Advances in Anesthesia 35 (2017) 145–157

ADVANCES IN ANESTHESIA

Quadratus Lumborum Blocks

Hesham Elsharkawy, MD, MSca,b,*
a
Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute,
Cleveland Clinic, 9500 Euclid Avenue, E-30 Cleveland, OH 44195, USA; bCleveland Clinic Lerner
College of Medicine, Case Western Reserve University, Cleveland, OH 44195, USA

Keywords
 Quadratus lumborum blocks  Anatomy  Mechanism of action  Indications
 Clinical pearls
Key points
 Quadratus lumborum (QL) block is a novel ultrasound-guided regional anesthetic
technique for managing postoperative pain in patients undergoing abdominal
and hip surgeries.
 The available limited literature and experiences demonstrate that QL blocks have
the potential to produce sensory blockade and analgesia along the lower
thoracic and lumbar dermatomal sensory regions.
 There is currently no general consensus on the mechanism(s) of action of QL
blockade. The subendothoracic fascial spread and direct spread to the lumbar
plexus branches are the proposed mechanism.
 This is a tissue (fascial) plane block that requires a large volume of local anes-
thetic to obtain a reliable block.

INTRODUCTION
A variant of the ultrasound-guided transversus abdominis plane (TAP) block
(initially termed a no-pops or posterior TAP block) was first described in an
abstract, in which local anesthetic injection occurs at the point where the inter-
nal oblique and transversus abdominis muscles taper off and abut the lateral
border of quadratus lumborum (QL) muscle [1].
The term quadratus lumborum block first appeared in 2 case reports
published in 2013, both of which used the term US-guided posterior TAP block
but emphasized the importance of the quadratus lumborum muscle as a

Disclosure: The author has no material conflicts of interest to report.

*Corresponding author. Departments of General Anesthesiology and Outcomes Research,

Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-30, Cleveland, OH
44195. E-mail address: elsharh@ccf.org

http://dx.doi.org/10.1016/j.aan.2017.07.007
0737-6146/17/ª 2017 Elsevier Inc. All rights reserved.
146 ELSHARKAWY

sonographic landmark [2,3]. In the same year, a transmuscular approach to the

ultrasound-guided QL block (TQL) was described by Børglum and colleagues
[4]. Development of further variations of the QL block (paramedian sagittal ob-
lique [anterior subcostal]) approach [5] and the transverse oblique paramedian
transmuscular (TOP TQL) approach [6] have been recently described.

ANATOMY
The QL muscle is a posterior abdominal wall muscle lying dorso-lateral to the
psoas major muscle along the posterior abdominal wall [7,8]. The QL muscle
originates from the inner lip of the posterior part of the iliac crest and inserts
into the lower medial border of the twelfth rib, and by 4 small tendons from
the apices of the transverse processes of the L1-L4 lumbar vertebrae. The sub-
costal, iliohypogastric, and ilioinguinal nerves pass between the QL muscle and
transversalis fascia (Fig. 1).
The thoracolumbar fascia (TLF) provides a retinaculum for the paraspinal and
posterolateral abdominal wall muscles [7,8]. The TLF includes a posterior layer,
which is attached to the spinous processes and wraps around the paraspinal

Fig. 1. QL muscle from the front. On the left side, the psoas muscle is cut away showing the
ventral rami of the spinal nerve roots passing in front of QL. QL, quadratus lumborum; TP, trans-
verse process. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photog-
raphy ª 2017. All Rights Reserved.)
QUADRATUS LUMBORUM BLOCKS 147

muscles, reaching a raphe on its lateral border. In the 2-layered model, the anterior
layer of the TLF separates the paraspinal muscles from the QL muscle. This layer
extends medially to the tips of the lumbar transverse processes. In this model, the
fascia on the anterior aspect of the QL muscle is also referred to as the transversalis
fascia (TF) [7,8] The TF covers the peritoneal surface of the transversus abdom-
inis muscle and continues postero-medially, covering the anterior side of the in-
vesting fascia of both the QL and psoas major (PM) muscles (Fig. 2).
The fascial layers in thoracic and lumbar regions are described separately in
anatomic textbooks; however, the thoracic and lumbar paravertebral spaces are
in continuity, signifying that this pathway or compartment between the
thoracic and lumbar paravertebral spaces is well described [9].
The lateral branches of the thoracoabdominal nerves arise proximal to the
angle of the rib and emerge through the overlying muscles in the midaxillary
line to supply the skin of the lateral thorax, abdomen, iliac crest, and the upper
thigh. The subcostal and iliohypogastric nerves pass over the anterior surface
of the QL muscle [10].
Vital structures that are susceptible to injury include the kidney, spleen, and
liver.
The left kidney, at the level of eleventh rib to second lumbar vertebra, and
the right kidney in a slightly lower position, twelfth rib to the upper part of the
third lumbar vertebra are both at potential risk of injury (Fig. 3).
If the block is performed above L3, or if a subcostal approach is used, caution
must be taken to avoid kidney injury. The lower pole of the kidneys lies anterior
to the QL muscle and can reach as low as the L3 level on the right. The kidneys
are separated from the QL muscle by perinephric fat, the posterior layer of renal
fascia, and the transversalis fascia [11]. The perinephric space contains a rich
network of blood vessels and lymphatics, which facilitate development of peri-
nephric hematoma and the spread of infection if it is penetrated by a needle.
The TF is not continuous posteriorly with the posterior layer of the renal fascia.
The posterior renal fascia (Zuckerkandl fascia or posterior Gerota fascia) is a
thick fascia that continues anterolateral as the lateroconal fascia and fuses with
the parietal peritoneum and lies against the transversalis fascia [12] (Fig. 4).

