Also, our results confirmed that the block characteristics of lateral and posterior QL blocks might be quite different from anterior QL blocks [7, 11]. Although this technique has similarities to the posterior transversus abdominis plane (TAP) block, the extent of its effects has been suggested to be greater because the target injection point is more dorsal and the potential cephalad spread of local anaesthetics could reach the thoracic paravertebral space [3, 4]. Atlas of Human Anatomy (7th ed.). In addition, no dye was detected intraperitoneally, and there was no dye observed spreading into the transversus abdominis plane. The cephalad-to-caudal spread pattern was overall similar to that seen in the conventional QL blocks. Finally, with the current sample size, it will be difficult to adjust for the within-cadaver correlations based on repeated injections. Anaesthesia. The ventral rami of the segmental nerves (ie, intercostal nerves) were always dyed. I would honestly say that Kenhub cut my study time in half. Gallaudet BB. and grab your free ultimate anatomy study guide! C, Dye surrounding the thoracic sympathetic trunk and the segmental nerves (blue arrows). Two posterior QL blocks showed a deeply stained posterior thoracolumbar fascia, and one of them was associated with obvious subcutaneous staining. Hansen CK, Dam M, Bendtsen TF, Brglum J. Ultrasound-guided quadratus lumborum blocks: definition of the clinical relevant endpoint of injection and the safest approach. Background: A quadratus lumborum (QL) block is an abdominal truncal block technique that primarily provides analgesia and anaesthesia to the abdominal wall. La Colla L., Ben-David B. Quadratus lumborum block: conundrums and questions. The blue arrow indicates the subcostal nerve, artery, and vein deep to the 12th rib. The colon, the kidneys and the diaphragm are located ventrally to the muscle, whereas the intrinsic back muscles lie dorsomedially. (a) Dye-stained subcutaneous tissue in a posterior QL block. Often the source of pain when neglected, learn more about the Quadratus Lumborum's anatomy, exercises, stretches and treatment methods. The large field of vision enables a cross-sectional view of the entire lumbar region of interest. 2015;32:764770. A A Case Rep. 2016;6:39. Further, the subcostal, iliohypogastric, and ilioinguinal terminal nerves are also stained consistently. Epidural spread up to 70% of the cases has been reported for thoracic paravertebral block.11,24 In several studies, it has been reported that the opening injection pressure is proportional to the risk of epidural spread through the epidural sleeve with thoracic paravertebral block. In addition, no dye was detected intraperitoneally, and there was no dye observed spreading into the transversus abdominis plane. Anesth Analg. In theory, a low-frequency curvilinear transducer will probably be considered more suitable to visualize anatomical structures in deep blocks like the TQL block, the Shamrock lumbar plexus block, or other lumbar paravertebral blocks. There were no cases which involved dye spread above the level of the 12th rib or below the iliac crest level. 19. Ten QL blocks were conducted on 5 cadavers independently chosen by the scientific officer of the YSAEC. Comparison of dye staining between the different needle approaches for QL blocks. Two cadavers from the TOP TQL group (consisting of 5 cadavers) were excluded from the study before injections because of inadequate sonographic visualization. Pathway. Dam M., Moriggl B., Hansen C. K., Hoermann R., Bendtsen T. F., Brglum J. Federal government websites often end in .gov or .mil. The subjects included three males and two females, with an average age of 76 years. 8600 Rockville Pike Introduction. This cadaveric anatomical study was approved by the institutional review board of Severance Hospital, Yonsei University Health System (ref. to maintaining your privacy and will not share your personal information without Because the needle tip is advanced towards the lateral vertex of the LIFT over the QL on the sonographic image when performing a posterior QL block with posteroanterior needle trajectory, the chance of spread to the subcutaneous layer or intramuscular infiltration seems to be low. 23. However, future studies are needed to elucidate this question. Posterior variants of abdominal wall block include the quadratus lumborum type I, quadratus lumborum type II and quadratus lumborum transmuscular blocks. The first incision followed the lower border of the 10th rib starting at its cartilagebone boundary. 1Department of Anatomy, Yonsei University College of Medicine, Seoul, Republic of Korea, 2Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea. The lumbar plexus was never dyed within the psoas major muscle; nor was the femoral nerve or the lumbar sympathetic trunk. Inferiorly, the iliac fossa, to which the middle layer of the TLF is attached, was also examined. Copyright Author: Quadratus lumborum muscle: want to learn more about it? 12. It is the deepest muscle of the posterior abdominal wall, and it is often mistakenly referred to as one of the muscles of the back. The main pathway of spread of injectate was posterior to the medial and lateral arcuate ligaments. The lumbar plexus was never dyed within the psoas major muscle (Figure 5C); nor were the femoral nerve or lumbar sympathetic trunk. In conclusion, the alternative approach in this study, a posterior QL block with posteroanterior needle trajectory, could achieve a comparable extent of dye spread, when compared to the conventional approach in soft-embalmed cadavers. Consequently, the peritoneal cylinder was mobilized and pushed anteromedially to expose the musculofascial compartments of the psoas major and quadratus lumborum muscles, respectively. No dye surrounds the lumbar plexus (white arrows). and R.H. Sometimes, the genitofemoral nerve and the lateral femoral cutaneous nerve are also covered. To determine the uppermost and foremost position of the dye spread, the thoracic paravertebral space and arcuate ligaments of the diaphragm were examined. The thoracic sympathetic trunk was dyed in 100% (CI, 0.391.00) of the cases. 