A practical, evidence-based guide for spine surgeons — why you should add this to your practice, exactly how to do it, and what the two new negative trials actually tested.
Updated October 2026 • Companion to “Blocked: Regional Analgesia in Spine Surgery on Trial” • Atlantic Spine SocietyThe erector spinae plane block (ESPB) has exploded in the anesthesia literature over the past decade, with more than 1,700 studies published. But the dominant technique — ultrasound-guided — requires an anesthesiologist with regional block expertise, an ultrasound machine, and dedicated pre-op block time. For most spine practices, that is a bottleneck: some lists get the block, most don't.
The fluoroscopy-guided ESPB changes the equation. We are already prone with the C-arm draped. We can perform this block ourselves, in roughly 1–3 minutes, with a spinal needle and the AP film we shoot anyway to confirm the level. The evidence shows equivalent analgesia with a faster, surgeon-controlled workflow.
The oft-quoted estimate is that a research finding takes about 17 years to reach routine care, and that only around 14% of original research ever gets there at all. Those figures are estimates and have been debated, but nobody argues the gap is small. The tension is that in AO Spine's own 2025 survey of 458 surgeons in 81 countries, 68% said published evidence and conference presentations are what change their practice. So why the gap?
AO Spine has made knowledge translation a formal priority. Its 2025 scoping review of 34 surgical implementation studies found the same barriers every time: a preference for existing practice, workflow disruption, cost and resources, and the absence of a local champion. What works is layered — education, a reminder embedded in the workflow, and feedback on outcomes. The AO Spine adoption survey put numbers on the barriers surgeons actually report. Here is how this block stacks up against each one:
| Barrier | How Often Surgeons Cite It | Fluoroscopic ESPB |
|---|---|---|
| Material logistics | 55% — the single biggest barrier (AO Spine survey) | Nothing to buy. A spinal needle and two syringes of local. |
| Unfamiliarity | 50% — “I don't know how to do it” | The C-arm and the AP film you read on every case. Bone contact as the endpoint. |
| Cost and reimbursement | 25% — no code, no budget line | No capital, no disposables, no billing. Three minutes of OR time. |
| Workflow disruption | Top barrier in the AO Spine KT scoping review | Done during the level check you already do, before the incision. |
| Depends on another department | Leadership and interdisciplinary buy-in cited as both barrier and enabler | You do it. Anesthesia's involvement is a conversation about the drug, not a block-room slot. |
Multiple studies now support fluoroscopy-guided ESPB specifically — not just extrapolations from the ultrasound literature — and every meta-analysis in lumbar surgery points the same way.
| Study | Design | N | Key Findings |
|---|---|---|---|
| Owen et al. 2023 Global Spine J |
Retrospective comparative | 76 | Surgeon-placed fluoroscopic ESPB before 1–2 level lumbar fusion: 37% lower opioid use on POD1 (32 vs 51 MED, p<.05), 53% more ambulation (312 vs 204 ft), shorter LOS (2.4 vs 3.2 days). 22% of block patients used zero opioids vs 5% of controls. |
| Gnanaprakash et al. 2025 Global Spine J |
Prospective RCT | 66 | Surgeon fluoroscopic ESPB vs. anesthetist ultrasound ESPB for single-level lumbar fusion: identical pain scores (VAS 2.7 vs 2.7, p=.91), identical opioid use. Fluoroscopy was faster (3.0 vs 4.7 min). |
| Wu et al. 2024 World Neurosurg |
Meta-analysis (25 RCTs) | 1,917 | Bilateral ESPB in spine surgery: lower pain scores and opioid consumption. High heterogeneity in agent, volume, timing and injection level. |
| Muthu et al. 2024 World Neurosurg X |
Systematic review / MA | — | PRISMA-compliant update: bilateral ESPB reduces postoperative pain and opioid requirement after lumbar spine surgery. |
| Oh et al. 2022 J Clin Anesth |
Systematic review / MA | — | Reduced 24-h opioid use and pain in lumbar surgery; effect strongest in open posterior procedures. |
| Khor et al. 2025 Global Spine J |
Meta-analysis (5 RCTs) | 432 | ESPB vs. thoracolumbar interfascial plane block: comparable analgesia; ESPB is simpler and safer to place. |
| Tulgar et al. 2018 Indian J Anaesth |
Feasibility | — | First demonstration of fluoroscopic ESPB as a feasible alternative to ultrasound guidance — a bony target instead of a probe. |
The needle stops on bone, distant from pleura, cord and great vessels. Systematic reviews report no pneumothorax or neuraxial injury attributable to ESPB. The site is compressible and the block is classified as superficial in the ESAIC/ESRA guidance, so antithrombotic therapy can continue. Measured plasma levels with 20–30 mL per side of 0.25–0.375% agents remain well below toxicity thresholds. Quadriceps weakness from lumbar plexus spread has been reported after large-volume blocks at L4 in ambulatory hernia patients; in the lumbar-level spine cohorts, Owen's block patients walked 53% farther on day one and Gnanaprakash reported no motor complications.
