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Erector spinae plane block (ESPB) is a newly described interfascial plane block, and the number of articles on the bilateral application of ESPB is increasing in the literature. In this paper, in addition to analyzing bilateral ESPB cases and studies published so far, we aimed to review the relevant anatomy, describe the mechanism of spread of the injectant, demonstrate varying approaches to ESPB, and summarize case reports and clinical trials, as well as provide current insight on this emerging and popular block. Randomized controlled studies, comparative studies of ESPB versus other methods, and pharmacokinetic studies of bilateral applications must be the next step in clearly understanding bilateral ESPB.

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To the Editor,A recent study published by Hand et al. described an ultrasonography-guided thoracolumbar interfascial plane (TLIP) block. 1 This block involves injecting local anesthetics between the multifidus and longissimus muscles at the third lumbar vertebral level to block the dorsal rami of thoracolumbar nerves. 2 Hand et al. made the injection between the multifidus and longissimus muscles by positioning the block needle at a 30°angle from the skin and advanced it from a lateral to medial direction ( Figure).Herein, we describe our TLIP modification where we inject the anesthetics between the longissimus and iliocostalis muscles after having advanced the needles at a 15°angle in a medial to lateral direction. Our modified method has several advantages.1. Advancing the needle from a medial to lateral direction eliminates the risk of possible inadvertent neuraxial injection.2. Injecting between the iliocostalis and longissimus muscles results in a dermatomal area of analgesia similar to that obtained with an injection made between the multifidus and longissimus muscles. We have demonstrated this area of analgesia using radiopaque dye injections (with specific patient consent) where the distribution of the local anesthetics spread two levels caudal and cranial to the injection site. Twenty minutes after injection, we could show a corresponding dermatomal area (using a pinprick test) of reduced sensation. 3. Sonographic imaging more easily discerns the distinction between the longissimus and iliocostalis muscles than between the multifidus and longissimus muscles, thereby potentially increasing the success rate of the block.These modifications to the TLIP block will require further study to investigate their potential advantages more fully. Such investigations, including magnetic resonance imaging and cadaveric studies combined with ultrasonography, should be beneficial for evaluating the block's potential anatomic spread. When compared with some other nerve blocks, interfascial plane blocks are highly dependent on sufficient volumes of local anesthetics to spread between the muscle layers and fascial planes. The TLIP block might be useful for 2 and 3 vertebral level spinal surgical procedures as well as minimally invasive spinal surgery.

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Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used interfacial plans, and it has been the most discussed block among the recently defined techniques. Lumbar ESPB administered at lumbar levels is relatively novel and is a new horizon for regional anesthesia and pain practice. In this article, we aim to explain and introduce different approaches and explain the possible mechanism of action of lumbar ESPB. The objective of this review is to analyze the case reports, clinical and cadaveric studies about lumbar ESPB that have been published to date. We performed a search in "Pubmed" and "Google Scholar" database. After a selection of the relevant studies, 59 articles were found eligible and were included in this review. While we believe that lumbar ESPB is reliable and easy, we suggest that its efficacy and indications should be verified with anatomical and clinical studies, and its safety should be confirmed with pharmacokinetic studies. Moreover, the possibility of complications must be considered.

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BackgroundOur aim is to compare the hemodynamic effects of combined psoas compartment-sciatic nerve block (PCSNB) with continuous spinal anaesthesia (CSA) in elderly high-risk patients undergoing hip replacement surgery.MethodsSeventy patients over the age of 60 with ASA III or IV physical status were randomly allocated to two groups: In the PCSNB group, ultrasound-guided psoas compartment block was performed with modified Winnie technique using 30 mL of 0.25% bupivacaine with 1:200.000 epinephrine (5 μgr/mL) and iliac crest block was performed using the same local anaesthetic solution (5 mL). All patients in the PCSNB group needed continuing infusion of propofol (2 mg/kg/h) during operation. In the CSA group, CSA was performed in the L3-L4 interspaced with the patient in lateral decubitus position using 2.5 mg of isobaric bupivacaine 0.5%. When sensory block was not reached to the level of T12 within 10 minutes in the CSA group, additional 2.5 mg of isobaric bupivacaine 0.5% was administered through the catheter at 5-min intervals by limiting the total dose of 15 mg until a T12 level of the sensory block was achieved.ResultsThe PCSNB group had significantly higher mean arterial blood pressure values at the beginning of surgery and at 5th, 10th and 20th minutes of surgery compared to the CSA group (P =0.038, P =0.029, P =0.012, P =0.009 respectively). There were no significant differences between groups in terms of heart rate and peripheral oxygen saturation values during surgery and the postoperative period (P >0.05). Arterial hypotension required ephedrine was observed in 13 patients in the CSA and 4 patients in the PCSNB group (P =0.012).ConclusionsCSA and PCSNB produce satisfactory quality of anaesthesia in elderly high-risk patients with fewer hemodynamic changes in PCSNB cases compared with CSA cases.Trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN12614000658617, Registered 24 June 2014.