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

Abstract

The spread of injectate with the TQL and TOP TQL approaches is cephalad from the lumbar point of administration between the quadratus lumborum and psoas major muscles, predominantly via a pathway posterior to the arcuate ligaments and into the thoracic paravertebral space to reach the somatic nerves and the thoracic sympathetic trunk in the intercostal and paravertebral spaces. The lumbar plexus and lumbar sympathetic trunk are not affected.

Evaluation of the effectiveness of the Quadratus Lumborum Block type I using ropivacaine in postoperative analgesia after a cesarean section — a controlled clinical study

“…There were no published studies evaluating the effectiveness of the QLB I and post-cesarean section until 2014, when the protocol of the clinical trial presented here was developed. According to various studies published since 2015, the QLB and its variants are an effective analgesic tool compared with the TAPB due to the absence of the paravertebral component; a smaller scope of activities; and the possibility of fewer complications [15,16,24].…”

“…Over the next 48 hours, all patients received 1 g of paracetamol iv at constant intervals of time (every 6 hours) and 5 mg of morphine subcutaneously depending on their intensity of pain (NRS > 3), or, on demand with the proviso of a 4-hour administration frequency. Next, the the level of pain intensity was evaluated, only in rest among the newly delivered mothers (using NRS scale 0-10 in which 0 = no pain and 10 = worst pain imaginable) and consecutively after 2,4,8,12,16,20,24,30,36, 42 and 48 hours. At every postoperative time-point the following parameters were measured: sedation (Ramsey scale); nausea, vomiting and itching (0 = none, 1 = mild, 2 = moderate, 3 = severe); the possibility of the free movement of limbs or any other possible side effects.…”

Quadratus lumborum block (QLB)

“…U svakodnevnoj kliničkoj praksi se primenjuju različiti pristupi izvođenja bloka, a razlike u širi-ni anesteziranog polja i dužini trajanja analgezije su značajne. Do sada urađene studije na kadaverima 18,21,22,23,24 pokazuju da ubrizgani kontrast za QLB može da se razlije kranijalno do torakalnog paravertebralnog prostora i interkostalnih prostora, sa zahvatanjem somatskih nerava i torakalnog simpatičkog stabla (truncus sympaticus) različite visine. Konzistentno je zahvatanje supkostalnog (n. subcostalis), iliohipogastričnog (n. iliohypogastricus) i iliongvinalnog nerva (n. ilioinguinalis).…”

“…Racionalno teorijsko objašnjenje leži u neposrednom anatomskom kontaktu TLF i ilijačne fascije i mogućnosti da se anestetik, dat pod kontrolom ultrazvuka, uz TLF razlije niz ilijačnu fasciju i izazove slabost kvadricepsa 22,52,53,59 . Dam i saradnici 21 , prilikom izvođenja QLB 3, ne rade punkciju MPM i ne dobijaju širenje kontrasta kaudalno. To nam ostavlja i potencijalni zaključak da ako nema punkcije MPM, nema neželjene slabosti kvadricepsa.…”

Shamrock sign: inadvertently inverted

“…The Shamrock sign is applicable as a sonoanatomical map guiding the lumbar plexus block3 as well as the transmuscular quadratus lumborum block 4. Maybe also useful for a lumbar ESPB—if it works as intended?…”