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Quadratus Lumborum Block - Dr. V Koyyalamudi
- 1. ©2017 MFMER | slide-1 Quadratus lumborum block Dr.V.Koyyalamudi Assistant Professor Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Arizona
- 2. ©2017 MFMER | slide-2 DISCLOSURE References to off-label usage(s) of pharmaceuticals or instruments in their presentation: Name Manufacturer/Provider Product/Device Veerandra Koyyalamudi, M.B.B.S. - None Relevant financial relationship(s) with industry Name Manufacturer/Provider Product/Device Veerandra Koyyalamudi, M.B.B.S. - None
- 3. ©2017 MFMER | slide-3 Learning Objectives • Describe the applied anatomy of the various types of Quadratus Lumborum blocks • Recognize the techniques and spread of the various types of Quadratus Lumborum blocks ( QL1,QL2,QL3,QL IM) • Distinguish between a QL block and a TAP block • Discuss the recent randomized control trials evaluating the QL block
- 4. ©2017 MFMER | slide-4 The Quadratus lumborum muscle • Lumborum- back • Quadratus- quadrilateral • Origin- Iliac crest • Insertion- L1-L4 transverse process and 12th rib
- 5. ©2017 MFMER | slide-5 Quadratus lumborum and the Thoracolumbar fascia With copyright permission Anterior to the anterior layer is the psoas muscle QL muscle enveloped by the anterior and middle layers of the thoracolumbar fascia Middle and posterior layers of the fascia covers the erector spinae muscle
- 6. ©2017 MFMER | slide-6 Transversalis fascia • Lies between the inner surface of the transverse abdominal muscle and the extraperitoneal fat and parietal peritoneum From NYSORA.COM QL KidneyTransversalis fascia ES Ps Anterior layer Thoracolumbar fascia
- 7. ©2017 MFMER | slide-7 Endothoracic fascia The transversalis fascia follows the QLM and psoas major superiorly through the diaphragm Transversalis fascia blends with the endothoracic fascia Pathway for the spread of injectate into the thoracic paravertebral space
- 8. ©2017 MFMER | slide-8 Continuity of the lumbar and thoracic paravertebral spaces • Cadaveric study, 15ml of dye injected at T11 • Spread was seen • Along the endothoracic fascia and splanchnic nerves • Through the medial and lateral arcuate ligaments, into the abdominal cavity • And along the transversalis fascia involving the subcostal, iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous and femoral nerves Anatomical bases for paravertebral anesthetic block: fluid communication between the thoracic and lumbar paravertebral regions. Saito T, Den S, Tanuma K, Tanuma Y, Carney E, Carlsson C. Surg Radiol Anat. 1999;21(6):359-63
- 9. ©2017 MFMER | slide-9 Types of QL Blocks QL 1 – Lateral QL Block Needle tip anterolateral to QL muscle, near the transversalis fascia , piercing the transversus abdominis aponeurosis QL 2 – Posterior QL Block Needle tip posterior to QL muscle, anterior to the middle thoracolumbar fascia separating it from the erector spinae QL 3 – Anterior QL Block/ transmuscular Needle tip between QL muscle and the Psoas muscle Intramuscular QL Block Needle tip within the QL muscle
- 10. ©2017 MFMER | slide-10 The QL Blocks © 2018 ASRA. All rights reserved, with permission QL1 - Lateral QL QL2 - Posterior QL QL3 - Anterior QL Intramuscular QL
- 11. ©2017 MFMER | slide-11 QL block positioning and probe location
- 12. ©2017 MFMER | slide-12 copyright © 2017, American Society of Regional Anesthesia and Pain Medicine (ASRA)
- 13. ©2017 MFMER | slide-13 Triangle of Petit http://e-safe-anaesthesia.org/e_library/09/Transversus_abdominis_plane_TAP_block_Update_2008.pdf Mid-axillary line: Lateral TAP Triangle of Petit: Posterior TAP
