Quadratus Lumborum Block - Dr. V Koyyalamudi

Quadratus Lumborum Block - Dr. V Koyyalamudi

1. Quadratus lumborum block Dr.V.Koyyalamudi Assistant Professor Department of Anesthesiology and Perioperative Medicine Mayo Clinic, Arizona

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. 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. The Quadratus lumborum muscle Lumborum - back Quadratus- quadrilateral Origin- Iliac crest Insertion- L1-L4 transverse process and 12 th rib

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. Transversalis fascia Lies between the inner surface of the transverse abdominal muscle and the extraperitoneal fat and parietal peritoneum From NYSORA.COM QL Kidney Transversalis fascia ES Ps Anterior layer Thoracolumbar fascia

7. Endothoracic fascia The transversalis fascia follows the QLM and psoas major superiorly through the diaphragm Transversalis fascia blends with the e ndothoracic fascia Pathway for the spread of injectate into the thoracic paravertebral space

8. Continuity of the lumbar and thoracic paravertebral spaces Cadaveric study, 15ml of dye injected at T11 Spread was seen A long 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. 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. The QL Blocks © 2018 ASRA. All rights reserved, with permission QL1 - Lateral QL QL2 - Posterior QL QL3 - Anterior QL Intramuscular QL

11. QL block positioning and probe location

12. copyright © 2017, American Society of Regional Anesthesia and Pain Medicine (ASRA)

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. QL block positioning and probe location

15. Pre injection-QL Block Post injection QL Anterior Block QL L4 PM TAP LA ES - Lateral QL - Posterior QL - Intramuscular QL - Anterior/ transmuscular QL

16. Posterior TAP vs Lateral TAP vs Lateral QL Copyright PACIRA PHARMACEUTICALS, Inc. Lateral TAP Posterior TAP Lateral QL

17. “posterior TAP block appears to produce more prolonged analgesia than the lateral TAP block”

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. 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. 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. Anterior/ Transmuscular QL Block spread- cadaveric studies Bilateral transmuscular ( anterior) QL blocks in six cadavers Spread to the lumbar paravertebral space in 63% L aterally 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. 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. 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. 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. 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. 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. 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. 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. RCT’s: QL Posterior vs TAP Oksuz et al- Fifty-three children undergoing unilateral inguinal hernia repair or orchiopexy surgery In the QL group: T he number of patients who required analgesia in the first 24 hours postoperatively was lower ( P < 0.05 ) T he postoperative 30-minute and 1-, 2-, 4-, 6-, 12-, and 24-hour FLACC scores were lower ( P < 0.05 ) P arent 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. 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. 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. 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. 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. Questions?