1978;102:6067.67. In this study, there was not much variation in the medial spread of dye surrounding the QL between different approaches for the QL block, although our alternative approach showed the spread of dye within the TAP with greater frequency. Sauter AR, Ullensvang K, Niemi G, et al. The target point of the posterior QL block was the LIFT, which is more superficially located on the posterolateral aspect of the QL. During the extension, the QL exerts a force of 10 N, compared to 100 N . Quadratus lumborum originates from the iliolumbar ligament and iliac crest. Quadratus lumborum originates from the iliolumbar ligament and iliac crest. Regarding the technical aspect of these blocks, the optimal injection point seems to be more easily achieved when using the posterior QL block with posteroanterior needle trajectory when compared with the conventional method, in our experience. B, T10 paravertebral injection showing radio-opaque dye hugging the vertebrae with cephalad and caudal spread. In particular, the injection between the QL and psoas muscles (Pm) resulted in a spread of the injectate within the QL-Pm interfascial plane. It runscraniomedially, attachingto the inferior border of12th riband the transverse processes of the 1st to 4th lumbar vertebrae. 2016;33:160171. The subcostal, iliohypogastric, and ilioinguinal nerves were mostly involved, and there was no statistically significant difference between conventional and alternative approaches (U=10.500, P=0.690). On the next day, the cadavers were dissected in layers, from superficial to deep, with subsequent verification of the extent of dye spread. . Anaesthesia. In all successful injections, the dye was seen to spread into the thoracic paravertebral space and the intercostal spaces to surround the somatic nerves and the thoracic sympathetic trunk. . Caudad to the diaphragm, the injected dye surrounded the subcostal, iliohypogastric, and ilioinguinal nerves in all cases, whereas the genitofemoral and lateral femoral cutaneous nerves were dyed in a varying degree. Eur J Anat. All fibers together give the muscle a rectangular appearance. In total, 5 posterior QL blocks with posteroanterior needle trajectory (an alternative approach) were performed (Figure 4). The quadratus lumborum (QL) muscle resides in the deep and posterior, lateral, and inferior areas of the spine, involving the iliac crest, the transverse processes of the lumbar vertebrae, and the 12th rib. Retroperitoneal spread of dye visible through the intact fasciae was photodocumented. For each fascicle, the sites of attachment, orientation, and physiological cross-sectional area were determined. 7. The magenta dotted line indicates the diaphragm; PM, psoas major. 2020a,b). Address e-mail to [emailprotected]. This cadaveric study was undertaken to compare the dye spread between different needle approaches for ultrasound-guided QL blocks in soft-embalmed cadavers. The authors are grateful to Dae Won Kim, Jun Ho Kim, and Yool Han for their technical support (all are staff members in the Surgical Anatomy Education Center at the Yonsei University College of Medicine). The cephalad-to-caudal spread pattern was similar between the lateral and posterior QL blocks. Anesthesia & Analgesia125(1):303-312, July 2017. Occasionally, the diaphragm had to be partially incised on the right side of the cadaver (depending on the individual liver size). Quadratus L=lumborumblocks have been shown to be successful in perioperative analgesia in abdominal and hip surgeries. 2017 . Cadaveric dissection following conventional lateral and posterior QL blocks. Much later, he gave a detailed description of the block technique using the name QLB ( 9 ). In a similar fashion to the lateral QL block, the needle was inserted towards the LIFT with the in-plane technique under ultrasound guidance (Figure 2). This manuscript was handled by: Honorio T. Benzon, MD. Each approach for QL blocks is illustrated in Figure 1. Third, the viscosity of our injected dye solution in the current study was higher compared with normal ropivacaine or saline solutions. One of the lateral QL blocks (50%, 95% CI 0.0260.973) was associated with dye spread within the TF plane, and the other lateral QL blocks showed partial spread of the dye within the plane between the EO and IO and intramuscular staining of the EO. Caudad to the diaphragm, the subcostal, iliohypogastric, and ilioinguinal nerves were dyed in 100% (CI, 0.391.00) of the cases, whereas the genitofemoral and lateral femoral cutaneous nerves were dyed to a varying degree (Table 2). No dye was seen to surround the lumbar plexus, femoral nerve, or lumbar sympathetic trunk. Regardless of the approach used, the middle thoracolumbar fascia was deeply stained in all blocks, but the anterior layer was