The Gnanaprakash et al. RCT (Global Spine Journal, 2025) is the first prospective head-to-head comparison. The result was equivalence — so the decision comes down to who can deliver the block, and when.
The target is the fascial plane between the deep surface of the erector spinae muscle (ESM) and the posterior surface of the transverse process (TP). Local anesthetic deposited here spreads cranio-caudally along the plane and blocks the dorsal rami of the spinal nerves — which supply the stripped and retracted paraspinal muscles, the facet capsules and periosteum, and the posterior skin. Those are the pain generators of a posterior approach, and they are segmental: whatever block we use has to reach the segments we operated on.
Figure 1. Axial cross-section showing the target erector spinae plane (green) between the deep surface of the erector spinae muscle and the transverse process. The needle is advanced to contact the TP, then withdrawn 1–2 mm before injection.
Once deposited in the ESP plane, local anesthetic spreads cranio-caudally along the fascial plane. Cadaveric dye studies show a single 20–30 mL injection reaches 2–5 vertebral levels — variable and unpredictable between specimens. Some anterior spread to the paravertebral space (and thus the ventral rami) has been demonstrated, though this too is variable and volume-dependent. The practical consequence: inject close to the operated segments. We inject one level above the construct — L3 for an L4–5 fusion — so that spread runs down over the operated levels, and the injection site stays clear of the dissection if you are going out to the transverse processes for a posterolateral fusion.
Figure 2. Schematic AP fluoroscopic view for an L4–5 fusion. The needle tip is directed to the posterior surface of the L3 transverse process — one level above the construct. Local anesthetic (green dashes) spreads cranio-caudally along the plane over the operated segments.
The block is performed after positioning and prep, at the moment you shoot your level-check film, before the incision. It is performed bilaterally for any midline posterior approach. Equipment: the draped C-arm, a 22G spinal needle, and two 20 mL syringes of local anesthetic. Nothing else — no ultrasound, no probe cover, no block room, no second specialist, no contrast.
Patient in prone position on the operative table, prepped exactly as for the case. Nothing changes in the room.
Endplates square, spinous process midline. For an L4–5 fusion, identify the L3 transverse process. This is the same film as your level check.
Skin entry approximately 2–3 cm off midline, over that transverse process. Injecting one level above the construct keeps the injection out of the field if you are dissecting out to the TPs for a posterolateral fusion, and the spread runs caudally over the operated segments.
Walk the spinal needle onto the posterior surface of the transverse process. Bone contact is your depth stop — you cannot go too deep if you stop on bone. The needle in your hand is the same one you would use to mark the level; the only difference is the endpoint.
The tip now sits in the plane deep to the erector spinae. Aspirate; if clear, inject 15–20 mL. The local should flow easily — stiff resistance on the syringe means the tip is in muscle, so re-seat on bone and back off again.
Two sides, about three minutes, before the incision. Then prep and drape exactly as usual. The block covers the dorsal rami territory — posterior paraspinal muscles and skin — which are the primary pain generators of a posterior approach.
Figure 3. Lateral schematic showing the needle contacting the transverse process, then being withdrawn 1–2 mm into the erector spinae plane. Local anesthetic (green arrows) spreads cranio-caudally along the fascial plane between the ESM and the transverse processes.
Published protocols vary. The following is a reasonable starting point based on the literature:
| Parameter | Lumbar fusion / decompression | Thoracic / thoracolumbar |
|---|---|---|
| Agent | Bupivacaine 0.25% or ropivacaine 0.2–0.5% | Ropivacaine 0.2% or bupivacaine 0.25% |
| Volume per side | 15–20 mL, one level above the construct | 20–30 mL (≈2.5 mL per level to cover) |
| Total, bilateral | 30–40 mL | 40–60 mL |
| Ceiling | Bupivacaine 2 mg/kg · ropivacaine 3 mg/kg — calculate for patient weight before drawing up, and subtract any wound infiltration you plan | |
| Extended-release option | Liposomal bupivacaine 10 mL + 10 mL saline per side (Owen protocol) for 48–72 h coverage. Off-label in many jurisdictions. | |
Do it at level-marking time, before the incision. Same film, same needle, one extra endpoint. Every surgeon-placed series put the block in before incision.
Inject one level above the construct. The spread runs down over the operated levels, and you stay out of your own dissection for a posterolateral fusion. One injection per side covers a two-level construct.
Think “touch bone and back off.” Advance until bony contact with the TP, withdraw 1–2 mm, aspirate, inject. The goal is to lift the ESM off the TP, not to inject into the muscle or onto the bone.
Bilateral for any midline approach. The dorsal rami don't cross the midline.
Tell PACU and the ward the block is in. It changes their opioid expectations — make sure the people giving the opioids know.
Intramuscular injection. Stiff resistance on the syringe. Go back to bone, back off again, re-aspirate.