- 14. ©2017 MFMER | slide-14 QL block positioning and probe location
- 15. ©2017 MFMER | slide-15 Pre injection-QL Block Post injection QL Anterior Block QL L4PM TAP LA ES - Lateral QL - Posterior QL - Intramuscular QL - Anterior/ transmuscular QL
- 16. ©2017 MFMER | slide-16 Posterior TAP vs Lateral TAP vs Lateral QL Copyright PACIRA PHARMACEUTICALS, Inc. Lateral TAP Posterior TAP Lateral QL
- 17. ©2017 MFMER | slide-17 “posterior TAP block appears to produce more prolonged analgesia than the lateral TAP block”
- 18. ©2017 MFMER | slide-18 Posterior TAP vs Lateral QL – is there a difference? Posterior TAP block Lateral QL block Injecting more posteriorly vs a lateral TAP block In the “ triangle of petit” Lateral to the QL muscle Injecting lateral to the QL muscle Deep to the transversus abdominis aponeurosis Superficial to the transversalis fascia Some feel Lateral QL and posterior TAP blocks are the same
- 19. ©2017 MFMER | slide-19 QL Block spread- MRI studies R. Blanco, T. Ansari, and E. Girgis, “Quadratus lumborum block for postoperative pain after caesarean section: a randomised controlled trial,” European Journal of Anaesthesiology, vol. 32, no. 11, pp. 812–818, 2015. When compared to the lateral QL Block , posterior QL block provided a more predictable spread of the local anesthetic into the paravertebral space ……Blanco et al
- 20. ©2017 MFMER | slide-20 QL Block spread- cadaveric studies A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. Carline L, McLeod GA, Lamb C. Br J Anaesth. 2016 Sep;117(3):387-94. doi: 10.1093/bja/aew224 ‘QL-Transmuscular blocks (anterior) more consistently blocked lumbar nerve roots, when compared to QL Lateral and posterior blocks
- 21. ©2017 MFMER | slide-21 Anterior/ Transmuscular QL Block spread- cadaveric studies • Bilateral transmuscular ( anterior) QL blocks in six cadavers • Spread to the lumbar paravertebral space in 63% • Laterally to the transversus abdominis muscle in 50% • Caudally to the anterior superior iliac spine in 63% • There was no radiographic evidence of spread to the thoracic paravertebral space. • Anatomical dissection revealed dye staining of the upper branches of the lumbar plexus and the psoas major muscle in 70% of specimens A radiologic and anatomic assessment of injectate spread following transmuscular quadratus lumborum block in cadavers. Adhikary SD, El-Boghdadly K, Nasralah Z, Sarwani N, Nixon AM, Chin KJ. Anaesthesia. 2017 Jan;72(1):73-79.
- 22. ©2017 MFMER | slide-22 QL Blocks and lower extremity weakness Retrospective study of 2382 patients, QL blocks using 20ml of 0.375% Levobupivacaine N= Incidence of LE Weakness Lateral QL 771 7 (1%) Posterior QL 1485 285 (19%) Anterior, Transmuscular QL 81 65 (90%) Intramuscular QL 45 0 (0%) Incidence of lower-extremity muscle weakness after quadratus lumborum block. Ueshima H, Hiroshi O. J Clin Anesth. 2017 Nov 23;44:104. doi: 10.1016/j.jclinane.2017.11.020.
- 23. ©2017 MFMER | slide-23 Quadratus lumborum block for femoral-femoral bypass graft placement: A case report. Watanabe K, Mitsuda S, Tokumine J, Lefor AK, Moriyama K, Yorozu T. Medicine (Baltimore). 2016 Aug;95(35):e4437. The ultrasound-guided continuous transmuscular quadratus lumborum block is an effective analgesia for total hip arthroplasty,” Journal of Clinical Anesthesia, vol. 31, p. 35, 2016 H. Ueshima, S. Yoshiyama, and H. Otake, “ Continuous quadratus lumborum block analgesia for total hip arthroplasty revision. Johnston DF, Sondekoppam RV. J Clin Anesth. 2016 Dec;35:235-237.