less stained. (b) Ultrasound image of the lumbar interfascial triangle (LIFT) (ES, erector spinae; LD, latissimus dorsi; QL, quadratus lumborum; EO, external oblique muscle; IO, internal oblique muscle; TA, transversus abdominis muscle; PM, psoas major; PPS, posterior pararenal space). A quadratus lumborum (QL) block is an ultrasound-guided regional anesthesia technique that targets the fascial plane of the QL muscle and could provide a sensorial blockade of multiple areas of the abdomen [].In recent years, some anatomical and spread studies have been published with the aim of evaluating its feasibility in dogs [2,3,4,5], cats [] and goats []. On the right side, injected dye solution (red color) spreads in the plane between the PM and QL muscles. All cadavers were placed in the lateral position, and blocks were performed by a single-experienced anesthesiologist with specialty in regional anesthesia and pain medicine. Because we utilized soft-embalmed cadavers, we were unable to substitute the excluded 2 cadavers with 2 new specimens; this resulted in 10 TQL and 6 TOP TQL injections. Ultrasound-guided thoracic paravertebral block. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. Importantly, the dye solution never reached the lumbar plexus within the psoas major muscle or the lumbar sympathetic trunk. Hrmann R, Moriggl B, Brenner E. Development of a new vascular and tissue casting solution. Instead, dissection revealed only a 1-mm thin fascial layer bilaterally. Quadratus lumborum block is a block of the posterior abdominal wall, "interfascial plane block," which is performed exclusively under ultrasound guidance. This research was supported by Basic Science Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT, & Future Planning (NRF-2016R1C1B1007808). All of the lateral and posterior QL blocks (100%, 95% CI 0.4621.000) demonstrated deep staining of the middle layer of the TLF, but slightly fainter deep staining of the anterior layer of TLF was observed. Modified excerpt from VH Dissector with permission from Touch of Life Technologies Inc (. The QL muscle is an integral part of the thoracolumbar fascia, a myofascial system that covers the posterior area of the human body, involving . Its shape is irregular, but is generally quadriangular, which is the reason why it is described as 'quadratus' in latin. Green lines indicate the rib cage and the iliac crest, respectively. or if you're feeling ready to test your knowledge right away, try out our abdominal muscles quiz! The external image and ultrasound images show the ultrasound probe position with an arrow indicating the needle trajectory. may email you for journal alerts and information, but is committed This article will discuss the anatomy and clinical importance of the quadratus lumborum muscle. In 2007, Blanco initially described a no pops transversus abdominis plane block technique3 and later elaborated on this technique as QLB1 and QLB 2.4 Concurrently, a new TQL block approach emerged,1,2 which uses a posterior needle approach and a curvilinear transducer. La Colla L., Ben-David B., Merman R. Quadratus lumborum block as an alternative to lumbar plexus block for hip surgery: a report of 2 cases. One block that involved staining of the TF showed dye spread below the iliac crest towards the iliac fossa, but the femoral nerve was not involved. A very recent cadaveric study also reported limited thoracic spread following posterior QL blocks similar to our study [3]. Blood supply to quadratus lumborum comes from thebranches of lumbar, subcostal,median sacral, andiliolumbar arteries. (d) The TF plane was deeply stained, but the PPS was preserved (ES, erector spinae; QL, quadratus lumborum; IC, iliac crest; EO, external oblique muscle; IO, internal oblique muscle; TA, transversus abdominis muscle; PPS, posterior pararenal space; TAP, transversus abdominis plane; TLF, thoracolumbar fascia; TF, transversalis fascia). Does the injectate cover the genitofemoral nerve either before the genitofemoral nerve enters the psoas muscle or after it emerges on the anterior surface of the muscle? Saito T, Den S, Tanuma K, Tanuma Y, Carney E, Carlsson C. Anatomical bases for paravertebral anesthetic block: fluid communication between the thoracic and lumbar paravertebral regions. 1. All this alternative QL blocks (100%, 95% CI 0.4621.000) were associated with a certain amount of staining of the TAP, and two of them showed a deeply stained TAP. This cadaveric study demonstrated that the posterior QL block with posteroanterior needle trajectory can achieve a comparable extent of dye spread to conventional QL blocks, although this alternative approach was more frequently associated with the spread to the TAP. Stained areas were recorded in brief sketches, notes, and photographs, documenting their relationship to fascial planes. They then left the dissection room, and B.M. It runs craniomedially, attaching to the inferior border of 12th rib and the transverse processes of the 1st to 4th lumbar vertebrae. In this study, there were no definite differences in nerve involvement patterns between QL blocks with different approaches. Animals: A group of 12 adult canine cadavers. In addition, our results showed that the caudad spread of dye stopped at the iliac crest. The spread of injectate resulting from a transmuscular quadratus lumborum (TQL) block and a transverse oblique paramedian (TOP) TQL block has never been examined. The quadratus lumborum (QL) block was first described by Blanco [ 1 ]. Netter, F. (2019). The spread to the subcutaneous layer or intramuscular infiltration was very rarely observed in this alternative approach. The QL and PM muscles adjacent to the DI create the shape of a funnel, which enables the injected local anesthetic trapped in the fascial plane between the 2 muscles to spread cephalad into the thoracic paravertebral space posterior to the diaphragmatic crus. In 8 of 10 cadavers, the quality of the sonographic visualization was judged to be good or adequate. 