Quadratus Lumborum Block(s)
Indications: Abdominal wall and hip analgesia
Open and laparoscopic abdominal procedures
Laparotomy, inguinal hernia, orchidopexy, colostomy closure
Ureteral reimplantation, pyeloplasty
Partial analgesia for femoral osteotomy and other hip procedures
Anatomy:
Quadratus lumborum block (QLB) QLB involves infiltration of local anesthetic adjacent to the quadratus lumborum muscle
The quadratus lumborum (QL) muscle is a posterior abdominal wall muscle which lies deep to the latissimus dorsi, adjacent to the erector spinae muscle group, and dorsolateral to the psoas major
The iliohypogastric and ilioinguinal nerves also traverse the ventral surface of the QL and provide sensory blockade from T12-L2
It is also thought that local anesthetic injected adjacent to the QL will spread to the thoracic paravertebral space and along the fascia to somatic nerves and lower levels of the thoracic sympathetic trunk
Multiple anatomic approaches have been described based on location of infiltration:
Lateral quadratus lumborum block (QL1)
Posterior quadratus lumborum block (QL2)
Anterior quadratus lumborum block (QL3)
Coverage: Block distribution varies in the literature, but has been described up to T7-L2 dermatomes
Dose: 0.25 - 0.75 mg/kg of Bupivacaine or Ropivacaine (roughly 0.2 - 0.5 mL/kg).
Technique: Ultrasound guided, in-plane approach. A linear transducer probe is usually suitable in pediatric patients but curvilinear low-frequency probe may be helpful in larger or obese children. Compressing the tissue with the probe can help straighten the layers out (hint, you may have to press hard!)
Positioning: patient can be supine (lateral tilt can be helpful), lateral, or prone. This is ultimately determined based on physician preference and intended needle trajectory based on anatomic approach.
Lateral (QL1) approach
Probe positioned in transverse plane between the costal border and the iliac crest, visualizing the transversus abdominis aponeurosis and QL muscle
Needle is advanced in plane in the anterior-to-posterior trajectory
Target for local anesthetic deposit is in the plane between the transversus abdominis aponeurosis at the lateral border of the QL muscle
This is the easiest approach to perform in the supine position
Posterior (QL2) approach
Technique very similar to lateral approach, but needle can be anterior-to-posterior or posterior-to-anterior
Target is more posterolateral, between the QL muscle and the erector spinae muscle/thoracolumbar fascia
Anterior (QL3) approach
Typically performed supine
Transverse probe positioning, medial-to-lateral or lateral-to-medial trajectory
Target is in the plane between the QL muscle and the psoas muscle
Potential Complications:
Block failure
Intravascular injection
Local anesthetic toxicity
Bleeding
Infection
EO: External Oblique IO Internal Oblique TA: Transverse Abdominus QL: Quadratus Lumborum PM: Piriformus Muscle
Long before Erector Spinae stole our collective hearts away, there was Quadratus Lumborum. I still remember waiting patiently many years ago until an opportunity for me to try this block finally presented itself. On call at 2 am would not have been my ideal, but we take our opportunities as they come. We spent quite a few years at my old institution collectively obsessing about how best to apply the various QL options to specific pediatric abdominal/hip procedures. Judging by the graphic to the left, we were not alone!
- John Hagen
Visoiu and Yakovleya, 2013. Case report describing unilateral continuous anterior QL catheter for analgesia following colostomy closure in a 5-year-old girl. 10ml ropivacaine 0.5% (0.43ml/kg) with placement, followed by continuous infusion started postoperatively with ropivacaine 0.2% at 5ml/hr (0.43mg/kg/hr). Concluded the patient had low pain scores, required morphine 0.096mg/kg on postoperative day 1, and maintained sensory level to T10 postoperatively.
