternative to standard systemic pain medications for emergency physicians and can reduce the incidence of systemic side effects from pain medications, especially in at-risk populations such as the elderly. More studies are needed to unequivocally demonstrate that this regional nerve block is both feasible and cost-effective in the ED setting. To conclude, the current literature supports ESPB as a safe, effective analgesic approach for intractable, nonsurgical abdominal pain of multiple etiologies. However, our review highlights the need for prospective, randomized controlled trials of ESPB.

Author contributions

Conceptualization: all authors; Investigation: all authors; Methodology: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Supplementary materials are available from https://doi.org/10.15441/ceem.23.171.

Supplementary Material 1.

PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist.
ceem-23-171-supplementary-Material-1.pdf
Fig. 1.
Insertion site and ultrasound view. (A) The transducer is oriented cephalocaudal and held over the transverse process. The needle insertion may be 1 to 2 cm from the probe. (B) Ultrasound view demonstrating the needle path contacting the posterior surface of the transverse process.
ceem-23-171f1.jpg
Fig. 2.
Flowchart of search strategy for studies that used erector spinae plane block (ESPB) to treat nonsurgical abdominal pain.
ceem-23-171f2.jpg
Table 1.
Summary of published studies discussing the use of ESPB in intractable, nonsurgical abdominal pain
Table 1.
Study Country Indications for ESPB Practice setting Study sample Type of study Details of block Outcome measure Key finding
Abdelhamid et al. [20] (2020) Canada Review article of ESPB in the ED ED 10 Studies Systematic review NA Indications for ESPB in the ED Of 10 total articles, nine were case reports or series (101 total cases)
Rib fractures, spine fractures, burns, herpes zoster, renal colic, and pancreatitis were all listed as potential indications
Abdelhamid and Salim [19] (2023) Canada Pain from mesenteric ischemia Inpatient pain service 1 Case (70 yr male patient with pain from mesenteric ischemia) Case report ESPB bilaterally at T6 using 20 mL 0.2% ropivacaine followed by 0.2% 0–10 mL/hr infusion Improvement of 3-point VAS Patient with improvement from 2–3/3 to 0/3 after ESPB
Ahiskalioglu et al. [18] (2018) Turkiye Pain from herpes zoster Outpatient pain clinic 1 Case (72 yr male patient with herpes zoster-related abdominal pain) Case report ESPB at T10 with 20 mL of 0.25% bupivacaine Improvement of VAS VAS improved from 9/10 to 3/10
Allos et al. [14] (2021) USA Pain from necrotizing pancreatitis Inpatient pain service 1 Case (27 yr female patient with postoperative necrotizing pancreatitis) Case report ESP catheter at T7, 30 mL of 0.25% bupivacaine Improvement of VAS, decreased use of other pain medications VAS improved from 10/10 to 0/10 after 1 hr
Opioid, precedex, and ketamine use was decreased
Ashworth et al. [11] (2022) USA Chronic pain from metastatic cancer ED 1 Case (54 yr female patient with metastatic colon cancer) Case report ESPB at T9 with 20 mL of 0.5% bupivacaine Improvement of pain indicated by numeric pain rating Patient reported complete resolution of pain 30 min after ESPB and reported 1/10 pain afterwards
She was able to be discharged
Aydin et al. [7] (2019) Turkiye Refractory pain from confirmed renal colic ED 3 Cases (56 yr male, 50 yr female, and 52 yr female patients with confirmed urolithiasis) Case series ESPB at T8, T9 with 20–30 mL of 0.25% bupivacaine mixed with 2% lidocaine Improvement of VAS, time needed before next oral analgesic Improvement of VAS:
from 10/10 to 0/10 (3 min),
from 8/10 to 2/10
from 10/10 to 2/10
Analgesic requirement time between 8–11 hr
Chung et al. [8] (2021) Korea Functional abdominal pain Outpatient pain clinic 3 Cases (59 yr male, 31 yr female, 34 yr female patients with chronic abdominal pain, no structural etiology) Case series ESPB at T10, T7 bilaterally (2) with 15 mL 0.5% lidocaine injected (single ESPB) and 10 mL 0.5% lidocaine followed by 2 mL/hr of 0.187% ropivacaine (continuous ESP catheter) Improvement of NRS directly after procedure, improvement in abdominal pain weeks-months after ESPB Initial (improvement of NRS):