Slipping medial off the TP toward the foramen. Withdraw, re-aspirate, and find bone again on the posterior TP surface. Always aspirate before injecting.
Forgetting the weight-based ceiling when going bilateral. Calculate mg/kg before starting, especially with bupivacaine in smaller patients.
Blocking the wrong level because the AP wasn't true. Square the endplates and centre the spinous process first.
Placing it after closure and expecting it to beat the morphine already on board. See Section 9.
Two randomized trials published in 2025–26 concluded that bilateral ESPB adds little to multimodal analgesia after lumbar fusion. Both are well-run, honestly reported studies in good journals. Both are also n = 76, single-centre, ultrasound-guided by anesthesiologists — and both injected at T12 for surgery at L4–5.
| Trial | Design | Result |
|---|---|---|
| van de Wijgert et al. 2026 Anesth Analg |
Placebo-controlled, blinded. Open posterior lumbar fusion, 1–4 levels. Bilateral US-guided ESPB at T12, 30 mL ropivacaine 0.375% per side vs 30 mL saline, placed after wound closure. Primary outcome: NRS 1 h after emergence. | NRS 3.8 vs 4.2 (p=.56); 12-h morphine 11 vs 13 mg. Time to first opioid 64 vs 41 min. “Not recommended.” |
| Jo et al. 2025 J Neurosurg Anesthesiol |
No-block control. MIS TLIF (50%) or OLIF (50%), mostly L4–5. Bilateral US-guided ESPB at T12, 25 mL bupivacaine 0.375% per side, pre-incision. Wound infiltration in both arms. Primary outcome: QoR-15 on day 1. | QoR-15 80 vs 81 (p=.90). But pain on first walk at 1 h 7 vs 9 (p=.013) and first ambulation 2 h vs 5 h (p=.038). |
1. Wrong level. L4–5 pain is carried by the L3–L5 dorsal rami. A T12 injection has to travel four to five segments to reach them, and single-injection spread in cadavers is 2–5 levels and unpredictable — both trials cite exactly that. The authors concede the point: Jo et al. write that results “may have been more favorable towards ESPB if the block had been performed at the level of surgery”; van de Wijgert et al. note “it is not clear if the lumbar and thoracic erector spinae are continuous anatomically.” Both chose T12 out of concern for lumbar plexus spread and motor block — a real phenomenon reported after large-volume L4 blocks in ambulatory hernia patients, but one not seen in the lumbar-level spine cohorts, where fluoroscopy stops the needle on bone and the patient is in bed while the block is densest.
2. Wrong timing (van de Wijgert). The block was placed after closure — after pre-op gabapentin, paracetamol and etoricoxib, after intra-op ketamine, sufentanil and dexamethasone, and after 0.1 mg/kg of morphine at closure — and judged one hour later. Every surgeon-placed series put the block in before incision. This trial asked whether a late block could beat a regimen that had already peaked.
3. Wrong operation (Jo). Half the cohort had an OLIF — a left-flank retroperitoneal approach past the psoas, whose pain is anterolateral and carried by the ventral rami and lumbar plexus. The dorsal rami weren't in the operation. The other half was tubular, muscle-splitting MIS TLIF, with far less erector spinae trauma than the open fusions in the positive trials. And every patient in both arms received 10 mL of 0.5% bupivacaine wound infiltration, the comparator ESPB least reliably beats.
4. Nobody checked for a block. Neither trial verified sensory blockade — van de Wijgert state this explicitly. And the van de Wijgert placebo was 60 mL of saline in the same plane, a hydrodissection of the erector spinae that has measurable analgesic effects of its own. A negative trial of an unverified block is a trial of the injection, not the block.
| Owen 2023 | Gnanaprakash 2025 | van de Wijgert 2026 | Jo 2025 | |
|---|---|---|---|---|
| Result | Positive | Equivalent to US | Null | Null (QoR-15) |
| Injection level | Surgical level | Surgical level | T12 | T12 |
| Timing | Pre-incision | Pre-incision | After closure | Pre-incision |
| Guidance / operator | Fluoro / surgeon | Fluoro / surgeon vs US / anesthetist | US / anesthetist | US / anesthetist |
| Operation | Open PLF, 1–2 levels | Open fusion, 1 level | Open fusion, 1–4 levels | MIS TLIF / OLIF |
| Comparator | No block | US ESPB | Saline 30 mL/side | No block; infiltration both arms |
| Sensory block checked? | No | No | No — “not verified” | No |
| n | 76 | 66 | 76 | 76 |
Agree the agent, the weight-based ceiling, and who draws it up. This page is written for both of you.
That's the whole equipment list. No committee, no capital, no contrast.
Bilateral, one level above the construct. Touch bone, back off, aspirate, inject.
Opioid orders, first walk, discharge. You'll notice — and so will the nurses.
A block changes opioid expectations; make sure the people giving the opioids know it's in.