MECHANISM OF LOCAL ANESTHETIC SPREAD

There is currently no consensus on the mechanism(s) of action of QL blockade.
The endothoracic fascia inferiorly is continuous with the fascia transversalis
dorsal to the diaphragm. Saito and colleagues [9] demonstrated spread of
dye from the thoracic paravertebral space to the retroperitoneal lumbar para-
vertebral region through the medial and lateral arcuate ligaments. This
pathway has been demonstrated clinically and in cadaver studies [13]. Injection
anterior to the QL muscle in the tissue plane between the QL and PM muscles
can spread cranially under the medial and lateral arcuate ligaments posterior to
the fascia transversalis (anterior layer of the TLF), thereby spreading into
the thoracic paravertebral space posterior to the endothoracic fascia. This sub-
endothoracic fascial spread from the retroperitoneal space in relation to the QL
148 ELSHARKAWY

Fig. 2. (A) Cross-section of the QL muscle and posterolateral abdominal wall and its
relation to the ventral rami, lumbar nerve, the abdominal branches of the lumbar arteries;
the different layers of the thoracolumbar fascia (TLF), renal fascia, and the anatomic rela-
tions of the QL muscle to the anterior, middle, and posterior layers of the TLF. (B) Cross-
sectional ultrasound image of the posterolateral abdominal wall and scanning technique
to identify QL, psoas, and ES muscles at the level of transverse process (top left, transverse
process view) and between 2 transverse processes (bottom left, intertransverse process
view) with correlating ultrasound images on the right. AP, articular process, EO,
external oblique; ES, erector-spinae (sacrospinalis); IO, internal oblique; LD, latissimus
dorsi; QL, quadratus lumborum; TA, transversus abdominis; TF, transversalis fascia; TP,
transverse process. ([A, B] Reprinted with permission, Cleveland Clinic Center for Medical
Art & Photography ª 2017. All Rights Reserved.)
QUADRATUS LUMBORUM BLOCKS 149

Fig. 3. Kidneys and their relation to the twelfth rib. Note the lower pole of the right kidney
may extend as caudal as the upper third of the L3 vertebra. (Reprinted with permission, Cleve-
land Clinic Center for Medical Art & Photography ª 2017. All Rights Reserved.)

muscle to the lower thoracic paravertebral space is believed to be the advantage

of the transmuscular (anterior) QL block approach versus other (lateral and
posterior) QL approaches and other TAP truncal blocks [14].
The transmuscular approaches target local anesthetic injection between the
quadratus lumborum and psoas major muscles, which have been demonstrated
to allow cephalad spread via a posterior pathway to the medial and lateral arcuate
ligaments (of the diaphragm) and into thoracic paravertebral spaces [14]. Howev-
er, other cadaveric studies of the transmuscular QL block approach demonstrated
injectate spread either only to the lumbar paravertebral spaces [15,16] or in a sin-
gle cadaveric model, no spread to the paravertebral space [17]. In addition, other
studies have demonstrated spread to the lumbar nerve roots within the psoas
muscle compartment, suggesting possible efficacy for hip procedures [15,16].
More recently, the subcostal paramedian sagittal approach (with local anesthetic

Fig. 4. Relationship of the kidney with the surrounding fascia. (Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography ª 2017. All Rights Reserved.)
150 ELSHARKAWY

injected anterior to quadratus lumborum just caudal to the twelfth rib) demon-
strated injectate spread to the ilioinguinal and iliohypogastric nerves and cephalad
spread through the arcuate ligaments to consistently spread to T9-T12 spinal
nerve roots, with frequent spread to T8 (83%) and T7 (67%) spinal nerve roots.
Thus, the available published anatomic studies suggest that: (1) the location of the
local anesthetic injection should be anterior to the QL muscle with the transmus-
cular approach vs lateral (QL block 1) or posterior (QLB 2) to the QL muscle; (2)
a more cephalad (subcostal) injection point enables cephalad spread (via the
arcuate ligaments) to the thoracic paravertebral space.