- 24. ©2017 MFMER | slide-24 QL blocks coverage Lateral QL T7 to L1 Coverage Posterior QL T7 to L1 Coverage- more consistent spread to thoracic paravertebral space when compared to lateral QL ( Blanco et al) Anterior QL T10 to L4 Coverage more consistently involves lumbar nerves, T6-L2 if using blocking more cephalad ( subcostal , L2 level- Elsharkawy et al) Intramuscular QL Spread confined to the to QL muscle
- 25. ©2017 MFMER | slide-25 QL vs TAP Blocks • Lateral TAP Block usually provides analgesia from T10--L1 dermatomes • Subcostal TAP Block usually provides analgesia from T7-T10 dermatomes • Lateral and posterior QL Blocks provide analgesia from T7-L1
- 26. ©2017 MFMER | slide-26 RCT’S: Posterior QL vs Sham • Blanco et al – 48 elective C-Section patients • Bilateral USG Posterior QL Blocks ( 0.2ml/kg 0.125% bupivacaine vs sham injection of NSaline) • Significantly lower rest pain/dynamic pain scores up to 48hrs post op ( except rest pain at 24h) • Significantly lower morphine use at 6h, 12h Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: a randomised controlleds trial. Eur J Anaesthesiol. 2015;32:812–818
- 27. ©2017 MFMER | slide-27 RCT’S: Lateral QL Vs Sham • Krohg et al - 40 elective C-Section patients, 20 per group • Bilateral USG Lateral QL Blocks ( 0.4ml/kg 0.2% ropivacaine vs sham injection of NSaline) • The cumulative ketobemidone consumption in 24 hours was significantly less (P = .04) • The effective analgesic scores were significantly better in the treatment group compared with the placebo group both at rest (P < .01) and during coughing (P < .01). The Analgesic Effect of Ultrasound-Guided Quadratus Lumborum Block After Cesarean Delivery: A Randomized Clinical Trial. Krohg A, Ullensvang K, Rosseland LA, Langesæter E, Sauter AR. Anesth Analg. 2018 Feb;126(2):559-565.
- 28. ©2017 MFMER | slide-28 RCT’s: Posterior QL vs TAP • Blanco et al – 76 elective C-Section patients • Bilateral USG posterior QL Blocks vs Lateral TAP Block (0.2ml/kg 0.125% bupivacaine each side) • QL block group used significantly less morphine (P < 0.05) at 12, 24, and 48 hours but not at 4 and 6 hours after cesarean delivery. • QL block group also had significantly fewer morphine demands (P < 0.05) at 6, 12, 24, and 48 hours after cesarean delivery. Blanco R, Ansari T, RiadW, et al. Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after cesarean delivery: a randomized controlled trial. Reg Anesth Pain Med 2016;41:757–62.
- 29. ©2017 MFMER | slide-29 RCT’s: QL Posterior vs TAP • Oksuz et al- Fifty-three children undergoing unilateral inguinal hernia repair or orchiopexy surgery • In the QL group: • The number of patients who required analgesia in the first 24 hours postoperatively was lower (P < 0.05) • The postoperative 30-minute and 1-, 2-, 4-, 6-, 12-, and 24- hour FLACC scores were lower (P < 0.05) • Parent satisfaction scores were higher (P < 0.05) Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Children Undergoing Low Abdominal Surgery: A Randomized Controlled Trial. Öksüz G, Bilal B, Gürkan Y, Urfalioğlu A, Arslan M, Gişi G, Öksüz H. Reg Anesth Pain Med. 2017 Sep/Oct;42(5):674-679.
- 30. ©2017 MFMER | slide-30 Dosage for QL Blocks • Volumes of 0.2 to 0.4 mL/kg (20–30 mL) unilaterally are usually recommended, similar to a TAP block • Vascular area ( abdominal branches of the lumbar arteries)
- 31. ©2017 MFMER | slide-31 Indications for QL Blocks • Any surgeries covering T7-L1 dermatome • Midline incisions and laparoscopic procedures require bilateral blocks for adequate coverage • Continuous QL catheters have been successfully used
- 32. ©2017 MFMER | slide-32 Concerns/complications with QL Blocks • Lumbar plexus involvement, especially with anterior QL blocks • Close proximity of the kidney and colon • Vascularity- branches of the lumbar arteries
- 33. ©2017 MFMER | slide-33 In conclusion • QL Blocks ( lateral/posterior) seem to be superior to the TAP blocks with regards to thoracic spread • Anterior QL blocks can be used as an alternative method of blocking the lumbar plexus • More clarification needed with regards the differentiation of lateral QL blocks and posterior TAP blocks • Further studies (RCT’s) are required to validate the various types of QL blocks in postoperative pain control, determine optimal dosage and needle position
- 34. ©2017 MFMER | slide-34 Questions?