from 8 to 3,
9 to 3 (30 min),
from 7 to 2 (30 min)
Long-term:
two patients had no return of their pain after 6 mo, one had a repeat procedure and after 2 wk NRS was maintained in the 2–3 range
Das et al. [9] (2023) UK Pain from acute pancreatitis Inpatient pain service 1 Case (72 yr male patient with acute pancreatitis) Case report ESP at T8 with 20 mL 1% lidocaine followed by 1 mL/hr 0.125% continuous infusion of levobupivacaine Improvement of VAS, reduction of oxycodone consumption VAS improved from 8–9/10 to 3–4/10 at 30 min, and was 1/10 at 1 hr
Significant reduction in oxycodone use within 10 hr, and none required at 24 hr
Elkoundi et al. [15] (2019) Morocco Pain from acute pancreatitis ED 1 Case (58 yr male patient with refractory pain in acute pancreatitis) Case report ESPB at T6, 15 mL of 0.5% bupivacaine Improvement of NRS NRS improved from 10/10 to 2/10
Pain reduction lasted until the next day
Elsharydah et al. [13] (2023) USA Pain from PHN, chronic lumbar pain Various settings 2 Studies Narrative review NA Previous evidence of ESPB efficacy Observational study (n=34), RCT (n=26 in block group) supporting use in PHN, cases supporting use in PHN, chronic low back pain (n=1), cancer-related pain (n=3)
1 Case of PHN
1 Case
1 Case series in chronic low back pain
Gopinath et al. [17] (2021) India Pain from pancreatitis ED 4 Cases with acute pancreatitis (50 yr female, 36 yr female, 44 yr male, 15 yr male) Case series ESPB at T7 with 30 mL of 1% lidocaine 5 mg/kg, 0.5% bupivacaine 2 mg/kg, and dexamethasone 8 mg bilaterally Improvement of DVPRS Median DVPRS before and after the procedure was 8 (IQR, 7) and 3 (IQR, 2.5) 30 min following ESPB.
2 Cases with chronic pancreatitis (38 yr male, 30 yr male) At 60 min, DVPRS was reduced to 2 (IQR, 4)
Gopinath et al. [10] (2022) India Chronic pain from cholangiocarcinoma ED 1 Case (62 yr male with refractory pain from cholangiocarcinoma) Case report ESPB at T7 bilaterally, 30 mL mixture of 1% lidocaine (2 mg/kg), 0.5% bupivacaine (1 mg/kg), 4 mg dexamethasone injected Improvement of DVPRS Pain rating decreased from 8/10 pre-procedure to 3/10 (15 min) and 2/10 (1 hr)
Improvement in sleep Sleep improved over the next 4 days
Bugada and Zarcone [12] (2020) Italy Chronic pain from colorectal cancer ED 1 Case (20 yr male with refractory pain from colorectal cancer) Case report ESPB at T7 bilaterally, 20 mL of 0.5% ropivacaine with 40 mg methylprednisolone injected Improvement of NRS over 2 wk NRS values decreased, and remained low for more than 2 wk, no rescue morphine needed for 3 days after the procedure
Mantuani et al. [16] (2020) USA Pain from acute pancreatitis ED 1 Case (32 yr male with refractory pain from acute pancreatitis) Case report ESPB at T7 bilaterally with 10 mL normal saline for hydrodissection, 15 mL of 0.5% bupivacaine with epinephrine Improvement of patient-reported numeric pain rating Pain reported 0/10 (30 min), 2/10 (5 hr, given 0.5mg hydromorphone), 0/10 (19 hr)
Summary (14 studies, 2018–2023) 8 Countries 181 Cases described: 84 traumatic fractures, 11 mechanical low back pains, 11 pancreatitis, 6 cancer-related chronic abdominal pains, 3 renal colic, 3 functional abdominal pains, 61 herpes zoster, 1 burn 8 EDs - 12 Case reports ESPB described from T6–T10, often bilaterally - Support of ESPB in all studies, with pain relief reported within the first 30 min, and some patients experienced no recurrence of pain
3 Inpatient pain services 1 Systematic review
2 Outpatient pain clinics 1 Narrative review
1 Review

ESPB, erector spinae plane block; ED, emergency department; NA, not available; VAS, visual analog scale; ESP, erector spinae plane; NRS, numerical rating scale; PHN, postherpetic neuralgia; RCT, randomized controlled trial; DVPRS, Defense and Veteran Pain Rating Scale; IQR, interquartile range.

