Quadratus Lumborum Block - PowerPoint Presentation

Slide1

Quadratus Lumborum Block

Dr. S.

Parthasarathy

. MD DA DNB PhD, FICA ,IDRA

Dip. software based statistics

Slide2

What is it ??

Local anesthetic is deposited within close proximity to

the quadratus

lumborum

muscle in the

lower

lumbar region

of

the trunk.

Posterior

interfascial

plane block

Target –

thoroco

lumbar

nerves

QL and its enclosure TLF is a bridge from anterior TA,IO,EO and posterior paravertebral region

Slide3

History

Dr. Rafael Blanco

as

a variant of the TAP block in 2007.

no pop ups !!

2013 – detailed description

Dr. Jens Borglum

(

Denmark) published a new ultrasound-guided

transmuscular

QL

blockade, describing the so-called “Shamrock sign,”

Dr

.

Mihaela

Visoiu

,

a

pediatric

anesthesiologist

in

Pittsburgh (USA), published a case report

with

continuous

QLB for postoperative analgesia

Slide4

Where is this muscle ?

Quadratus

lumborum

is a posterior abdominal wall

muscle

that

originates from the

posteromedial iliac crest and inserts into the medial border of the twelfth rib and the transverse processes of the first to fourth lumbar vertebrae.

Slide5

Anatomy

Slide6

From the front !!

Slide7

Action of the quadratus lumborum

Lateral

flexion of vertebral column,

with

ipsilateral contraction

Extension of lumbar vertebral

column

, with bilateral contractionfix the 12th rib during forced expirationElevates the ilium (bone), with ipsilateral contraction

Slide8

Thoracolumbar fascia

The

Thoracolumbar

fascia is part of a

myofascial girdle

that surrounds the lower torso and is

important for

posture, load transfer, and stabilization of the lumbar spine. engulfs QL Connecting abdominal muscles with paraspinal

muscles

Two layered model – anterior and posterior

Three layered model –

Anterior middle and posterior

Slide9

TLF

Cranially, the anterior layer of the thoracolumbar

fascia (the

transversalis fascia in the two-layer model) divides

into two

layers. One layer is continuous with the

endothoracic

fascia in the thorax, and the other layer blends with the diaphragm at the arcuate ligaments. Caudally, this fascial layer is continuous with the fascia

iliaca

Slide10

Picture modified from the internet for closed non commercial academic use only

ES

Slide11

TLF – continues as

endothoracic

fascia

Can spread to lumbar plexus

Proprioception

Rich receptors -

there is a thick network of sympathetic neurons. may be involved in acute and chronic pain Possible mechanism of visceral anesthesia

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A lot of cadaveric studies

70 % L3

T12 – 30 %

Fascial plane is a must !!

Slide15

Sagittal section showing the fascial relations of the lower thoracic subendothoracic

paravertebral space and the retroperitoneal space.

Slide16

Cranial spread – more on the left side

Slide17

Vessel rich

The four lumbar arteries arise from the aorta

;

they course posterior to the psoas major muscle.

The

abdominal branches of the lumbar arteries run laterally behind the QL muscle and then forward between the abdominal

musclesColor doppler use before drug !!

Slide18

In short

basically TLF – fascial compartment engulfing Para spinal muscles

Two layered or three layered

Continuous with

endothoracic

fascia

Fascia

iliaca Through the diaphragm – paraveterbral - ??

Slide19

Picture modified from the internet for closed non commercial academic use only

Slide20

See the nerves

Slide21

Picture modified from the internet for closed non commercial academic use only

Slide22

Types of block

Slide23

Picture modified from the internet for closed non commercial academic use only

Slide24

Shamrock sign

QL 1 , 2 and 3

Slide25

QL 3

Which Type Is Better?

 

Presently

, there is no available literature comparing the safety and efficacy of the three types of QL block. 

QL 3 is less invasive than lumbar plexus block

Slide26

Needle length – 80 to 150 mm

Thickness – need for a catheter or not

Local anesthetic dosage in the range of 0.2 to 0.4 ml/kg

of 0.2

to 0.5%

ropivacaine

or 0.1 to 0.25% bupivacaine per side is recommended.18-24 ml for a 60 Kg patient each side !! May go upto 30 ml in 70 kg – eye on toxic dose

Block onset time varies from 10 to 30 minutes after injection. 