6. FOIA Thus, the injectate administered with the TQL block might also spread to surround these nerves. C, Green dye is visualized to spread posterior to the transversalis fascia on the PM muscle. The psoas major muscle is divided into a posterior and anterior layer. The final needle tip placement for the alternative approach in this study was the same as that of the conventional posterior QL block (Figure 2). Anaesthesia. Currently, the QL block is performed as one of the perioperative pain management procedures for all generations (pediatrics, pregnant, and adult) undergoing abdominal surgery [ 2 - 4 ]. However, the anterior layer of the TLF, especially in the fascia between the QL and psoas muscle, showed relatively insufficient staining in both approaches. Green dots indicate the spinous processes. (d) The TF plane was stained, but the PM was not involved, in a lateral QL block. Thus, relatively well-distinguished spread patterns are presented as proportions (%) with 95% confidence intervals (CIs). Acta Anat. 1995;50:118121. Anesth Analg. As a library, NLM provides access to scientific literature. F, Sagittal image at the level of the apex of the 12th rib. The white arrow indicates needle trajectory with the TQL approach at the L4 level, with the end point in the plane between the QL and PM muscles. , , Carline et al., who specifically looked at the different types of QLB, found the anterior, or transmuscular QLB (TQLB), to have the most consistent upper lumbar plexus s. Elsharkawy H., El-Boghdadly K., Kolli S., et al. The Quadratus Lumborum is a muscle located deep within your lower back and is involved in many functions such as walking and standing. Lung and parietal pleura were first mobilized and then reflected ventrally. Inferior border of rib 12, transverse processes of vertebrae L1-L4, Subcostal nerve (T12), anterior rami of spinal nerves L1-L4, Lumbar, median sacral, iliolumbar and subcostal arteries, Bilateral contraction - fixes Ribs 12 during inspiration, trunk extension, D. Drenckhahn/J. Most of the blocks, regardless of needle trajectory, were consistently associated with dye staining of the upper branches of the lumbar plexus, including the subcostal, iliohypogastric, and ilioinguinal nerves. 2010;110:17351739. Meanwhile, an anterior QL block is performed in the plane between the QL and the psoas muscle with the posteroanterior needle trajectory [5, 6]. 2016;71:603604. In addition, there was a consistent spread of dye reaching the thoracic sympathetic trunk in all cadavers with normal anatomy. Funding: The Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, and Division of Clinical and Functional Anatomy, Medical University of Innsbruck, provided funding for this study. For the 4TOP TQL injections, the pathway of dye reaching the thoracic paravertebral space was posterior to both the medial and lateral arcuate ligaments in 75% (CI, 0.190.99) of the cases, and in 25% (CI, 0.0060.81) of the cases, the dye spread only posterior to the medial arcuate ligament (Table 2). The pathway of injectate spread with the transmuscular quadratus lumborum block: a cadaver study. The primary aims of our current descriptive cadaveric study were to answer the following 4 questions after injection with the TQL technique: (1) Does the injectate spread cephalad from the lumbar point of injection at the level of lumbar vertebra L4 to the thoracic paravertebral space via the pathway posterior to the arcuate ligaments? 2016;117:387394. and C.K.H. Blanco R, McDonnell J. Optimal point of injection: The quadratus lumborum type I and II block. In order to palpate the muscle one needs place the fingers above the posterior iliac crest at the level of the hip. Achudhan Karunaharamoorthy, Arzt Murouchi T., Iwasaki S., Yamakage M. Quadratus lumborum block: Analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery. The transducer was wrapped with a sterile plastic cover (Safersonic sterile sonography cover; Safersonic Medizinprodukte Handels, Ybbs, Austria). A quadratus lumborum (QL) block is an abdominal truncal block technique that primarily provides analgesia and anaesthesia to the abdominal wall. Caudad to the diaphragm, the subcostal, iliohypogastric (Figure 5, A and B), and ilioinguinal nerves were dyed in 100% (CI, 0.671.00) of the cases, whereas the genitofemoral and lateral femoral cutaneous nerves were dyed to a varying degree (Table 1). Then, the probe was moved anterolaterally in order to visualize the anterolateral margin of the QL and the aponeurosis of the two abdominal wall muscles (IO: internal oblique muscle; TA: transversus abdominis muscle). A, Green dye is visualized surrounding the subcostal nerve (blue dotted circle) cephalad to the diaphragm (magenta dotted line). Fourth, Carline et al21 performed their dissection procedure 72 hours after having injected their dye solution, whereas we performed our dissection procedure 30 minutes after the injections. Considering the cadaveric