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Erector spinae plane block for intractable, nonsurgical abdominal pain: a scoping review
Clin Exp Emerg Med. 2024;11(4):379-386.   Published online March 15, 2024
DOI: https://doi.org/10.15441/ceem.23.171
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Erector spinae plane block for intractable, nonsurgical abdominal pain: a scoping review
Clin Exp Emerg Med. 2024;11(4):379-386.   Published online March 15, 2024
DOI: https://doi.org/10.15441/ceem.23.171
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Erector spinae plane block for intractable, nonsurgical abdominal pain: a scoping review
Image Image
Fig. 1. Insertion site and ultrasound view. (A) The transducer is oriented cephalocaudal and held over the transverse process. The needle insertion may be 1 to 2 cm from the probe. (B) Ultrasound view demonstrating the needle path contacting the posterior surface of the transverse process.
Fig. 2. Flowchart of search strategy for studies that used erector spinae plane block (ESPB) to treat nonsurgical abdominal pain.

Fig. 1.

Fig. 2.

Erector spinae plane block for intractable, nonsurgical abdominal pain: a scoping review
Study Country Indications for ESPB Practice setting Study sample Type of study Details of block Outcome measure Key finding
Abdelhamid et al. [20] (2020) Canada Review article of ESPB in the ED ED 10 Studies Systematic review NA Indications for ESPB in the ED Of 10 total articles, nine were case reports or series (101 total cases)
Rib fractures, spine fractures, burns, herpes zoster, renal colic, and pancreatitis were all listed as potential indications
Abdelhamid and Salim [19] (2023) Canada Pain from mesenteric ischemia Inpatient pain service 1 Case (70 yr male patient with pain from mesenteric ischemia) Case report ESPB bilaterally at T6 using 20 mL 0.2% ropivacaine followed by 0.2% 0–10 mL/hr infusion Improvement of 3-point VAS Patient with improvement from 2–3/3 to 0/3 after ESPB
Ahiskalioglu et al. [18] (2018) Turkiye Pain from herpes zoster Outpatient pain clinic 1 Case (72 yr male patient with herpes zoster-related abdominal pain) Case report ESPB at T10 with 20 mL of 0.25% bupivacaine Improvement of VAS VAS improved from 9/10 to 3/10
Allos et al. [14] (2021) USA Pain from necrotizing pancreatitis Inpatient pain service 1 Case (27 yr female patient with postoperative necrotizing pancreatitis) Case report ESP catheter at T7, 30 mL of 0.25% bupivacaine Improvement of VAS, decreased use of other pain medications VAS improved from 10/10 to 0/10 after 1 hr
Opioid, precedex, and ketamine use was decreased
Ashworth et al. [11] (2022) USA Chronic pain from metastatic cancer ED 1 Case (54 yr female patient with metastatic colon cancer) Case report ESPB at T9 with 20 mL of 0.5% bupivacaine Improvement of pain indicated by numeric pain rating Patient reported complete resolution of pain 30 min after ESPB and reported 1/10 pain afterwards
She was able to be discharged
Aydin et al. [7] (2019) Turkiye Refractory pain from confirmed renal colic ED 3 Cases (56 yr male, 50 yr female, and 52 yr female patients with confirmed urolithiasis) Case series ESPB at T8, T9 with 20–30 mL of 0.25% bupivacaine mixed with 2% lidocaine Improvement of VAS, time needed before next oral analgesic Improvement of VAS:
from 10/10 to 0/10 (3 min),
from 8/10 to 2/10
from 10/10 to 2/10
Analgesic requirement time between 8–11 hr
Chung et al. [8] (2021) Korea Functional abdominal pain Outpatient pain clinic 3 Cases (59 yr male, 31 yr female, 34 yr female patients with chronic abdominal pain, no structural etiology) Case series ESPB at T10, T7 bilaterally (2) with 15 mL 0.5% lidocaine injected (single ESPB) and 10 mL 0.5% lidocaine followed by 2 mL/hr of 0.187% ropivacaine (continuous ESP catheter) Improvement of NRS directly after procedure, improvement in abdominal pain weeks-months after ESPB Initial (improvement of NRS):
from 8 to 3,
9 to 3 (30 min),