POINTS OF INJECTION, NOMENCLATURE

The lack of consensus on the mechanism of spread (and analgesic mechanism)
for QL block may be partially attributed to the variable descriptions of the ap-
proaches (transducer placement, needle direction, and most importantly, nee-
dle tip target location). A recent review article [18] and letter to the editor
[19] published in Regional Anesthesia and Pain Medicine provided an excellent
framework for renaming (classifying) QL blocks based on the anatomic loca-
tion of needle tip placement in relation to the QL muscle, as this is most likely
to influence the pattern of injectate (local anesthetic) spread, and thus clinical
effect. Based on the anatomic location of needle tip placement in relation to
the QL muscle, QL1 would be named the lateral QL block; the QL2 block

Fig. 5. Proposed nomenclature, needle trajectory, and needle tip location for the 3 ap-
proaches (lateral, posterior, and anterior) of QL block. (Reprinted with permission, Cleveland
Clinic Center for Medical Art & Photography ª 2017. All Rights Reserved.)
QUADRATUS LUMBORUM BLOCKS 151

would be called the posterior QL block, and the transmuscular QL block

would be an anterior QL block (Fig. 5). These QL blocks are interfascial plane
blocks. Additionally, a recent study described the target location for local anes-
thetic injection within the substance of the QL muscle (intramuscular or intra-
fascial plane QL block) [20,21].
Lateral quadratus lumborum block
The needle can be directed from anterior to posterior toward the junction of
tapered transversus abdominis muscle and lateral border of QL muscle. Local
anesthetic will then be deposited in the lateral border of QL muscle at the junc-
tion with the transversalis fascia, and penetrate the aponeurotic attachment of
the transversus abdominis muscle (potential space medial to the abdominal wall
muscles and anterolateral to QL muscle).
Posterior quadratus lumborum block
By advancing the needle more posteriorly (superficially), local anesthetic can be
deposited posterior to the lateral edge of the QL muscle, with local anesthetic
injection in the interfascial plane between the posterior border of the QL mus-
cle and the middle thoracolumbar fascia (located anterior to latissimus dorsi
[LD] and erector spina [sacrospinalis] muscles).
Anterior quadratus lumborum block (transmuscular quadratus
lumborum)
The needle can be advanced either from posterior through erector spinae mus-
cle or anterior through the LD muscle and then through QL muscle (transmus-
cular approach, type, anterior) to deposit the local anesthetic in the fascial plane
between the QL and psoas major muscles.
This includes the transmuscular QL (TQL) block [4,14], the transverse ob-
lique paramedian (TOP) TQL [6,14], and caudal-to-cranial subcostal parame-
dian sagittal TQL [5,22].

THE ANTERIOR SUBCOSTAL PARAMEDIAN OBLIQUE SAGITTAL

TRANSMUSCULAR QUADRATUS LUMBORUM BLOCK
To obtain an oblique sagittal view of QL muscle, the ultrasound transducer is
positioned approximately 6 to 8 cm (variable with patient body habitus) lateral
to the lumbar spinous process at the L1-2 level with a parasagittal orientation
just above the cross-over point of the erector spinae and the QL [5,22]. Using a
curvilinear transducer with the orientation marker of the ultrasound cephalad,
it is shifted cranially, and the probe is slightly tilted medially. In addition, the
cranial part of the ultrasound probe is slightly tilted medially and the caudal
part of the probe laterally (thus, the paramedian oblique approach). 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 mus-
cle, 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
152 ELSHARKAWY

Fig. 6. Anterior subcostal paramedian sagittal oblique QL block approach. ES, erector spi-
nae; LD, latissimus dorsi; QL, quadratus lumborum. (Reprinted with permission, Cleveland
Clinic Center for Medical Art & Photography ª 2017. All Rights Reserved.)

cephalad direction close to the twelfth rib, with a crescent-shaped distribution

of local anesthetic with anterior displacement of the ATLF. Fig. 6.

