The Pathway of Injectate Spread With the Transmuscular Quadratus Lumborum Block: A Cadaver Study

Advances in regional anaesthesia and acute pain management: a narrative review

Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided techniques of peripheral nerve blockade have become the gold standard thanks to the associated improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical performance of existing blocks concerning simplicity and safety, as well as the development of new regional anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The preliminary results of investigations into these fascial plane blocks are promising but require further research to establish their true value and role in clinical care. One of the challenges that remains is how best to prolong regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into optimising continuous catheter techniques and their management, intravenous and perineural pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy. This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid administration.

Description of ultrasound-guided quadratus lumborum block technique and evaluation of injectate spread in canine cadavers

OBJECTIVE

To describe a quadratus lumborum (QL) block technique in canine cadavers and the spread of injectate.

STUDY DESIGN

Prospective, randomized, descriptive, experimental anatomic study.

ANIMALS

A group of 12 adult canine cadavers.

METHODS

Gross and ultrasound anatomy of the sublumbar musculature and the relationship with the spinal nerves was studied in two cadavers. Bilateral ultrasound-guided injections were performed in eight cadavers in the fascial plane between the QL and psoas muscle using a dye-lidocaine solution [low volume (LV) 0.15 mL kg^-1 or high volume (HV) 0.3 mL kg^-1]. The ultrasound transducer was positioned caudal and parallel to the proximal aspect of the last rib, and an insulated needle was introduced in-plane using a ventrolateral to dorsomedial approach. Dissections were performed to determine the number of spinal nerves successfully stained (>1 cm) and the presence of injectate in the epidural space or abdominal cavity. Additionally, two cadavers were transversally cryosectioned after QL injection.

RESULTS

Ventral branches of the last thoracic and first three lumbar spinal nerves ran between the bundles of the QL muscle and between the QL and psoas muscles. The target fascial plane was ultrasonographically identified and filled with the dye solution following all injections. Ventral branches of the thirteenth thoracic and first, second and third lumbar nerves were stained by 0.0%, 71.4%, 100%, 100%, and 25%, 100%, 100%, 100% using LV and HV, respectively. Multisegmental spread stained the lumbar sympathetic trunk on 0 (0-3) and 3 (0-4) vertebral levels with LV and HV, respectively. No abdominal or epidural spread was identified.

CONCLUSION AND CLINICAL RELEVANCE

Although no significant differences were found, HV resulted in a higher percentage of stain on spinal nerves and sympathetic trunk than LV. Further studies are warranted to determine if the QL block provides somatic and visceral abdominal analgesia in dogs.

A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy

BACKGROUND

Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy.

METHODS

Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB (n = 31) or continuous epidural (n = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed.

RESULT

The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group (p = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter (p < 0.001) in the QLB group.

CONCLUSION

The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia, and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.

Quadratus lumborum block versus transversus abdominis plane block for postoperative pain management after laparoscopic colorectal surgery: A randomized controlled trial

BACKGROUND

This study aimed to compare the quadratus lumborum block (QLB) method with transversus abdominis plane block (TAPB) for postoperative pain management in patients undergoing laparoscopic colorectal surgery.

METHODS

Seventy-four patients scheduled for laparoscopic colorectal surgery were randomly assigned into 2 groups. After surgery, patients received bilateral ultrasound-guided single-dose of QLB or TAPB. Each side was administered with 20 ml of 0.375% ropivacaine. All patients received sufentanil as patient-controlled intravenous analgesia (PCIA). Resting and moving numeric rating scale (NRS) were assessed at 2, 4, 6, 24, 48 hours postoperatively. The primary outcome measure was sufentanil consumption at predetermined time intervals after surgery.

RESULTS

Patients in the QLB group used significantly less sufentanil than TAPB group at 24 and 48 hours (P < .05), but not at 6 hours (P = .33) after laparoscopic colorectal surgery. No significant differences in NRS results were found between the two groups at rest or during movement (P > .05). Incidence of dizziness in the QLB group was lower than in TAPB group (P < .05).

CONCLUSIONS

The QLB is a more effective postoperative analgesia as it reduces sufentanil consumption compared to TAPB in patients undergoing laparoscopic colorectal surgery.