Slide27

Infusions set doses

For

continuous infusions,

ropivacaine

at concentrations of 0.1% to 0.2% is used with a basal infusing rate of 6 to 8 mL an hour and patient-controlled bolus of 5 to 12 mL every hour

Slide28

The patient can be positioned supine with a lateral tilt,

lateral, sitting

or prone, largely depending on physician

preference, patient

mobility, and planned needle

trajectory.

Slide29

Technique

Keep the probe between iliac crest and subcostal margin transverse

Inplane

No TAP perforation

Needle to the end of TAP

Elastance

-prick - feel and USG guidance

Slide30

Slide31

Where does the drug go ??

Anterior

quadratus

lumborum

block

injectate

may spread to the lumbar nerve roots and branches (plexus) in addition to the thoracic paravertebral space. Posterior quadratus

lumborum

blocks appear

to demonstrate

their clinical effect by

injectate

spread

along the

middle thoracolumbar fascia

intertransverse

area

.

Lateral

quadratus

lumborum

blocks are associated

with

injectate

spread to the transversus abdominis muscle

plane

and

to subcutaneous tissue

Slide32

Slide33

Can keep the probe like this also

variation is

maintaining

the

transducer in transverse orientation but placing it

more medially

, approximately 3 cm lateral to the L2 spinous

process.This has been referred to as the transverse oblique paramedian placement, and the image is enhanced with

medial rocking of the transducer and slight

caudal rotation

of the lateral aspect of the transducer

Slide34

Rafael

Blanco Abu Dhabi UAE

John

McDonnell Galway Ireland

Letter to the editor

The TLF is cover with two types of mechanoreceptors the

Ruffini's

corpuscles and the Vater-Paccini corpuscles . These receptors surround mainly the blood vessels and are assumed

to lower the sympathetic nervous system

activity.

Fast and effective in QL 3

–

is it so ??

Slide35

What is achieved !

analgesia is achieved in T7–L1

dermatomes

Rarely cranial spread to T4–T5,

and caudal spread to L2–L3

The

height

- influenced by the choice of the site for the application of local anesthetics, both in relation to QLM and in relation to the distance from the iliac crest

and costal

margin

The

rate of the drug application

and

the individual anatomical variations can

also influence the height

of the block.

Slide36

Slide37

Indications

abdominal

, obstetric,

gynecologic

, and urologic

surgeries.

Iliac crest grafting

Hip surgeries , orchiectomy, hernias lumbar vertebrae surgeries ?? Combination of lumbar erector spinae plane block and transmuscular

quadratus

lumborum

block for surgical anaesthesia in hemiarthroplasty for femoral neck fracture

T7–L2 dermatomes

Visceral pain

Slide38

Other indications

Ultrasound guided continuous Quadratus

Lumborum

block hastened recovery in patients undergoing open liver resection: a randomized controlled, open-label trial

Quadratus

lumborum

block provides improved immediate postoperative analgesia and decreased opioid use compared with a multimodal pain regimen following hip

arthroscopyIncarcerated hernia Duration may exceed 24 hours – liposmal bupivacaine – 2-3 days

Slide39

Tricks

Try

to aim away from the tip of the transverse process as the local anesthetic might then spread along the transverse process toward the lumbar plexus within the psoas muscle

QL 3 catheters used for all perioperative

anesthesia

care

Hydrodissection

Twice a day

Slide40

Between TAP and QL

Visceral pain

Lower limbs

Difficult learning curve

More anatomy knowledge

Slide41

Contraindications

local infection,

allergy

to local anesthetics,

a

known bleeding

diathesis

Anticoagulants ? Deep block

Slide42

Complications

Local

anesthetic

toxicity

Hypotension

Lumbar plexus block and knee paralyses

Bleeding

Pleural injury Kidney injury

Slide43

Summary

Quadratus

lumborum

muscle anatomy

TLF –

Types

Mechanism

Indications Contraindications Complications

Thank you all