PATIENT POSITIONING AND EQUIPMENT SELECTION

Ultrasound transducer
Low-frequency (5-2 MHz) curved array ultrasound transducers can be used to
provide a simultaneous adequate visualization of the 3 lateral abdominal wall mus-
cle layers, the QL muscle, retroperitoneal space including the kidney, transverse
processes, and the adjoining lumbar paravertebral area. A high- or intermediate-
frequency transducer may more accurately appreciate the fascial plans, and may
suffice in some patients, particularly in children. The orientation marker can be
directed laterally for a transverse scan and cranially for parasagittal scan.

Patient position
Lateral
The lateral decubitus position gives more exposure to the neuraxial structures,
provides more stability in handling the ultrasound probe and needle, and is
often more comfortable when performed in awake patients. All 3 approaches
may be performed in this position.
Supine
It is feasible to perform QL block 1 and QLB 2 in the supine position and
lateral tilt of the torso with wedge under the lower flank, tilting the transducer
probe posteromedially. The disadvantage of the supine position is impaired
visualization of the lumbar paravertebral area. The transmuscular (anterior) ap-
proaches are not feasible in the supine position.
Prone
The procedure can also be performed in the prone position with a pillow under
the abdomen. However, positioning the patient can be logistically difficult,
especially postoperatively after abdominal procedures and in the anesthetized-
intubated patient.
QUADRATUS LUMBORUM BLOCKS 153

Sitting
With the TOP TQL [6] and subcostal approach [5], the patient can be
positioned in the sitting position, which facilitates bilateral block procedure
without patient repositioning. This may be done either preoperatively or post-
operatively in the postanesthesia care unit (PACU). It may prove technically
difficult to place an anesthetized-intubated patient in the sitting position.

CLINICAL PEARLS
The QL muscle is attached to the apices (lateral tip) of transverse process,
which once identified, provides orientation for the operator.
If the QL muscle is small and difficult to delineate, the ipsilateral hip joint is
abducted and laterally flexed toward the same side of the block to contract
the QL muscle, which will temporarily will thicken the QL muscle. Generally,
QL is hypoechoic, in contrast to the more hyperechoic psoas muscle, but
similar in echogenicity to the kidney.
While performing the block especially with the subcostal approach, it is com-
mon to visualize the lower pole of the kidney and lower lobe of the liver and
spleen. Caution should be taken to avoid any visceral injury.
Apply color Doppler before insertion of the needle to detect the abdominal
branches of the lumbar arteries on the posterior aspect of the QL muscle or any
other vessels close to the transverse process, and on the intended track of the needle.
The tactile feedback (as pops) when encountering different fascial planes is
not accurate in QL blocks because of complexity of the anatomic planes, multi-
layered components of the TLF, muscle, and the approach angle. Therefore,
the visual confirmation using ultrasound and hydro dissection should be used.
With the TQL block, the local anesthetic is deposited in the plane between
the QL and psoas major muscle. Both during administration of and subsequent
to administration of the local anesthetic solution, the transducer should be
moved from the transverse to the longitudinal position. With the curvilinear
probe in the longitudinal position, the local anesthetic can be seen to spread
cephalad from the iliac crest to the twelfth rib.

DOSE AND VOLUME OF LOCAL ANESTHETIC

This is a tissue plane block and thus requires a large volume of local anesthetic
to obtain a reliable block. Volumes of 0.2 to 0.4 mL/kg (20–30 mL) unilaterally
are usually recommended. The dose of local anesthetic needs to be considered
for the size of the patient to ensure maximum safe dose is not exceeded, espe-
cially with bilateral blocks. The QL muscle and tissue plans are vascular areas,
and as described, the abdominal branches of the lumber arteries are in the vi-
cinity of the local anesthetic injection.
Murouchi [21] has investigated the local pharmacokinetics with 1 type of the
QL blocks (posterior QL), where the QL block resulted in a widespread and
long-lasting analgesic effect compared with historical controls after laparoscopic
ovarian surgery and resulted in lower peak arterial ropivacaine concentrations
154 ELSHARKAWY

compared with those of lateral transversus abdominis plane block after 150 mg
ropivacaine injection.

INDICATIONS
All the indications described are based on small studies, case reports, and personal
communications [2,3,23,24]. Any type of operation that requires intra-abdominal
visceral pain to be covered plus abdominal wall incisions as cephalad as T6 and as
caudal as L1. Midline incision and laparoscopic procedures require bilateral
blocks for adequate coverage: exploratory laparotomy, large bowel resection,
ileostomy, open/laparoscopic appendectomy, cholecystectomy, inguinal hernia
repair (open or laparoscopic), scrotal surgery, cesarean section (citation), total
abdominal hysterectomy, chronic pelvic floor pain, open prostatectomy, renal
transplant surgery, percutaneous nephrolithotomy or nephrolithotripsy, nephrec-
tomy, abdominoplasty, iliac crest bone graft, and total hip arthroplasty.