Anterior quadratus lumborum block analgesia for total hip arthroplasty: a randomized, controlled study

BACKGROUND AND OBJECTIVES

Quadratus lumborum (QL) block is a new regional analgesic technique for upper and lower abdominal surgeries as part of a multimodal analgesic regime. It has also been reported to relieve pain after total hip arthroplasty (THA). In this prospective, randomized, double-blind study, we compared QL block with control (no block) in patients undergoing primary THA.

METHODS

Eighty patients undergoing primary THA surgery under spinal anesthesia were randomized into two groups, one with and one without QL block. The patients in both groups were randomized after sedation, positioning and ultrasound scanning. Both the patient and the researcher collecting data were blinded to the patient's group assignment. Opioid consumption and visual analog scores (VAS) pain scores were measured at 12, 24, and 48 hours after surgery. Also, the ambulation distance, patient satisfaction, and length of stay were recorded.

RESULTS

The study analysis included 36 patients in the QL group and 35 patients in the control group. Both VAS pain score at 24 hours (difference -1.76, 95% CI -2.87 to -0.64) and cumulative opioid consumption were significantly lower in the QL group at 12, 12-24, 24, 24-48, and 48 hours after surgery as compared with the control group (difference at 48 hours -36.13, 95% CI -62.89 to -9.37) (p<0.05). However, there was no difference in pain score at 12 and 48 hours, nor in the ambulation distance and duration of hospital stay between the two groups. The patient satisfaction score was significantly higher in the QL group.

CONCLUSIONS

Our preliminary data show that the QL block provided effective analgesia and decreased opioid requirements up to 48 hours after primary THA.

TRIAL REGISTRATION NUMBER

NCT03408483.

Ultrasound-guided quadratus lumborum block for postoperative pain control in patients undergoing unilateral inguinal hernia repair, a comparative study between two approaches

BACKGROUND

Early postoperative ambulation and reduction of hospital stay necessitate efficient postoperative analgesia. Quadrates Lumborum Block (QLB) has been described to provide adequate postoperative analgesia after abdominal surgery. This randomized comparative trial was designed to compare the duration of analgesia provided by two different QLB approaches; the posterior QLB (QLB-2) and transmuscular QLB (QLB-3) in patients undergoing surgical repair of unilateral inguinal hernia.

METHODS

Forty patients, aged from 18 to 50 years, ASA physical status I or II, scheduled for unilateral inguinal hernia repair were enrolled. At the end of the surgical procedure and before recovery from general anesthesia, Patients were randomly assigned into two groups to receive either posterior QLB (Group QLB-2) or transmuscular QLB (Group QLB-3) using 20 ml 0.25% bupivacaine. Duration of analgesia, postoperative VAS and postoperative opioid consumption were recorded.

RESULTS

Duration of block was significantly longer in QLB-3 group when compared to QLB-2 group (20.1 + 6.2 h versus 12.0 + 4.8 respectively) with P value of < 0.001. A statistically significant lower VAS score was recorded in QLB-3 group immediately and 12 h postoperative. QLB-3 group showed a statistically significant delayed time of first analgesic request and less postoperative morphine consumption with P value of < 0.001 and 0.001 respectively.

CONCLUSIONS

Ultrasound guided postsurgical transmuscular approach of QLB (QLB-3) using 20 ml 0.25% bupivacaine produces more postoperative analgesic effect and less postoperative opioid consumption when compared to posterior QLB approach (QLB-2) in patients underwent unilateral inguinal hernia repair under general anesthesia.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03526731 - on 16 May 2018.

Comparison of ultrasound-guided transmuscular quadratus lumborum block catheter technique with surgical pre-peritoneal catheter for postoperative analgesia in abdominal surgery: a randomised controlled trial