nature of this study, changes in tissue integrity could affect diffusion of the injectate. In cases of anterior QL blocks, recent studies also have shown conflicting results regarding the thoracic spread [4, 6, 7]. With charts listingthe attachments, innervations and functions of every muscle, our trunk wall muscle chart is an essential revision tool. Besides the spine, it also attaches to the twelwth rib, which makes it very important for stabilization of bothvertebral columnand the rib during various movements of the spine. With both techniques, the needle was advanced through the quadratus lumborum muscle until the tip of the needle penetrated the investing fascia of the quadratus lumborum muscle (Figures 1 and 2). As shown in our results, spread to the subcutaneous layer or intramuscular infiltration was seldom observed in posterior QL blocks with a different needle trajectory. when called upon by B.M. Fourth, we had intended to study a total of 10 cadavers. Animals A group of 12 adult canine cadavers. B, The Shamrock sign (ie, the TP of L4 and the 3 muscular structures consisting of the QL, PM, and ES muscles). All cadavers utilized in the present study were legally donated to the Surgical Anatomy Education Center at Yonsei University College of Medicine (YSAEC). Last reviewed: February 21, 2023 10. Palastanga, N., & Soames, R. (2012). Quadratus lumborum is innervated by the subcostal nerve (T12) and anterior rami of spinal nerves L1-L4. Cowie B, McGlade D, Ivanusic J, Barrington MJ. Anatomical details relevant for the TQL and TOP TQL injections. The .gov means its official. Despite accurate needle placement, all lateral QL blocks were associated with a certain amount of intramuscular or subcutaneous infiltration. Kenhub. For the clinician, it is worth remembering that anatomical variations can explain an unsuccessful block, as clearly shown in our study with 1 cadaver, and we believe that the study by Carline et al21 also highlights the potential to accidentally block the spinal nerve roots of the lumbar plexus if the needle tip pierces the psoas major muscle. 18. A transverse oblique approach to the transmuscular Quadratus Lumborum block. In conclusion, our data show that the dye solution spreads from the lumbar point of injection into the thoracic paravertebral space predominantly posterior to the arcuate ligaments with both TQL injection techniques. M. Schnke/E. All content published on Kenhub is reviewed by medical and anatomy experts. Methods Seventy-two patients aged between 18 and 70 years with an ASA I-II and scheduled for laparoscopic adrenalectomy were randomized to receive a single-shot TMQLB with 0.4 ml/kg 0.5 % ropivacaine or 0.4 ml/kg 0 . . These new findings regarding TQL injections in this study entirely contradict the very recent published results by Carline et al.21 In a very relevant study, Carline et al21 investigated 5 cadavers (10 sides) (ie, 4 TQL injections and 3 injections with the QLB1 and QLB2 technique each). Standring, S. (2016). With the TQL block, the local anesthetic is deposited in the plane between the quadratus lumborum and the psoas major muscles. The Magenta dotted line indicates diaphragm. Essentially, the quadratus lumborum contributes to the stabilization andmovement of the spineand the pelvis. Read more. The site is secure. In living subjects, the extent of the cutaneous sensory block after a lateral QL block seems to be quite variable, with the sensory block only consistently achieved in the flank, groin, and upper lateral thigh [12]. All fibers together give the muscle a rectangular appearance. A recent cadaver study reported that deep back muscle injection or spread of injectate posteriorly to the subcutaneous tissue can occur in lateral and posterior QL blocks [7]. A, Axial image of the TOP TQL injection at the level of L2. This anatomical characteristic was sometimes used as an explanation for the superiority of posterior QL blocks over lateral QL or TAP blocks [10]. Subsequently, the muscle fasciae were opened to allow for direct inspection and photodocumentation. Laterally, the IO was stripped off, and then, the TAP was revealed on the TA muscle. The dissection did not include the dorsal rami. 1 Based on the different injection sites, there are four types of quadratus lumborum block, namely, lateral quadratus lumborum block, posterior quadratus lumborum block, anterior (or transmuscular) quadratus l. It was described by anesthesiologist Dr. Rafael Blanco ( 8) as a variant of the TAP block in 2007. 2013. Surg Radiol Anat. The spread of dye in the abdominal cavity. Carline et al21 reported that all TQL injections consistently spread to L1 and L3 nerve roots and also within psoas and quadratus lumborum muscles. um -lm-br-m. A feline cadaver positioned in right lateral recumbency demonstrating the approach to a quadratus lumborum injection. (c) A successful, deeply stained middle layer of the TLF; however, the posterior layer of TLF below the LD was also stained in this posterior QL block. A total of 16 injections were performed. The ultrasound scanning and injection techniques regarding the TQL and TOP TQL approaches have both been described previously.1,2,5 Briefly, the cadavers were positioned lateral, with the side to be injected turned upward. Data were analysed using the Statistical Package for the Social Sciences 23.0 (SPSS Inc, Chicago, IL, USA). We observed no discernable difference in the pattern of injectate spread with the 2 transmuscular approaches apart from the 2 unsuccessful injections in the cadaver with an anatomical variation. A, Within the thoracic cage, the lung is gently reflected away, and the thoracic paravertebral space is dissected. Other causes can be direct damage or any type of imbalance of the pelvis or spine which forces the quadratus lumborum to stabilize them. Among the newest techniques, the US-guided quadratus lumborum (QL) block has been described recently in canine cadavers ( Garbin et al. Letter to the Editor. 