Quadratus Lumborum (QL) block was initially introduced and described by Blanco et al. at ESRA annual congress as a novel method to provide a greater spread of local anesthetic than the classical transverse abdominis plane (TAP) block. Blanco et al., in their correspondence, described two different types of Quadratus Lumborum blocks. QL-1 involves injection at the lateral border of the Quadratus Lumborum muscle, whereas QL-2 is in the posterior direction to the muscle. They describe a spread up to the thoracic paravertebral space with both QL1 and QL2 blocks.
Besides these two blocks, the trans muscular approach to Quadratus Lumborum (QL-3) block was initially described by Borglum et al. from an adaptation of their “shamrock” lumbar plexus block.
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What is Quadratus Lumborum Block?
Quadratus Lumborum Block (QLB) is the posterior abdominal block that differs from the Transversus Abdominis Plane (TAP). The thoracolumbar fascia (TLF) is a back extension of the abdominal wall muscle fascia surrounding the back muscles. QLB is also known as an interfascial plane block (Quadratus Lumborum, Erector spine muscles, and Psoas major). The TLF contains three layers as anterior, middle, and posterior based on the relation of TLF to the back muscles it encloses.
Variants of this block are described as follows.
Quadratus Lumborum Block Type 1
The deposition of local anesthetic lateral to the Quadratus Lumborum muscle is known as a Quadratus Lumborum Block type 1 (QLB-1) or lateral quadratus lumborum block. This action can be performed utilizing an in-plane methodology by inserting a needle lateral (anterior) to the ultrasound transducer with a front-to-back needle direction. After the needle tip passes the transversus abdominis aponeurosis, a local anesthetic is deposited at the lateral boundary of the quadratus lumborum muscle.
Quadratus Lumborum Block Type 2
QLB-2 (posterior quadratus lumborum block) is a type of quadratus lumborum block in which local anesthetic is injected into the posterior quadratus lumborum muscle, anterior to the thoracolumbar fascia (TLF). This separates the QL muscle from the latissimus dorsi muscles and the erector spine in the lumbar interfascial triangle region. This can be performed utilizing an in-plane methodology by using a front to back (anterior to posterior) or back to foremost (posterior to anterior) direction. This technique was used in two randomized controlled preliminary studies that found quadratus lumborum block to be more narcotic-saving than placebo or transversus abdominis plane block after a cesarean segment.
Quadratus Lumborum Block Type 3
Quadratus Lumborum Block type 3 (QLB-3) is also named anterior quadratus lumborum block or the trans muscular method because the typical needle methodology is used as an injection anterior to the Quadratus Lumborum muscle. This action can be performed utilizing an in-plane methodology, with an insertion of a needle medial to the ultrasound transducer, using a back-to-front direction.
On the other hand, an in-plane methodology with an anterior to posterior approach can be utilized. Another choice is the subcostal slanted anterior technique, in which the needle is added caudal to the transducer and the path is in-plane, caudal–lateral to cranial–medial. In the tissue plane, the mark of local anesthetic injection is located between the quadratus lumborum and psoas muscles.
Quadratus Lumborum Block Complications
Quadratus Lumborum Block can result in the distribution of local anesthetic to the lumbar plexus and lengthy motor block that delay mobilization and discharge from hospital. In some cases, lower-limb weakness has been reported after using all the approaches of Quadratus Lumborum Block. Due to the spread of the local anesthetic to the paravertebral space, hypertension has also been reported in some cases. Due to the area’s continuous high dosage and vascularity, the local anesthetic systemic harmful effect can become a potential risk. However, the high concentrations of local anesthetic are lowered after Quadratus Lumborum blocks.
Because of the proximity of the quadratus lumborum block to the pleura and kidney in the subcostal anterior approach, direct needle trauma is a risk. The possibility of bleeding complications is not known till now. There is no evidence found yet regarding the risk of bleeding due to Quadratus Lumborum methods.
As a result, both physicians and specialists are advised to carefully review and observe anesthesia and pain management protocols when treating such deep peripheral blocks.