Following abdominal surgery, the provision of postoperative analgesia with local anaesthetic infusion through both transmuscular quadratus lumborum block and pre-peritoneal catheter have been described. This study compared these two methods of postoperative analgesia following laparotomy. Eighty-two patients 18-85 years of age scheduled to undergo elective surgery were randomly allocated to receive either transmuscular quadratus lumborum block or pre-peritoneal catheter block. In the transmuscular quadratus lumborum group, an 18-gauge Tuohy needle was passed through the quadratus lumborum muscle under ultrasound guidance to reach its anterior aspect. A 20-ml bolus of ropivacaine 0.375% was administered and catheters placed bilaterally. In the pre-peritoneal catheter group, 20 ml of ropivacaine 0.375% was infiltrated at each of three subcutaneous sub-fascial levels, and pre-peritoneal plane catheters were placed bilaterally. Both groups received an infusion of ropivacaine 0.2% at 5 ml.h^-1 , continued up to 48 h along with a multimodal analgesic regime that included regular paracetamol and patient-controlled analgesia with fentanyl. The primary end-point was postoperative pain score on coughing, assessed using a numerical rating score (0-10). Secondary outcomes were pain score at rest, fentanyl usage until 48 h post-operation, satisfaction scores and costs. There was no treatment difference between the two groups for pain score on coughing (p = 0.24). In the transmuscular quadratus lumborum group, there was a reduction in numerical rating score at rest (p = 0.036) and satisfaction scores on days 1 and 30 (p = 0.004, p = 0.006, respectively), but fentanyl usage was similar. In the transmuscular quadratus lumborum group, the highest and lowest blocks observed in the recovery area were T4 and L1, respectively. The transmuscular quadratus lumborum technique cost 574.64 Australian dollars more per patient than the pre-peritoneal catheter technique.

Transmuscular quadratus lumborum block for percutaneous nephrolithotomy reduces opioid consumption and speeds ambulation and discharge from hospital: a single centre randomised controlled trial

BACKGROUND

Percutaneous nephrolithotomy (PNL) is associated with severe postoperative pain. The current study aimed to investigate the analgesic efficacy of transmuscular quadratus lumborum (TQL) block for patients undergoing PNL surgery.

METHODS

Sixty patients were enrolled in this single centre study. The multimodal analgesic regime consisted of oral paracetamol 1 g and i.v. dexamethasone 4 mg before surgery and i.v. sufentanil 0.25 μg kg-1 30 min before emergence. After operation, patients received paracetamol 1 g regularly at 6 h intervals. Subjects were allocated to receive a preoperative TQL block with either ropivacaine 0.75%, 30 ml (intervention) or saline 30 ml (control). Primary outcome was oral morphine equivalent (OME) consumption 0-6 h after surgery. Secondary outcomes were OME consumption up to 24 h, pain scores, time to first opioid, time to first ambulation, and hospital length of stay. Results were reported as mean (standard deviation) or median (inter-quartile range).

RESULTS

Morphine consumption was lower in the intervention group at 6 h after surgery (7.2 [8.7] vs 90.6 [69.9] mg OME, P<0.001) and at 24 h (54.0 [36.7] vs 126.2 [85.5] mg OME, P<0.001). Time to first opioid use was prolonged in the intervention group (678 [285-1020] vs 36 [19-55] min, P<0.0001). Both the time to ambulation (302 [238-475] vs 595 [345-925] min, P<0.004) and length of stay (2.0 [0.8] vs 3.0 [1.2] days, P≤0.001) were shorter in the intervention group.

CONCLUSIONS

This is the first blinded, RCT that confirms that unilateral TQL block reduces postoperative opioid consumption and hospital length of stay. Further study is required for confirmation and dose optimisation.

CLINICAL TRIAL REGISTRATION

NCT02818140.

Postoperative analgesic effects of various quadratus lumborum block approaches following cesarean section: a randomized controlled trial

Purpose

Quadratus lumborum block (QLB) is shown to be effective on analgesia following cesarean section. This study aimed to compare the effects of three practical QLB approaches and classic epidural analgesia (EA) for cesarean section under spinal anesthesia.

Patients and methods

Parturients undergoing elective cesarean section were randomized as group 1 (QLB type 2), group 2 (QLB type 3), group 3 (QLB type 2+3) and group 4 (EA). The block was performed at the end of the operation, and the epidural group was given a single epidural bolus. All subjects were provided with intravenous patient-controlled analgesia under identical settings. In addition, the postoperative pain severity was assessed by the VAS, which together with the morphine consumption at specific time intervals, was recorded within 48 hrs after surgery. Data were collected from December 2017 to June 2018.

