🔹 *IJA COMPENDIUM – QL Block*
Planning to
conduct a study related to quadratus lumborum nerve blocks or introduce it to
your clinical practice?
Check all IJA manuscripts related to QL Block:
https://journals.lww.com/ijaweb/pages/results.aspx?txtKeywords=quadratus+lumborum+block
Quadratus Lumborum (QL) Blocks – Comprehensive Overview
QL blocks are truncal fascial plane blocks that target the thoracolumbar fascia to provide analgesia for abdominal and lower limb surgeries. These blocks are classified into different approaches based on the injection site and spread pattern.
🟢 1. Lateral QL Block (QL1)
🔸 Injection Site: Between the quadratus lumborum muscle (QLM) and transversus abdominis aponeurosis.
🔸 Spread: Local anesthetic spreads along the lateral abdominal wall but does not extend to the paravertebral space.
🔸 Indications:
✅ Lower abdominal surgeries (e.g., appendectomy, hernia repair, cesarean section).
✅ Postoperative analgesia for laparoscopic procedures.
✅ Pediatric abdominal surgeries.
🔸 Benefits:
✔ Good somatic analgesia for the anterior abdominal wall.
✔ Reduces opioid consumption in abdominal surgeries.
🔸 Limitations:
❌ Limited visceral analgesia (does not block visceral afferents).
❌ Less effective for deep intra-abdominal pain.
🟡 2. Posterior QL Block (QL2)
🔸 Injection Site: Posterior to the quadratus lumborum muscle (between QLM and the thoracolumbar fascia).
🔸 Spread: Extends posteromedially towards the paravertebral space, covering dermatomes T7 to L3.
🔸 Indications:
✅ Major abdominal surgeries (e.g., colectomy, nephrectomy, cesarean section).
✅ Hip surgeries.
✅ Lumbar spine procedures.
🔸 Benefits:
✔ Wider dermatomal coverage than QL1.
✔ Effective for both somatic and limited visceral analgesia.
🔸 Limitations:
❌ Variable spread; may not always reach the paravertebral space.
❌ Onset can be slower compared to neuraxial blocks.
🔴 3. Transmuscular QL Block (QL3) / Anterior QL Block
🔸 Injection Site: Between the quadratus lumborum and psoas major muscles.
🔸 Spread: Reaches the lumbar plexus (L1-L4) and can extend into the thoracic paravertebral space.
🔸 Indications:
✅ Major abdominal surgeries (e.g., hysterectomy, nephrectomy, cesarean section, colectomy).
✅ Orthopedic surgeries (e.g., hip replacement, femur fractures).
✅ Postoperative pain management for visceral pain.
🔸 Benefits:
✔ Provides both somatic and visceral analgesia.
✔ Long-lasting analgesia (up to 24 hours).
✔ Can reduce the need for neuraxial analgesia in high-risk patients.
🔸 Limitations:
❌ Technically challenging (requires careful ultrasound guidance).
❌ Risk of lumbar plexus involvement, leading to quadriceps weakness.
🟣 4. Intramuscular QL Block
🔸 Injection Site: Directly within the quadratus lumborum muscle.
🔸 Spread: More localized, may not extend to the paravertebral or lumbar plexus.
🔸 Indications:
✅ Adjunct analgesia for abdominal surgeries.
✅ Patients with high bleeding risk where deeper fascial blocks are contraindicated.
🔸 Benefits:
✔ Less risk of neuraxial spread (avoids lumbar plexus block).
🔸 Limitations:
❌ Unpredictable spread – may have inconsistent pain relief.
❌ Shorter duration of action than other QL blocks.
🔹 Key Comparisons of QL Blocks
| Block Type | Injection Location | Spread | Best for | Analgesic Effect |
|---|---|---|---|---|
| QL1 (Lateral) | Between QL and transversus abdominis aponeurosis | Lateral abdominal wall | Lower abdominal surgeries (hernia, appendectomy) | Somatic only |
| QL2 (Posterior) | Posterior to QL muscle | May reach paravertebral space (T7-L3) | Cesarean, nephrectomy, lumbar surgeries | Somatic + mild visceral |
| QL3 (Anterior/Transmuscular) | Between QL and psoas major muscle | Lumbar plexus + paravertebral spread | Major abdominal, hip surgeries | Somatic + visceral |
| Intramuscular QL | Inside the QL muscle | Localized effect | Postoperative adjunct analgesia | Unpredictable |
🔹 Final Takeaways
1️⃣ For Lower Abdominal Surgeries → QL1 or QL2.
2️⃣ For Visceral Analgesia (e.g., major abdominal surgeries) → QL3 (Transmuscular) is best.
3️⃣ For Hip or Lumbar Spine Surgeries → QL2 or QL3.
4️⃣ If Avoiding Neuraxial Spread is Important → Intramuscular QL may be considered.
