Quadratus Lumborum Flashcards
What are the indications for a Quadratus Lumborum Block?
Abdominal Surgery:
-Ex Lap
-Whipple
-Liver resection
-Gastrectomy
-Abdominal hysterectomy
-Nephrectomy
Anterior Hip
What is the block distribution for a QL block?
Analgesia to T6-L1
-Covers whole abdominal cavity
-Bilateral or unilateral
Somatic pain relief:
-To abdominal skin, muscles, parietal peritoneum
Possible Visceral pain relief: (assoc. with abdominal surgery)
-Due to paravertebral spread
-Better than TAP block
Ex: Deep back injection: PV spread in Lumbar region up to T7/T6 with L3 injection. Better pain relief
What is the relevant anatomy for a QL Block?
Anterior/lateral abdominal wall muscles:
-Rectus Abdominis
-External Oblique
-Internal Oblique
-Transversus Abdominis
Posterior abdominal wall:
-Erector spinae (located between TP and Spinous process)
-Psoas major (deep muscle, found lateral on either side of body of vertebra)
-Quadratus lumborum
-Thoracolumbar fascia (envelopes QL and runs continuously with Transversus Abdominis Fascia
Describe the needle placement for QL1?
Original one. At lateral border of QL, as the transversus muscle fades into a ligament. Inject in between the two muscle bellies
Describe the needle placement for QL2?
More superficial. Advantage over QL 1 as it’s much closer to vertebral bodies, more likely to have paravertebral spread over vertebral bodies and spinal nerves
Describe the needle placement for QL3?
Transmuscular, right next to vertebral bodies. Theorized to have the most paravertebral spread. The deepest muscle approach. More risk of entering peritoneal cavity, piercing a kidney, etc.
What is unique about performing the QL Block?
-Deeper: 4-8 cm deep
-Need Curvilinear transducer
-20-40 mL LA per side
How does the sitting position effect the QL muscle? (same as prone)
-QL has thinner appearance
-Can do R/L blocks without repositioning
How does the lateral decubitus position effect the QL muscle?
-QL has thicker appearance when hip abducted making it easier to identify
-May be ergonomically better
How do you perform the QL Block via US?
-Not midline. Off to the lateral side a few inches.
-Looking back towards midline, towards spine itself.
-Bright white shadow under ES is transverse process.
-Right below Psoas is edge of peritoneal cavity.
-Needle passes through ES, entering into QL, passing through QL (transmuscular or QL 3 approach).
-Needle enters into Psoas muscle, retract a bit to enter space.
-Then inject fluid. LA spreads the 2 planes apart.
-Needle cautiously when kidney, liver, or spleen in your US view
-Using color flow may be helpful in identifying lumbar arteries that run on posterior surface of QL
-Larger volumes of LA may give you better paravertebral spread (but may catch lumbar plexus if far enough over and can result in leg weakness)
What is the CPT code for the QL Block?
CPT code 64450 “other”
-So new blocks that insurance companies don’t have a way to bill for them.