Results

A total of 94 parturients had completed the study. At almost all postoperative time points, the VAS scores at rest and with movement in QLB type 2+3 group were lower than those in QLB type 2 or 3 group. The mean additional morphine consumption in QLB type 2+3 group (2.7 mg) was lower than that in QLB type 2 or 3 group (6.1 mg and 5.7 mg, respectively) within 48 h after surgery (P<0.001). Besides, the total morphine consumption in EA group (1.3 mg) was lower than that in any other QLB group (P<0.001).

Conclusions

The analgesic effect of QLB is highly dependent on the injection position of local anesthetic. Besides, the ultrasound-guided QLB type 2+3 can provide superior analgesic effect following cesarean section to that of QLB type 2 or 3 block. However, it remains to be further validated about whether the combination of QLB type 2 and 3 is the best approach.

Ultrasound-guided transmuscular quadratus lumborum block for elective cesarean section significantly reduces postoperative opioid consumption and prolongs time to first opioid request: a double-blind randomized trial

BACKGROUND

Elective cesarean section (ECS) can cause moderate to severe pain that often requires opioid administration. To enhance maternal recovery, and promote mother and baby interaction, it is important to reduce postoperative pain and opioid consumption. Various regional anesthesia techniques have been implemented to improve postoperative pain management following ECS. This study aimed to investigate the efficacy of bilateral ultrasound-guided transmuscular quadratus lumborum (TQL) block on reducing postoperative opioid consumption following ECS.

METHODS

A randomized double-blind trial with concealed allocation was conducted in 72 parturients who received bilateral TQL block with either 30 mL ropivacaine 0.375% or saline. TQL block injectate was deposited in the interfascial plane between the quadratus lumborum and psoas major muscles, posterior to the transversalis fascia. Primary outcome was opioid consumption, which was recorded electronically. Pain scores and time to first opioid request were also evaluated.

RESULTS

Opioid consumption (oral morphine equivalents, OME) was significantly reduced in group ropivacaine (GRO) in the first 24 hours compared with group saline (65 mg OME vs 94 mg OME) with a mean difference of 29 mg OME; 95% CI 3 to 55, p<0.03. Time to first opioid request was significantly prolonged in GRO, p<0.003. Numerical rating scale pain scores were significantly lower in GRO in the first 6 hours after surgery, p<0.03.

CONCLUSIONS

Bilateral TQL block significantly reduced 24 hours' opioid consumption. Further, we observed significant prolongation in time to first opioid, and significant reduction of pain during the first 6 postoperative hours.

Quadratus lumborum block for postoperative analgesia after full abdominoplasty: a randomized controlled trial

Background and aims

The quadratus lumborum block (QLB) provides regional analgesia of the anterior abdominal wall, theoretically matching the postoperative pain after postbariatric standard full abdominoplasty. We investigated the effectiveness of a QLB as an addition to the current multimodal analgesia regimen in postbariatric patients treated with standard full abdominoplasty.

Methods

Randomized, placebo-controlled, triple blinded study (n = 50). All patients received perioperative paracetamol and intraoperative local anesthetic infiltration. QLB was administered bilaterally before induction of general anesthesia with 2 × 20 mL of either ropivacaine 3.75 mg/mL (n = 25) or placebo (saline 9 mg/mL) (n = 25). Patients received intravenous patient controlled opioid analgesia postoperatively. The primary endpoint was opioid use during the first 24 postoperative hours. Secondary endpoints were acute and chronic postoperative pain, postoperative nausea and vomiting, and other side effects.

Results

Patient characteristics were similar between groups. The primary endpoint in morphine equivalent units was similar between groups during the first 24 h with mean (SD) of 26 (25) vs. 33 (33) mg (p = 0.44) in the ropivacaine and placebo group, respectively. The observed effect was smaller, and SD larger than assumed in the sample size estimation. Linear mixed effects modeling indicated a minimal inter-group difference. No differences were found for secondary endpoints.

Conclusions

The QLB did not provide significant additional benefit in terms of reduced opioid requirements or secondary endpoints when administered as part of a multimodal pain regimen to postbariatric patients undergoing standard full abdominoplasty. A minimal difference of little clinical importance the first 12 postoperative hours may have been missed.

