Comparing two posterior quadratus lumborum block approaches with low thoracic erector spinae plane block: an anatomic study

Reg Anesth Pain Med. 2019 Mar 28;rapm-2018-100147. doi: 10.1136/rapm-2018-100147. Online ahead of print.


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.

Keywords: anatomy; cadaver; erector spinae plane block; interfascial plane blocks; quadratus lumborum block; regional anesthesia.