2014;36:383392. However, in 1 cadaver, in which bilateral TOP TQL injections were performed, a rare anatomical variation was present on both sides (ie, no quadratus lumborum muscle was present). It starts at your lowest rib and ends at the top of your pelvis . government site. Among the newest techniques, the US-guided quadratus lumborum (QL) block has been described recently in canine cadavers (Garbin et al. Carline L, McLeod GA, Lamb C. A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. One layer is continuous with the endothoracic fascia, and another layer becomes the inferior diaphragmatic fascia.9 The transversalis fascia also covers the subcostal (T12), iliohypogastric, ilioinguinal, genitofemoral, and the lateral femoral cutaneous nerves. The second incision started where the first incision crossed the posterior axillary line and was brought down along this line close to the iliac crest. A, Transmuscular quadratus lumborum injection showing extensive spread of dye, particularly in cephalic direction. Reg Anesth Pain Med. Klein SM, Nielsen KC, Ahmed N, Buckenmaier CC, Steele SM. We hypothesized that different needle trajectories could have spread less to the subcutaneous layer or intramuscular infiltration. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. EO, external oblique muscle; IO, internal oblique muscle; TA, transverse abdominis muscle; TAP, transversus abdominis plane; TF, transversalis fascia. There were no cases that showed dye spread to the posterior layer of the TLF, the subcutaneous layer, or intramuscular injection. Address correspondence to Jens Brglum, MD, PhD, Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, University of Copenhagen, Sygehusvej 10, DK-4000 Roskilde, Denmark. Relations Quadratus lumborum muscle Musculus quadratus lumborum 1/4 ES indicates erector spinae; K, kidney; PM, psoas major; QL, quadratus lumborum; TOP, transverse, oblique and paramedian; TP, transverse process; TQL, transmuscular quadratus lumborum. Third, Carline et al21 report in a summary of block characteristics for all 4 transmuscular injections that the quadratus lumborum and psoas major muscles were consistently pierced. With our TQL and TOP TQL techniques, we avoided piercing the psoas major muscle because this could easily facilitate spread within the psoas major muscle to reach the lumbar plexus. A, The TQL approach (model photo). Ten cadavers donated to the Division of Clinical and Functional Anatomy of the Medical University of Innsbruck for scientific and educational purposes were allocated to our study.14,15 All cadavers were preserved using an arterial injection of an ethanolglycerol solution and immersion in phenolic acid in water for 1 to 3 months.16 This special embalming allows for both flexibility and excellent ultrasonographic images of cadavers in contrast to the regular preservation used for student dissection courses.17. Waschke: Taschenbuch Anatomie, 1st edition, Urban & Fischer Verlag/Elsevier (2008), p. 145. The muscle is positioned superficially to the psoas major. Visser WA, Gielen MJ, Giele JL, Scheffer GJ. Considering the cadavers used in this study, which lack diaphragm or any other muscle movements, the spread of injectate may be more dynamic and extensive in living subjects. Chin K. J., McDonnell J. G., Carvalho B., Sharkey A., Pawa A., Gadsden J. Essentials of our current understanding: abdominal wall blocks. Functional anatomy: Musculoskeletal anatomy, kinesiology, and palpation for manual therapists. Bethesda, MD 20894, Web Policies In this position, the ES (paraspinal muscles: multifidus, longissimus, and iliocostalis), which is contained within the paraspinal retinacular sheath, was identified, and the probe was then moved laterally to identify the QL, located below the ES and the latissimus dorsi (LD) muscle and superficial to the psoas muscle. Thus, 5 cadavers received bilateral USG TQL dye injections (10 sides), and 3 cadavers received bilateral USG TOP TQL dye injections (6 sides). With the TQL injection, the curvilinear transducer was oriented in the transverse plane above the iliac crest at the posterior axillary line to identify the Shamrock sign. Wolters Kluwer Health Clinically Oriented Anatomy (7th ed.). The subcostal, iliohypogastric, and ilioinguinal nerves were mostly involved, but the thoracic paravertebral space and lumbar plexus were not affected in all blocks. C, QL muscle colored purple. Schulte/U. The weak back muscles must now be compensated by the quadratus lumborum leading to painful tension and stiffening of the muscle. Chronic Pain Medicine: Original Laboratory Research Report. Green arrow indicates the Genitofemoral nerve. Some error has occurred while processing your request. Thus, with this procedure, 5 cadavers (10 sides) were a priori allocated to bilateral TQL injections, and 5 cadavers (10 sides) were a priori allocated to bilateral TOP TQL injections. First, postmortem changes regarding temperature and lack of muscle tone might alter the spread of the injectate compared with the living. This study used a small sample size. The lumbar region and abdominal flank were dissected 72 h later. This cut ended 3 finger breadths away from the respective vertebral body. HHS Vulnerability Disclosure, Help This study has some limitations. However, despite accurate needle tip placement, unintended dye spread along the posterior layer of the TLF or the LD surface towards the subcutaneous layer was observed, especially in conventional posterior QL blocks. 