Implications

Including the QLB in the current multimodal pain regimen cannot be recommended based on these findings. The study does not preclude QLB use in individual cases where the multimodal regimen is inadequate or contraindicated. The effectiveness of the QLB for supraumbilical pain remains undocumented.

Transmuscular quadratus lumborum block versus thoracic paravertebral block for acute pain and quality of recovery after laparoscopic renal surgery: study protocol for a randomized controlled trial

Background

Quadratus lumborum block (QLB) is increasingly gaining popularity as a novel abdominal truncal block in abdominal surgery; however, the mechanism of QLB is not yet thoroughly illustrated. The focus of our study is transmuscular QLB (TMQLB), as the latest anatomical evidence shows that anesthetics spread into the thoracic paravertebral space to exert an analgesic effect. Therefore, we designed this study to compare TMQLB with thoracic paravertebral block (TPVB) in laparoscopic renal surgery in the hope of providing clinical evidence on the analgesic mechanism of TMQLB and its application in laparoscopic renal surgery.

Methods

This trial is a prospective, randomized, single-center, open-label, parallel, three-arm, non-inferiority trial. We intend to include 120 participants undergoing laparoscopic nephrectomy and before surgery they will be randomized into three groups for postoperative pain control: TMQLB experimental group 1 (0.4 ml/kg body weight 0.5% ropivacaine), TMQLB experimental group 2 (0.6 ml/kg body weight 0.5% ropivacaine) or TPVB control group (0.4 ml/kg body weight 0.5% ropivacaine at vertebra T10). Patients will be excluded if they have allergy to anesthetics, infection at the injection site, are on coagulopathy or anticoagulants, on analgesics for chronic illness, have history of substance abuse or have a barrier to communication. Morphine is given in boluses of 1.5~2 mg by intravenous patient-controlled analgesia (IPCA) in the first 48 h after surgery. The primary outcome is the difference between TMQLB group 1 and the TPVB group in the mean visual analogue scale (VAS) pain score in the first 24 h after surgery. Secondary outcomes are the difference between TMQLB group 2 and the TPVB group in the mean VAS score in the first 24 h after surgery, cumulative morphine consumption, long-term pain control, dermatomal distribution of sensory loss, nausea score, pruritus score, ambulation time, time till recovery of bowel movement, quality of recovery, postoperative length of hospital stay and patient satisfaction with anesthesia. Safety data on procedure-related complications will also be summarized.

Discussion

This will the first randomized controlled trial to compare TMQLB with TPVB for analgesia in laparoscopic surgery. This trial aims to provide important clinical evidence to elaborate on the analgesic mechanism of TMQLB.

Trial registration

ClinicalTrials.gov, NCT03414281. Registered on 9 January 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3359-7) contains supplementary material, which is available to authorized users.

Anatomical and ultrasound description of two transmuscular quadratus lumborum block approaches at L2 level and their application in abdominal surgery

The transmuscular quadratus lumborum (TQL) block is one of the recently evolved myofascial blocks utilised in abdominal surgery. It involves injecting local anaesthetic into the fascial plane anterior to the thoracolumbar fascia. This block has previously been described with a transverse oblique paramedian approach at the L2 level in the sitting position. We describe a TQL block at the same level in the lateral position using a transverse posterolateral approach to provide analgesia for patients undergoing abdominal surgery. We elaborate on these two approaches of TQL block at the L2 level, in relation to the anatomy, sonoanatomy and technical aspects.

Urinary retention: a possible complication of unilateral continuous quadratus lumborum analgesia - a case report

OBJECTIVE

Continuous quadratus lumborum (QL) analgesia is a new option for proximal femur surgery considered safe and effective. The purpose of this report was to show that we may not be aware of all the possible complications of this technique, and urinary retention may occur even when the block is performed unilaterally.

CASE REPORT

To an obese, intubated, mechanically ventilated, female patient, operated in prone position for removal of a femur tumour, we performed a trans-muscular quadratus lumborum block (TQL). We mounted a catheter and administered continuous infusion of local anaesthetic in the postoperative period. The patient experienced urinary retention. A urinary catheter was placed and it was maintained for the entire period of local anaesthetic infusion. When the catheter was removed, 72 hours after the surgery, the patient resumed normal bladder functions.

CONCLUSION

Urinary retention is a possible complication when continuous quadratus lumborum analgesia is used, even when performed unilaterally.