Öksüz et al, 2017. Prospective, single center, double-blind, randomized study. Compared QL block and transversus abdominis plane block (TAP) in 50 pediatric patients 1-7 years old undergoing lower abdominal surgery (inguinal hernia repair or orchidopexy). Posterior QL block with 0.5ml/kg bupivacaine 0.2%. Statistically significant reduction in opioid requirements in the QL block group with longer and more effective postoperative analgesia compared to TAP. No complications.
Aksu and Gürkan, 2018. Case series describing 10 patients age 3-12 years who underwent inguinal hernia repair and received single shot QL block for postoperative analgesia. Anterior QL block with 0.5ml/kg (max 20ml) bupivacaine 0.25%. They report good analgesia with IV acetaminophen at the conclusion of the procedure, and no additional analgesics though follow-up on postoperative day 2. No complications.
Sato, 2019. Prospective, single center, double-blind, randomized study. Compared QL block to caudal with morphine in 47 patients aged 1-17 years old undergoing ureteral reimplantation via low transverse incision. Posterior QL block with 0.5ml/kg ropivacaine 0.2% per side vs caudal with 0.03mg/kg morphine in 1.0ml/kg ropivacaine 0.2%. Postoperative rescue analgesia with fentanyl was significantly lower in the QL block group during the first 24 hours (but not at 30min, 4 or 48 hours). No complications were observed.
Öksüz et al, 2020. Prospective, single center, double-blind, randomized study. Compared QL block and caudal block in 53 patients 1-9 years old undergoing inguinal hernia repair and orchidopexy. Posterior QL block with 0.7ml/kg bupivacaine 0.25% vs caudal with 0.7ml/kg of bupivacaine 0.25% without epinephrine. Found significantly lower number of patients requiring analgesics in the first 24 hours, significantly lower FLACC scores at 4, 6 and 12 hours, as well as significantly higher parent satisfaction in the QL group. No complications were observed.
While much of the focus of novel regional blocks has shifted to ESP of late, for quite a few years a LOT of focus was directed at understanding the analgesic benefit of various QL blocks. While I too have shifted my focus to more novel blocks (ESP, M-TAPA) in an effort to optimize the block coverage to the specific situation, the QL remains a workhouse for abdominal procedures, and sometimes newer doesn’t always mean better.
Blanco R. Tap block under ultrasound guidance: the description of a ‘no pops’ technique [abstract]. Reg Anesth Pain Med. 2007;32(S1):130.
Elsharkawy, H., El-Boghdadly, K. and Barrington, M., 2019. Quadratus lumborum block: anatomical concepts, mechanisms, and techniques. Anesthesiology, 130(2), pp.322-335.
Visoiu, M. and Yakovleva, N., 2013. Continuous postoperative analgesia via quadratus lumborum block–an alternative to transversus abdominis plane block. Pediatric Anesthesia, 23(10), pp.959-961.
Öksüz, G., Bilal, B., Gürkan, Y., Urfalioğlu, A., Arslan, M., Gişi, G. and Öksüz, H., 2017. Quadratus lumborum block versus transversus abdominis plane block in children undergoing low abdominal surgery: a randomized controlled trial. Regional Anesthesia & Pain Medicine, 42(5), pp.674-679.
Aksu C, Gürkan Y: Ultrasound guided quadratus lumborum block for postoperative analgesia in pediatric ambulatory inguinal hernia repair. J Clin Anesth 2018; 46:77–8.
Sato, M., 2019. Ultrasound‐guided quadratus lumborum block compared to caudal ropivacaine/morphine in children undergoing surgery for vesicoureteric reflex. Pediatric Anesthesia, 29(7), pp.738-743.
Öksüz, G., Arslan, M., Urfalıoğlu, A., Güler, A.G., Tekşen, Ş., Bilal, B. and Öksüz, H., 2020. Comparison of quadratus lumborum block and caudal block for postoperative analgesia in pediatric patients undergoing inguinal hernia repair and orchiopexy surgeries: a randomized controlled trial. Regional Anesthesia & Pain Medicine, 45(3), pp.187-191.