2011;66:10231030. Purcell-Jones G, Pither CE, Justins DM. Additionally, the thoracic paravertebral space and lumbar plexus within the psoas muscle were not affected in all blocks regardless of approaches. Does the injectate spread over the branches of the lumbar plexus within the psoas major muscle? Eur J Anaesthesiol. Superiorly, the intercostal spaces, with layers between the intercostal muscles, endothoracic membrane, and parietal pleura were examined after removal of the lower intercostal muscles. The results regarding the TQL injections are presented in Table 1, and the results regarding the TOP TQL injections are presented in Table 2. Before Methods: All cadavers were placed in the lateral position and the quadratus lumborum muscle seen using a 3-9 MHz ultrasound probe placed in the flank. While they are situated at the lower back between the pelvis and the lowest ribs, and thus commonly referred to as a low back muscle, these muscles are considered to be the deepest abdominal muscles. In 1 cadaver, in which bilateral TOP TQL injections were performed, a rare anatomical variation was present on both sides (ie, no quadratus lumborum muscle was present). 1932;17:458459. B, Green dye is visualized surrounding the iliohypogastic nerve (blue dotted circle). The . Further research to determine which approach yields best results is warranted. Tesarz J., Hoheisel U., Wiedenhfer B., Mense S. Sensory innervation of the thoracolumbar fascia in rats and humans. 3. Riederer BM, Bolt S, Brenner E, et al. The alternative approach was more associated with spread of injectate to the transversus abdominis and transversalis fascia plane. The Shamrock lumbar plexus block: A dose-finding study. At completion of the injection, the needle was finally withdrawn after flushing out the dye. The velocity of cephalad spread of local anesthetic from the lumbar position of injection with the TQL block into the thoracic paravertebral space is probably not related to the injection pressure, but rather to elastic recoil of the quadratus lumborum and psoas major muscles, and the pressure gradients associated with the respiratory function. Massive edema and air/gas entrapment made it impossible to identify the muscular and fascial structures. The quadratus lumborum muscle is located laterally in the posterior abdominal wall. Both the psoas major and the quadratus lumborum muscles pass posterior to the diaphragm and attach within the thoracic cage to the thoracic spine and the 12th rib, respectively. The most cephalad spread of dye reached the level of the lumbar vertebra T10. The most cephalad spread of dye reached the level of the T9 vertebral body. Study design Prospective, randomized, descriptive, experimental anatomic study. 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. The authors have no conflicts of interest to declare. sharing sensitive information, make sure youre on a federal Dam, Mette MD*; Moriggl, Bernhard MD, PhD; Hansen, Christian K. MD*; Hoermann, Romed; Bendtsen, Thomas F. MD, PhD; Brglum, Jens MD, PhD*. Elsharkawy H. Quadratus lumborum block with paramedian sagittal oblique (subcostal) approach. Looking for a fast and effective way to consolidate your knowledge on the quadratus lumborum? 2012;16:121. Our alternative approach could allow for reaching the LIFT with a shorter needle path, whereas the conventional approach requires a longer needle path because the needle passes through the layers of the abdominal wall muscles in most cases. When the muscle is only activated on one side, the trunk is bent towards that direction (lateral flexion). You may be trying to access this site from a secured browser on the server. A radiologic and anatomic assessment of injectate spread following transmuscular quadratus lumborum block in cadavers. Cadaveric dissection following the posterior QL block with an alternative needle approach. CE, Sagittal image at the level of the apex of the transverse process of L4. 11. No thoracic spread was recorded. This composition of injectate was chosen based on the results of a previous cadaver study [7]. The transducer is positioned with a TOP orientation 3 cm lateral to the level of L2 spinous process. Karmakar MK. 2016;41:275288. The key sonographic landmarks were readily identified in all posterior to lateral abdominal walls of all cadavers. The 8 cadavers demographically represent 3 men and 5 women with the following median (range) characteristics: age, 92 years (8298); height, 166.5 cm (150171); weight, 64 kg (5382); and body mass index, 23.9 kg/m2 (21.128.1). Cadaver studies evaluating the spread of QLB injectate have been mixed, with some finding no coverage of the lumbar plexus nerve roots, while others found consistent spread. Edinburgh: Churchill Livingstone. The skin and subcutaneous tissue on the abdominal flank, spreading horizontally from the midline to the midaxillary line and vertically from the 10th thoracic vertebra to the sacrum, were removed to reveal the