Ultrasound-guided lateral versus posterior Quadratus Lumborum Block for postoperative pain after laparoscopic cholecystectomy: a randomized controlled trial

Objectives

The aim of the present study was to investigate the effect of ultrasound-guided bilateral posterior quadratus lumborum block (QLB) and lateral QLB on postoperative pain scores after laparoscopic cholecystectomy.

Material and Methods

In this prospective, randomized, single-blind study; 60 patients with elective laparoscopic cholecystectomy operations were randomized into two groups as group P (n= 30): Posterior Quadratus Lumborum Block + IV patient-controlled analgesia (PCA) tramadol and group L (n= 30): Lateral Quadratus Lumborum Block + IV PCA tramadol. Primary outcome measures included the amount of total consumption (24 hours) of tramadol. Secondary outcome measures; Visual Analog Scala (VAS) scores at rest and on movement (postoperative 30th minute, 2nd, 6th, 12th, and 24th hours) were recorded. Adverse effects (nausea and vomiting), additional analgesic requirement, and intraoperative opioid requirement were recorded.

Results

Postoperative total consumption amounts of tramadol and VAS scores (rest and on movement) were compared, and there was no statistically significant difference between the two groups (p> 0.05). There was no statistically significant difference in adverse effects (nausea and vomiting), additional analgesic requirement, and intraoperative opioid requirement between the two groups (p> 0.05).

Conclusion

Similar postoperative tramadol consumption values and VAS scores were determined in both lateral QLB and posterior QLB block applications in the results of our study.

Ultrasound guided continuous Quadratus Lumborum block hastened recovery in patients undergoing open liver resection: a randomized controlled, open-label trial

Background

Quadratus lumborum (QL) block is increasingly being used as a new abdominal nerve block technique. In some studies of mid and lower abdominal and hip analgesia, continuous QL block achieved favorable outcomes as an alternative to continuous intravenous analgesia with opioids. However, the use of continuous QL block for upper abdominal pain is less well characterized. This study aimed to investigate the effects of continuous anterior QL block (CQLB) on postoperative pain and recovery in patients undergoing open liver resection.

Methods

Sixty-three patients underwent elective open liver resection were randomly divided into continuous anterior QL block (CQLB, n = 32) group and patient-controlled intravenous analgesia (PCIA, n = 31) group. Patients in CQLB group underwent ultrasound-guided anterior QL block at the second lumbar vertebral transverse processes before general anesthesia, followed by postoperative CQLB analgesia. Patients in PCIA group underwent continuous intravenous analgesia postoperatively. Postoperative numerical rating scale (NRS) pain scores upon coughing and at rest, self-administered analgesic counts, rate of rescue analgesic use, time to first out-of-bed activity and anal flatus after surgery, and incidences of analgesic-related adverse effects were recorded.

Results

Postoperative NRS pain scores on coughing in CQLB group at different time points and NRS pain score at rest 48 h after surgery were significantly lower than those in PCIA group (P < 0.05). Time to first out-of-bed activity and anal flatus after surgery in CQLB group were significantly earlier than those in PCIA group (P < 0.05). No significant differences of postoperative self-administered analgesic counts, rate of postoperative rescue analgesic usage, or incidences of analgesic-related adverse effects were found between the two groups (P > 0.05).

Conclusions

Ultrasound-guided anterior QL block significantly alleviated the pain during coughing after surgery, shortened the time to first out-of-bed activity and anal flatus, promoting postoperative recovery of the patients undergoing open liver resection.

Trial registration

This study has been registered in April 1, 2018 on Chinese Clinical Trail Registry, the registration number is ChiCTR1800015454.

Quadratus Lumborum Block: Anatomical Concepts, Mechanisms, and Techniques

A review of anatomy, potential mechanisms of action, and techniques and summary of clinical evidence for quadratus lumborum block.

