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Quadratus lumborum block: an imaging study of three approaches
  1. Angela Lucia Balocco1,
  2. Ana M López1,
  3. Cedric Kesteloot2,
  4. Jean-Louis Horn3,
  5. Jean-François Brichant4,
  6. Catherine Vandepitte1,
  7. Admir Hadzic1 and
  8. Philippe Gautier2
  1. 1 Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
  2. 2 Anesthesiology, Clinique Sainte-Anne Saint-Remi, Brussels, Belgium
  3. 3 Anesthesiology, Stanford University, Stanford, California, USA
  4. 4 Anesthesiology and Intensive Care Medicine, Centre Hospitalier Universitaire de Liège, Liege, Belgium
  1. Correspondence to Dr Philippe Gautier, Anesthesiology, Clinique Sainte-Anne Saint-Remi, Brussels, 1070 Brussels, Belgium; p.gautier{at}


Background and objectives Different injection techniques for the quadratus lumborum (QL) block have been described. Data in human cadavers suggest that the transverse oblique paramedian (TOP) QL3 may reach the thoracic paravertebral space more consistently than the QL1 and QL2. However, the distribution of injectate in cadavers may differ from that in patients. Hence, we assessed the distribution of the injectate after the QL1, QL2, and TOP QL3 techniques in patients.

Materials and methods Thirty-four patients scheduled for abdominal surgery received QL blocks postoperatively; 26 patients received bilateral and 8 patients received unilateral blocks. Block injections were randomly allocated to QL1, QL2, or TOP QL3 techniques (20 blocks per each technique). The injections consisted of 18 mL of ropivacaine 0.375% with 2 mL of radiopaque contrast, injected lateral or posterior to the QL muscle for the QL1 and QL2 techniques, respectively. For the TOP QL3, the injection was into the plane between the QL and psoas muscles, proximal to the L2 transverse process. Two reviewers, blinded to the allocation, reviewed three-dimensional computed tomography (3D-CT) images to assess the distribution of injectate.

Results and discussion The QL1 block spread in the transversus abdominis plane (TAP), QL2 in the TAP, and posterior aspect of the QL muscle, whereas TOP QL3 spread consistently in the anterior aspect of the QL muscle with occasional spread to the lumbar and thoracic paravertebral areas.

Conclusions The spread of injectate after QL1, QL2, and QL3 blocks, resulted in different distribution patterns, primarily in the area of injection. The TOP QL3 did not result in consistent interfascial spread toward the thoracic paravertebral space.

  • regional anesthesia
  • pain
  • postoperative
  • ultrasonography

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  • Contributors ALB and AML helped in analysis and interpretation of data, manuscript preparation, and revisions. CK helped in conducting the study and data collection. J-LH, J-FB, and CV helped in manuscript preparation and revisions. AH helped in analysis and interpretation of data, manuscript preparation, and revisions. PG helped in study design, conducting the study, data collection, data analysis, manuscript preparation, and is the archival author.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AH has consulted and/or performed sponsored research for Philipps, Pacira, BBraun Medical, and Heron Therapeutics. He owns and manages (education), MedXpress.Pro (IP), and VisionExpo (medical design). He has developed and licenses technologies to the medical device industry (BBraun, LifeTech). Other authors declare no competing interests.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request from Dr Philippe Gautier.