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Original article
Comparing two posterior quadratus lumborum block approaches with low thoracic erector spinae plane block: an anatomic study
  1. Hesham Elsharkawy1,
  2. Gausan Ratna Bajracharya2,
  3. Kariem El-Boghdadly3,
  4. Richard L. Drake4 and
  5. Edward R. Mariano5,6
  1. 1Departments of General Anesthesia and Pain Management, Outcomes Research, Anesthesiology Institute. Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2Resident, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
  3. 3Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London, UK
  4. 4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, USA
  5. 5Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
  6. 6Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
  1. Correspondence to Dr Hesham Elsharkawy, Departments of General Anesthesia and Pain Management, Outcomes Research, Anesthesiology Institute. Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH 44195, USA; elsharh{at}ccf.org

Abstract

Background and objectives Both posterior quadratus lumborum (QL) and erector spinae plane (ESP) blocks have been described as new truncal interfascial plane blocks. Distribution of injectate is influenced by fascial anatomy; therefore, different injection sites may produce similar spread. This anatomic study was designed to test the hypothesis that a posteromedial QL block at L2 level will more closely resemble a low thoracic ESP block when compared with the posterolateral approach at L2 level.

Methods Left-sided ESP blocks were performed in six cadavers at T10–11. Three of these cadavers received right-sided posteromedial QL block at L2, while the other three received right-sided posterolateral QL block at L2. All injections were composed of 20 mL methylcellulose 0.5 % mixed with India ink and 10 mL of Omnipaque (Iohexol) 240 mg/mL. CT 24 hours after injection and cadaver dissection were used to evaluate injectate spread.

Results Cephalocaudal spread of injectate by CT and cadaveric dissection was highly correlated (r=0.85 [95% CI 0.51 to 0.95]). Cadaver dissection showed ESP injectate spread deep to the muscle (mean [SD]) 11.7 (2.3) levels compared with 7.3 (1.2) levels for posterolateral QL and 9.7 (1.5) for posteromedial QL (p=0.04 overall, with a statistically significant pairwise difference between ESP and posterolateral QL only). The subcostal nerve and dorsal rami were commonly involved in most blocks, but the paravertebral space and ventral rami had inconsistent involvement. The lumbocostal ligament limited cranial spread from the posterlateral QL block approach.

Conclusions The posteromedial QL block at L2 produces more cranial spread beyond the lumbocostal ligament than the posterolateral QL block, and this spread is comparable with a low thoracic ESP block. Both posterior QL and ESP blocks show unreliable spread of injectate to the paravertebral space and ventral rami, but the dorsal rami were frequently covered.

  • regional anesthesia
  • interfascial plane blocks
  • quadratus lumborum block
  • erector spinae plane block
  • cadaver
  • anatomy

https://doi.org/10.1136/rapm-2018-100147

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    Footnotes

    • Contributors Study design/planning: all authors. Data analysis: all authors. Drafting and writing paper: all authoirs. Revision and approval of the final manuscript: all authors. All authors agree to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • 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 HE is a consultant for PACIRA (Troy Hills, New Jersey, USA). This company had no input into any aspect of the present project design or manuscript preparation.

    • Patient consent for publication Not required.

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

    • Author note Permission to use included images was obtained from the Cleveland Clinic Department of Art Photography.

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