Written by Chris Thom
Spoon Feed
In this case series of pancreatic cancer patients, an ultrasound-guided erector spinae plane (ESP) block provided excellent analgesia and a reduction in systemic opioid requirements.
Delivering pain relief without opioid side effects
This was a case series of four patients with pancreatic cancer who presented to the ED with severe pain. In each case, an ultrasound-guided ESP block was performed, which resulted in a significant drop in pain and opioid consumption.
Each of the four patients had an initial pain score of 9/10 on the numeric rating scale. In three cases, the pain reduced to 0/10 following the ESP block, while one patient’s pain reduced to 1/10. Opioid utilization reduction ranged from 50% to 70%, and the duration of pain relief lasted from 10 to 24 hours following the block.
How will this change my practice?
The ESP block is still a relatively new tool in our analgesic toolbox. It is perhaps best studied in patients with acute rib fractures, but prior work has shown potential efficacy for pancreatitis and kidney stones. In the current case series, we see early evidence that this may be a useful adjunct for patients with severe pain secondary to pancreatic cancer. Given that this is an easy block to learn and execute in the ED environment, I will consider employing it in my next patient with severe pain secondary to pancreatic pathology.
POCUS Pro-Tips and Clips:
The ultrasound-guided ESP block is terrific in that it is safe, easy to learn, and effective. In this block, we get to rely on bony landmarks, which are fairly consistent from patient to patient. We’ll use our high-frequency probe and place the probe in the mid to upper back, over midline, in the long axis (sagittal) orientation. Slide the probe laterally to medially to identify the spinous processes, the transverse processes (TPs), and the ribs. The TPs will be rounded and “tombstone” in appearance. I will often find the ribs and the pleura, then slide back towards midline to identify the point where the ribs transition to the TPs. You’ll then bring your needle in, cranial to caudal, under US guidance until you contact the bony TP. At this point, you can begin injecting your anesthetic, which will distribute along the facial plane deep to the erector spinae muscle layer.
Source
Erector spinae plane block for acute pain management of pancreatic cancer at the emergency department. Ultrasound J. 2025 Nov 4;17(1):56. doi: 10.1186/s13089-025-00461-1. PMID: 41186619; PMCID: PMC12586832.
