Ultrasound-guided injection of local anesthetic in the fascial plane offers anesthesiologists a method that is effective and safe with few complications. One relatively new approach in this realm is the quadratus lumborum (QL) block, a variant of the transversus abdominis plane (TAP) block.
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Over the past four years, Hesham Elsharkawy, MD, staff in the Department of General Anesthesiology, and his colleagues at Cleveland Clinic have extensively studied the QL block. They have developed a specialized approach to performing it and have successfully lobbied for a change in the procedure’s nomenclature. “The QL block has advantages,” Dr. Elsharkawy says, “because you can tailor it to different areas of the body such as the lower chest wall, the upper abdomen, lower abdomen and even the hip and lower extremities.”
The following illustrations highlight important considerations for physicians performing the QL block. All images are republished with permissions from Elsevier and were originally published in Advances in Anesthesia.
<p>These illustrations depict the anterior subcostal paramedian sagittal oblique QL block devel-oped by Dr. Elsharkawy and colleagues. In order to have an oblique sagittal view of the QL muscle, the ultrasound transducer is positioned 6 to 8 cm lateral to the lumbar spinous process at the L1-L2 level with a parasagittal orientation just above the crossover point of the erector spinae and the QL. Then, using a curvilinear transducer with the orientation marker of the ul-trasound cephalad, it is shifted cranially, and the probe is slightly tilted medially. The needle is advanced in plane with ultrasound in a caudal-to-cephalad direction, through the LD then QL muscles. Local anesthetic is deposited anterior to the QL muscle, between the QL muscle and the anterior layer of the thoracolumbar fascia (ATLF). The needle tip is then advanced more cephalad, and local anesthetic, after negative aspiration, is deposited incrementally, observing spread in cephalad direction close to the twelfth rib, with a crescent-shaped distribution of local anesthetic with anterior displacement of the ATLF.</p>