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Year : 2020  |  Volume : 36  |  Issue : 1  |  Page : 120-121

RACK approach to erector spinae plane block

Department of Anaesthesia and Pain Management, CARE Hospitals, Bhubaneswar, Odisha, India

Date of Submission03-Aug-2019
Date of Acceptance27-Aug-2019
Date of Web Publication18-Feb-2020

Correspondence Address:
Dr. Gaurav Agarwal
Department of Anaesthesia and Pain Management, CARE Hospitals, Bhubaneswar, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_248_19

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How to cite this article:
Roy R, Agarwal G, Pradhan C, Kuanar D. RACK approach to erector spinae plane block. J Anaesthesiol Clin Pharmacol 2020;36:120-1

How to cite this URL:
Roy R, Agarwal G, Pradhan C, Kuanar D. RACK approach to erector spinae plane block. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2022 Sep 28];36:120-1. Available from:


Erector spinae plane (ESP) block has emerged as a novel, simple, easier, and effective regional analgesia technique, with potential applications from acute postoperative pain to chronic pain, where a drug is injected in interfascial plane deep to erector spinae muscle.[1],[2],[3],[4],[5],[6] It is hypothesized to spread close to ventral and dorsal rami of spinal nerves, with multidermatomal spread with a single injection, on the basis of cadaveric and contrast studies.[1],[3],[4] ESP block gives a blockade comparable with paravertebral block (PVB) without risk of pleural injury.[5] ESP block eliminates risk of hypotension of epidural analgesia, epidural spread and vascular puncture of PVB, their procedural complications because of vicinity to spinal cord and pleura, respectively, and pneumothorax associated with intercostal nerve block and interpleural block.[7],[8] ESP block was first described by Forero et al. for thoracic analgesia but since then it has been used for many different indications where PVB and epidural anesthesia are currently the main regional techniques.[1],[2],[3]

Forero et al's parasagittal technique of ESP block needed the patient to be in sitting position and ergonomically sometimes challenging for the operator. The spread of drug in the muscle layers might also mimic the splaying of the layers, resulting in an inadequate blockade. We have been practicing a transverse approach to the ESP block called the RACK approach. The approach involves identifying the interspinous view of the spine using a low-frequency probe of ultrasound [Figure 1], identifying the articular process, posterior complex, and transverse process lying in a single line, mimicking like lying on a rack (RACK) [Figure 2]. The probe here is slid to ipsilateral side to insert needle in-plane to target the area below ESP muscle, above the lateral edge of the transverse process (target point), and the drug is injected to split and raise the ESP muscle complex [Figure 3]. The lumbar ESP block can also be blocked in a similar way [Figure 4]. The advantages of this approach being ease of administration ergonomically, in-plane needling can be done with ease, in-plane insertion of catheters is also easy, and last but not the least, lateral most part of the transverse process adjacent to the costotransverse junction is identified which is the ideal target point for ESP block.
Figure 1: Curvilinear probe position

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Figure 2: Interspinous view

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Figure 3: Thoracic ESP approach

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Figure 4: Lumbar ESP approach

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Conflicts of interest

There are no conflicts of interest.

  References Top

Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 1
Tulgar S, Kapakli MS, Şentürk O, Selvi O, Serifsoy TE, Ozer Z. Evaluation of ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: A prospective, randomized, controlled clinical trial. J Clin Anesth 2018;49:101-6.  Back to cited text no. 2
Gürkan Y, Aksu C, Kuş A, Yörükoǧlu UH, Kılıç CT. Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: A randomized controlled study. J Clin Anesth 2018;50:65-8.  Back to cited text no. 3
Adhikary SD, Pruett A, Forero M, Thiruvenkatarajan V. Erector spinae plane block as an alternative to epidural analgesia for postoperative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth 2018;62:75-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
Singh S, Chowdhary NK. Erector spinae block an effective block for postoperative analgesia in modified radical mastectomy. Indian J Anaesth 2018;62:148-50.  Back to cited text no. 5
[PUBMED]  [Full text]  
Jadon A, Jain P, Sinha N. The erector spinae plane block for postoperative analgesia in abdominoplasty – A case report. BAOJ Anaesth 2017;1:1-4.  Back to cited text no. 6
El-Boghdadly K, Pawa A. The erector spinae plane block: Plane and simple. Anaesthesia 2017;72:427-38.  Back to cited text no. 7
Nandhakumar A, Nair A, Bharath VK, Kalingarayar S, Ramaswamy BP, Dhatchinamoorthi D. Erector spinae plane block may aid weaning from mechanical ventilation in patients with multiple rib fractures: Case report of two cases. Indian J Anaesth 2018;62:139-41.  Back to cited text no. 8
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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