Editor's Notes
- Ultrasound-guided transversus abdominis plane (TAP) block has become a common analgesic method after surgery involving the abdominal wall. Because TAP blockade is limited to somatic anesthesia of the abdominal wall and highly dependent on interfascial spread, various newer techniques have been proposed to enhance analgesia, either in addition to TAP block or as a single modality. In particular, variants of quadratus lumborum blocks (QLBs) have been proposed as more consistent methods with an aim to accomplish somatic as well as visceral analgesia of the abdomen. The present evidence, mainly case reports, suggests that different variants of QLB have different analgesic effects and mechanisms of action, although this has not been formally validated. In particular, transmuscular QLB and the so-called QLB2 may result in wider and longer sensory blockade compared to TAP block (T4–L1 for QL block vs. T6–T12 for the TAP blocks) Quadratus lumborum (QL) block is a novel ultrasound-guided regional anesthetic technique for managing postoperative pain in patients undergoing abdominal and hip surgeries. •The available limited literature and experiences demonstrate that QL blocks have the potential to produce sensory blockade and analgesia along the lower thoracic and lumbar dermatomal sensory regions. •There is currently no general consensus on the mechanism(s) of action of QL blockade. The subendothoracic fascial spread and direct spread to the lumbar plexus branches are the proposed mechanism. •This is a tissue (fascial) plane block that requires a large volume of local anesthetic to obtain a reliable block.
- These blocks are technically straightforward and relatively safe and reduce pain and opioid requirements in many clinical settings. The data supporting these outcomes, however, can be inconsistent because of heterogeneity of study design. The extent of sensory blockade is also somewhat variable, because it depends on the achieved spread of local anesthetic and the anatomical course of the nerves being targeted. The blocks mainly provide somatic analgesia and are best used as part of a multimodal analgesic regimen
- Posterior abdominal wall muscle- along with iliacus, psoas major/minor, diaphragm Lies dorsal to the iliopsoas
- PrepThoracolumbar fascia The thoracolumbar fascia consists of the three layers; posterior, middle and anterior. Anterior and middle layers attach to the transverse processes, posterior layer attaches to the spinous process 3 layers, 2 spaces, Psoas major ant to anterior layer Muscles are enclosed between these layers: Quadratus lumborum – between the anterior and middle layers. Deep back muscles – between the middle and posterior layers- erector spinae The posterior layer extends between the 12th rib and the iliac crest posteriorly. Laterally the fascia meets the internal oblique and transversus abdominis muscles, but not the external oblique. As it forms these attachments it covers the latissimus dorsi. The anterior layer attaches to the anterior aspect of the transverse processes of the lumbar vertebrae, the 12th rib and the iliac crest. Laterally the fascia is continuous with the aponeurotic origin of the transversus abdominis muscle. Superiorly the fascia thickens to become the lateral arcuate ligament, which joins the iliolumbar ligaments inferiorly.
- Transversalis fascia is a thin aponeurotic membrane which lies between the inner surface of the transverse abdominal muscle and the extraperitoneal fat and parietal peritoneum Outer surface of this fascia lines the transversus abdominus/quadratus lumboum and psoas muscle The transversalis fascia follows the QLM and psoas major superiorly through the diaphragm, passing under the lateral and medial arcuate ligaments and blending with the endothoracic fascia of the thorax These relationships of the thoracolumbar fascia, transversalis fascia and associated muscles have important implications for the potential spread of local anesthetic injected in the posterior abdominal wall The lower pole of the kidney lies anterior to the QL muscle and can reach the L4 level with deep inspiration. Therefore, this should be checked when performing QL block This anterior layer blends medially with the fascia of the psoas major and blends laterally with the transversalis fascia. An alternative simpler anatomical model in fact refers to this layer anterior to the QL muscle as the transversalis fascia, and only 2 layers of TLF, posterior and anterior (identical to the middle layer in the 3-layered model), are recognized and named.