CONTINUOUS QUADRATUS LUMBORUM BLOCKADE

A continuous technique has recently been successfully used for many indica-
tions, including major colorectal surgeries, nephrectomy, kidney transplant,
(Hesham Elsharkawy, unpublished data, 2016), with infusion of local anes-
thetic up to 1 week without reported complications.
A 17- or 18-gauge Tuohy needle is advanced utilizing the in-plane needle
insertion approach. The needle is advanced until it enters the site of injection.
After a negative aspiration is confirmed, 1 to 3 mL of local anesthetic are in-
jected slowly to confirm that the Tuohy needle has penetrated the appropriate
fascial layers. A total of 10 mL of the same solution is then injected slowly; a
catheter is subsequently advanced 2 to 4 cm past the tip of the needle. 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.

QUADRATUS LUMBORUM BLOCK IN THE ANTICOAGULATED

PATIENT
The risks of bleeding complications are not known, and there are no specific rec-
ommendations. Because of the vascularity of the area, the potential for retroper-
itoneal spread of hematoma, and proximity of the transmuscular approach to the
paravertebral area and the lumbar plexus, The American Society of Regional
Anesthesia guidelines should be considered in patients on anticoagulants who
are receiving QL block (especially the anterior TQL approaches), either single
shot or catheter [25]. Risk versus benefits should be carefully considered.

SUPPORTING EVIDENCE
There are few published clinical data, particularly from randomized
controlled trials (RCTs); most of the published data are from case report,
case series, and small studies. QL blocks result in a wider sensory blockade
compared with TAP block when performed using a similar volume of local
QUADRATUS LUMBORUM BLOCKS 155

anesthetic [18]. The traditional ultrasound lateral TAP block has been shown
to provide sensory analgesic coverage from T10 to T2-L1. Thus, it is not
indicated for upper abdominal incisions. In contrast, the subcostal TAP
approach has been shown to provide sensory analgesic coverage only from
T6 to T10. Thus, it is not indicated for lower abdominal incisions. In order
to provide complete coverage for extensive abdominal surgery (from T6-7 to
L1), 4 injections (catheters) are required, which can be done but may be
impractical in daily practice [23].
Kadam described ultrasound-guided QL block with single-shot injection of
0.5% ropivacaine in a patient undergoing laparotomy for excision of a
duodenal tumor. The block resulted in appropriate pain control during the first
day [3].
Visoiu described a similar block with placement of a catheter in a pediatric
patient undergoing colostomy takedown [2]. Other case reports have shown
that local anesthetic injection around the QL is effective in providing pain relief
after various abdominal operations [21,26,27].
A bilateral continuous QL block was performed as an alternative to opioid
analgesia in a patient who underwent colorectal surgery and experienced
respiratory arrest on postoperative day 1 because of excessive opioid use.
Cases demonstrate that bilateral continuous QL catheters can provide
extended postoperative pain control [26]. QL blocks have been used in
pediatric patients undergoing pyeloplasty, providing good analgesia [27]. There
are case reports of using the posterior approach and continuous transmuscular
analgesia after total hip arthroplasty [24,28,29]. An RCT comparing posterior
QL block with control (QL block with 0.9% normal saline) after caesarean sec-
tion demonstrated effective (opioid-sparing) analgesia in combination with a
typical postoperative analgesic regimen [30]. In another RCT comparing
directly posterior QL block with midaxillary lateral TAP block, the QL block
was more effective in reducing morphine consumption and demands than
transversus abdominis plane blocks after cesarean section up to 48 hours post-
operatively [31]. Bilateral QL catheters have also been reported as a method for
analgesia for breast flap reconstruction [32].

SUMMARY
There is clinical interest for the QL block as an expanding appealing alterna-
tive to neuraxial blocks and possible superior analgesic efficacy compared
with traditional TAP blocks. The available limited literature and experiences
demonstrate that QL blocks have the potential to produce sensory blockade
and analgesia along the lower thoracic and lumbar regions, and can poten-
tially be an analgesic modality for abdominal and hip surgeries. Current lim-
itations must be acknowledged with realistic expectations. Well-designed,
larger studies are needed in the future, not only to clarify indications (and
contraindications), but also to supports analgesic efficacy (vs placebo, TAP
blocks, and neuraxial block), complications, and mechanism(s) of analgesic
efficacy.
156 ELSHARKAWY

Acknowledgments
The author acknowledged the contribution of Jeff Lorech to the images pre-
sented in this article. All images are taken with permission from Cleveland
Clinic art photography department.

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