from 7 to 2 (30 min)
Long-term:
two patients had no return of their pain after 6 mo, one had a repeat procedure and after 2 wk NRS was maintained in the 2–3 range
Das et al. [9] (2023) UK Pain from acute pancreatitis Inpatient pain service 1 Case (72 yr male patient with acute pancreatitis) Case report ESP at T8 with 20 mL 1% lidocaine followed by 1 mL/hr 0.125% continuous infusion of levobupivacaine Improvement of VAS, reduction of oxycodone consumption VAS improved from 8–9/10 to 3–4/10 at 30 min, and was 1/10 at 1 hr
Significant reduction in oxycodone use within 10 hr, and none required at 24 hr
Elkoundi et al. [15] (2019) Morocco Pain from acute pancreatitis ED 1 Case (58 yr male patient with refractory pain in acute pancreatitis) Case report ESPB at T6, 15 mL of 0.5% bupivacaine Improvement of NRS NRS improved from 10/10 to 2/10
Pain reduction lasted until the next day
Elsharydah et al. [13] (2023) USA Pain from PHN, chronic lumbar pain Various settings 2 Studies Narrative review NA Previous evidence of ESPB efficacy Observational study (n=34), RCT (n=26 in block group) supporting use in PHN, cases supporting use in PHN, chronic low back pain (n=1), cancer-related pain (n=3)
1 Case of PHN
1 Case
1 Case series in chronic low back pain
Gopinath et al. [17] (2021) India Pain from pancreatitis ED 4 Cases with acute pancreatitis (50 yr female, 36 yr female, 44 yr male, 15 yr male) Case series ESPB at T7 with 30 mL of 1% lidocaine 5 mg/kg, 0.5% bupivacaine 2 mg/kg, and dexamethasone 8 mg bilaterally Improvement of DVPRS Median DVPRS before and after the procedure was 8 (IQR, 7) and 3 (IQR, 2.5) 30 min following ESPB.
2 Cases with chronic pancreatitis (38 yr male, 30 yr male) At 60 min, DVPRS was reduced to 2 (IQR, 4)
Gopinath et al. [10] (2022) India Chronic pain from cholangiocarcinoma ED 1 Case (62 yr male with refractory pain from cholangiocarcinoma) Case report ESPB at T7 bilaterally, 30 mL mixture of 1% lidocaine (2 mg/kg), 0.5% bupivacaine (1 mg/kg), 4 mg dexamethasone injected Improvement of DVPRS Pain rating decreased from 8/10 pre-procedure to 3/10 (15 min) and 2/10 (1 hr)
Improvement in sleep Sleep improved over the next 4 days
Bugada and Zarcone [12] (2020) Italy Chronic pain from colorectal cancer ED 1 Case (20 yr male with refractory pain from colorectal cancer) Case report ESPB at T7 bilaterally, 20 mL of 0.5% ropivacaine with 40 mg methylprednisolone injected Improvement of NRS over 2 wk NRS values decreased, and remained low for more than 2 wk, no rescue morphine needed for 3 days after the procedure
Mantuani et al. [16] (2020) USA Pain from acute pancreatitis ED 1 Case (32 yr male with refractory pain from acute pancreatitis) Case report ESPB at T7 bilaterally with 10 mL normal saline for hydrodissection, 15 mL of 0.5% bupivacaine with epinephrine Improvement of patient-reported numeric pain rating Pain reported 0/10 (30 min), 2/10 (5 hr, given 0.5mg hydromorphone), 0/10 (19 hr)
Summary (14 studies, 2018–2023) 8 Countries 181 Cases described: 84 traumatic fractures, 11 mechanical low back pains, 11 pancreatitis, 6 cancer-related chronic abdominal pains, 3 renal colic, 3 functional abdominal pains, 61 herpes zoster, 1 burn 8 EDs - 12 Case reports ESPB described from T6–T10, often bilaterally - Support of ESPB in all studies, with pain relief reported within the first 30 min, and some patients experienced no recurrence of pain
3 Inpatient pain services 1 Systematic review
2 Outpatient pain clinics 1 Narrative review
1 Review
Table 1. Summary of published studies discussing the use of ESPB in intractable, nonsurgical abdominal pain

ESPB, erector spinae plane block; ED, emergency department; NA, not available; VAS, visual analog scale; ESP, erector spinae plane; NRS, numerical rating scale; PHN, postherpetic neuralgia; RCT, randomized controlled trial; DVPRS, Defense and Veteran Pain Rating Scale; IQR, interquartile range.

Table 1.

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