A radiological inquest to determine the destiny of ultrasound guided trans-muscular quadratus lumborum plane catheters

After a quadratus lumborum (QL) block, the course of QL plane catheter is unpredictable. This case series discusses the course and fate of trans-muscular QL catheters by following and discussing the contrast spread through the fascial planes. Intrao-peratively, the catheters were tracked by the surgeons and were checked for integrity of anterior thoracolumbar fascia (ATLF) by injecting sterile 0.9% saline. The ATLF was intact upon injection and there was cephalad and medial saline spread with slight bulging of ATLF. On day 3 after written informed consent from all patients, computed tomography (CT) contrast studies were performed. Post-operative contrast spread was variable and was visualised in transversus abdominis plane, QL plane, lower thoracic paravertebral space, inter-vertebral foramina and anterior epidural space. CT contrast images demonstrated a variable spread. In conclusion, injection in ATLF of QL can spread along the path of least resistance and is unpredictable.

Quadratus lumborum block provides improved immediate postoperative analgesia and decreased opioid use compared with a multimodal pain regimen following hip arthroscopy

The purpose of our study was to evaluate the effect on immediate patient outcomes following hip arthroscopy with use of a preoperative, single shot quadratus lumborum (QL) block. We retrospectively reviewed patients who underwent hip arthroscopy following a preoperative QL block. These patients were matched by age and gender to patients who had not received a block. Visual analogue scale (VAS) pain scores immediately postoperatively and at the time of discharge were recorded. Hourly and overall opioid intake in the postanesthesia care unit (PACU) was also recorded. Continuous data was analysed with paired t-test, with significance being defined as P < 0.05. Complications in the immediate postoperative period were recorded, as was time from admission to PACU to discharge. Fifty-six patients were included. Twenty-eight patients underwent QL block and 28 did not undergo a block. QL block patients required significantly less hydromorphone (P = 0.010) and oxycodone (P = 0.001) during their time in the PACU, and significantly fewer morphine equivalents overall and per hour in the PACU (P < 0.001). Despite receiving less opioid analgesia, QL block patients had significantly less pain immediately postoperatively (P = 0.026) and at the time of discharge (P = 0.015). The mean time to PACU discharge was 155 ± 49 min, and there was no difference in time to discharge between groups (P = 0.295). One patient in the QL block group experienced persistent flank numbness. Hip arthroscopy patients who received a preoperative QL block had less pain and a lower opioid requirement in PACU than those who did not receive a block.

Level of Evidence: Level III (Retrospective matched cohort study).

Cadaveric Evaluation of Different Approaches for Quadratus Lumborum Blocks

Background

A quadratus lumborum (QL) block is an abdominal truncal block technique that primarily provides analgesia and anaesthesia to the abdominal wall. This cadaveric study was undertaken to compare the dye spread between different needle approaches for ultrasound-guided QL blocks in soft-embalmed cadavers.

Methods

After randomization, an experienced anesthesiologist performed two lateral, three posterior, and five alternative QL blocks on the left or right sides of five cadavers. The target injection point for the alternative approach was the lumbar interfascial triangle, same as that of conventional posterior QL block, with a different needle trajectory. For each block, 20 ml of dye solution was injected. The lumbar region and abdominal flank were dissected.

Results

Ten blocks were successfully performed. Regardless of the approach used, the middle thoracolumbar fascia was deeply stained in all blocks, but the anterior layer was less stained. The alternative approach was more associated with spread of injectate to the transversus abdominis and transversalis fascia plane. Despite accurate needle placement, all lateral QL blocks were associated with a certain amount of intramuscular or subcutaneous infiltration. Two posterior QL blocks showed a deeply stained posterior thoracolumbar fascia, and one of them was associated with obvious subcutaneous staining. The subcostal, iliohypogastric, and ilioinguinal nerves were mostly involved, but the thoracic paravertebral space and lumbar plexus were not affected in all blocks.

Conclusions

The alternative approach for QL blocks was able to achieve a comparable extent when compared to the conventional approach.

A Review of the Quadratus Lumborum Block and ERAS

The use of truncal nerve blocks has been described since 2001. Since then, there have been many studies trying to understand the ideal clinical scenarios for its use. Since 2001, the transversus abdominis plane block has evolved in many ways including from landmark based technique to ultrasound guided and more recently, into the quadratus lumborum (QL) block. Its anatomical placement, concentration of local anesthetic, volume of local anesthetic, and anatomic placement have all been raised as clinical questions. This article will discuss the literature of the QL block in an effort to understand how it is best used in a variety of clinical scenarios.