LD, external oblique muscle (EO), and the posterior layer of the TLF. However, the estimated injectate volume that infiltrates into the thoracic paravertebral space appears to be too small for posterior QL blocks in living subjects, as well as cadavers [10]. Cadavers were scanned before injections, and the sonographic visualization was evaluated as good/adequate/inadequate. Illustration demonstrating the needle trajectory and tip location of the three different approaches to the ultrasound-guided QL block. Photographic documentation of the spread of dye was performed by M.D. With an anteroposterior needle trajectory, the target injection point of a lateral QL block is the anterolateral margin of the QL, and that of a posterior QL block is the lumbar interfascial triangle (LIFT) on the posterior surface of the QL [1, 5]. The lumbar region and abdominal flank were dissected. 2007;32:130. Because part of the analgesic effect of the TQL block in patients presumably can be attributed to spread of local anesthetic into the thoracic paravertebral space, the clinician might well choose a direct thoracic paravertebral block as an obvious first choice of analgesic technique. Finally, the TQL block is intended to provide analgesia for intraperitoneal and retroperitoneal surgeries, not to anesthetize the lumbar plexus. Green lines indicate the rib cage and the iliac crest, respectively. Ultrasound-guided thoracic paravertebral blockade: a cadaveric study. The QL blocks were successfully performed on each side of all five cadavers (10 sides) including 2 lateral QL blocks, 3 posterior QL blocks, and 5 alternative QL blocks (the posterior QL block with a different needle trajectory). Anaesthesia. Accepted for publication December 22, 2016. McHanwell S, Brenner E, Chirculescu ARM, et al. Inclusion in an NLM database does not imply endorsement of, or agreement with, Rawal N. Current issues in postoperative pain management. However, thoracic paravertebral block is associated with a risk of pneumothorax (even with ultrasound guidance).23 In addition, with direct paravertebral block, anticoagulation therapy probably presents a larger risk of procedure-related bleeding or hematoma in the thoracic paravertebral space compared with the TQL blocks. Karmakar MK, Gin T, Ho AM. On the left side, the dye solution was yellow, and on the right side, it was green. A cadaver study has raised many doubts about the action of QL. Available at: 2. Nonetheless, the alternative QL blocks were more frequently associated with the spread of dye from areas anterior to the QL to those lateral to the flank along the TF plane. Anterior quadratus lumborum block: subcostal approach. 1999;21:359363. A quadratus lumborum (QL) block is an abdominal truncal block technique that primarily provides analgesia and anaesthesia to the abdominal wall [1, 2]. The quadratus lumborum block is a novel truncal block where local anaesthetic is injected adjacent to the quadratus lumborum muscle. Our findings from this cadaver study will need confirmation from future randomized controlled clinical trials for selected surgical procedures. Reprints will not be available from the authors. One typical cause is the habit of sitting at the desk using a reclined seat, which releases the intrinsic back muscles and weakens them in the long term. Injection pressure (psi) was not measured. 2006;103:13181321. Finally, we never observed the dye solution staining the lumbar sympathetic trunk. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Read more. Dam M, Hansen CK, Brglum J, Chan V, Bendtsen TF. In conventional lateral QL blocks, the target injection point can sometimes be ambiguous in real clinical practice, because there are many anatomical structures, such as the anterior and middle layers of the TLF, multilayer of TA aponeurosis, and adjacent muscles, gathered around the anterolateral margin of the QL. 13. This study supported that lateral and posterior QL blocks, regardless of the needle approach used, might not always be a suitable replacement for lumbar plexus blocks. Although we hypothesized that dye injection in the LIFT would spread cranially to the thoracic paravertebral space, our results showed the contrary. After removal of the TA muscle, the anterior layer of the TLF and transversalis fascia (TF) lining on the inside of the QL and TA muscle was exposed on the posterior pararenal space. Saito T, Den S, Tanuma K, et al. Quadratus lumborum can be performed through different approaches which requires sound knowledge of anatomy. Two of the three posterior QL blocks (66.6%, 95% CI 0.1250.982) demonstrated spread of the dye along the posterior layer of TLF, and one of these blocks was clearly associated with subcutaneous tissue infiltration by the dye. Br J Anaesth. However, in some cases, the surgical procedure entails surgical drains at the flank level (or the anatomical structures are poorly visualized at this position). These anatomical findings might be useful knowledge when planning perioperative pain relief for surgical procedures such as undescended testicles, hydrocele, inguinal hernia repair, and bone graft harvest from the iliac crest and hip repair. All lateral QL blocks (100%, 95% CI 0.1971.000) and two of the three posterior QL blocks (66.6%, 95% CI 0.1250.982) showed a certain extent of the lateral dye spread within the TAP, but one of the posterior QL blocks showed a predominantly medial dye spread. 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