- Endothoracic fascia- loose connective tissue deep to the ribs/intercoastal spaces superficial to the parietal pleura, equivalent with the transversalis fascia of the abdomen Injection between the anterior layer and QL can spread cranially under the lateral arcuate ligament to the endothoracic fascia and reach the lower thoracic paravertebral space posterior to the endothoracic fascia- loose conective tissue deep to the ribs/intercoastal spaces superficial to the parietal pleura, equivalent with the transversalis fascia of the abdomen
- An injection of a local anesthetics in the paravertebral region produces an analgesic field on the same side of the body, a paravertebral block. One point in question about this block is whether the local anesthetic spreads from the thoracic to the lumbar level of the paravertebral region. The purpose of this study was to find how the anesthetic fluid traveled to the lumbar paravertebral region, if at all. Twelve cadavers were used in this study. 15 ml of crimson dye was injected into the paravertebral region at the 11th thoracic level. The viscerae were removed so that we could examine the dye spread. While the crimson dye spread in the endothoracic fascia posterior to the parietal pleura, it also spread downward in the fascia mostly along the splanchnic nerves, at the upper surface of the diaphragm the dye spread laterally in the fascia, and entered the abdominal cavity through the medial and lateral arcuate ligaments. In the abdominal cavity, the dye was found to have spread so widely in the transversalis fascia that the subcostal, iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous and femoral nerves were involved. We concluded that the dye in the thoracic paravertebral region can enter the abdominal cavity through the medial and lateral arcuate ligaments. This study explained possible fluid communication between the thoracic and lumbar paravertebral regions and confirmed our former clinical observations. The result is important for the future clinical application of paravertebral anesthesia
- No randomized control trials comparing one type over another, Cadaveric study by
- Of the 3 muscle layers of the anterolateral abdominal wall, the TAM and IOM taper off posteriorly into their origins from the thoracolumbar fascia. The EOM, on the other hand, ends posteriorly in a free edge, which abuts against the latissimus dorsi Muscle Medial and anterior to the QLM lies the psoas major muscle. The posterior and middle layers of thoracolumbar fascia fuse again lateral to the paraspinal muscles and merge with the aponeuroses of the IOM and TAM
- Posterior TAP- in the triangle of Petit Lateral TAP- Mid axillary line
- Posterior TAP- in the triangle of Petit Lateral TAP- Mid axillary line Several possible explanations may account for these findings. First, a more posterior injection point may allow the TAP block to capture lateral cutaneous branches of thoracolumbar nerves before entering into the TAP where they undergo extensive branching and anastomoses.33–36 Secondly, the posterior—but not the lateral—technique results in a retrograde local anaesthetic spread that reaches the paravertebral space37
- Posterior TAP- in the triangle of Petit Lateral TAP- Mid axillary line Several possible explanations may account for these findings. First, a more posterior injection point may allow the TAP block to capture lateral cutaneous branches of thoracolumbar nerves before entering into the TAP where they undergo extensive branching and anastomoses.33–36 Secondly, the posterior—but not the lateral—technique results in a retrograde local anaesthetic spread that reaches the paravertebral space37
- Blanco et al, not randomized, made an observation, spread was more widespread and greater into the paravertebral space In fact, based on these results, Blanco’s group changed their practice and now exclusively use the posterior QL block
- Carline et al compared QL1 lateral, QL2 and QL 3 transmuscular blocks by injecting 20ml of Indian ink into soft embalmed cadavers 4 transmuscular QL blocks, 3 QL1 blocks and 3 QL2 blocks QL TM block as an alternative to a lumbar paravertebral approach to the lumbar nerve roots Inadequate thoracic spread, possibly due decreased elasticity in cadavers, absent pressure differentials between various compartments in the body and absence of cardiorepiratory movements In contrast, two out of three QL 1 lateral and QL 2 posterior blocks spread anteriorly to the TAP plane between the internal oblique and transversus abdominis muscles and posteriorly to subcutaneous tissue surrounding the abdominal flank over latissimus dorsi”
- This study included 2382 patients. The total lateral, posterior, anterior, and intramuscular QL blocks were 771, 1485, 81, and 45 retrospectively. All QL blocks were performed by injection of 40 mL of 0.375% levobupivacaine (20 mL injected into each side). Of them blocks, the number of cases that reported quadriceps muscle weakness after a lateral, posterior, anterior and intramuscular QL block were 7(1%), 285(19%), 65(90%), and 0(0%) respectively.
- Under spinal, QL block vs Sham block
- Under spinal, QL block vs Sham block
- Any type of operation that requires intra-abdominal visceral pain to be covered plus abdominal wall incisions as cephalad asT6 and as caudal as L1. Midline incision and laparoscopic procedures require bilateral blocks for adequate coverage: exploratory laparotomy, large bowel resection, ileostomy, open/laparoscopic appendectomy, cholecystectomy, inguinal hernia repair (open or laparoscopic), scrotal surgery, cesarean section (citation), total abdominal hysterectomy, chronic pelvic floor pain, open prostatectomy, renal transplant surgery, percutaneous nephrolithotomy or nephrolithotripsy, nephrectomy, abdominoplasty, iliac crest bone graft, and total hip arthroplasty.