Clinical Focus Review Jerrold H. Levy, M.D., F.A.H.A., F.C.C.M.

, Editor

Quadratus Lumborum Block

Anatomical Concepts, Mechanisms, and Techniques
Hesham Elsharkawy, M.D., M.B.A., M.Sc., Kariem El-Boghdadly, M.B.B.S., B.Sc., F.R.C.A., E.D.R.A., M.Sc.,
Michael Barrington, Ph.D., M.B.B.S., F.A.N.Z.C.A.

U ltrasound-guided quadratus lumborum block is a

recently described fascial plane block where local
anesthetic is injected adjacent to the quadratus lumborum
lumborum muscles.1 In the two-layered model, the fas-
cia on the anterior aspect of quadratus lumborum is
the transversalis fascia, a fascial structure that is embry-
muscle with the goal of anesthetizing the thoracolumbar ologically independent from the thoracolumbar fascia.
nerves. The objective of this article is to review the relevant The transversalis fascia lines the peritoneal surface of
anatomy, potential mechanisms, approaches, and techniques the transversus abdominis muscle and wraps the ante-
and summarize the clinical evidence for quadratus lumbo- rior aspect of the investing fascia (epimysium) of both
rum block. quadratus lumborum and psoas muscles. The two-lay-
ered model follows the embryological development of
the trunk muscles, where quadratus lumborum and psoas
Anatomical Concepts muscles belong to the hypaxial muscle compartment,
anterior to the transverse processes, whereas the erector
Muscles spinae muscles belong to the epaxial muscle compart-
ment, posterior to the transverse processes.1 We illustrate
Quadratus lumborum is a posterior abdominal wall mus- the two-layered model of the thoracolumbar fascia at L4
cle that originates from the posteromedial iliac crest and schematically in figure 2.
inserts into the medial border of the twelfth rib and the In the three-layered model, the posterior thoracolum-
transverse processes of the first to fourth lumbar vertebrae. bar fascia layer surrounds the erector spinae muscles, the
The lateral free border of quadratus lumborum is angled middle layer passes between the erector spinae muscles
from craniomedial to caudolateral (fig. 1A). The quadratus and quadratus lumborum, and the anterior layer lies ante-
lumborum and psoas major muscles traverse posterior to rior to both quadratus lumborum and psoas muscles. We
the lateral and medial arcuate ligaments of the diaphragm, illustrate the three-layered model of the thoracolumbar
respectively (fig. 1B). Posterior to the quadratus lumborum fascia at the L4 level schematically in figure 2.
muscle lies the erector spinae muscle group, consisting of Cranially, the anterior layer of the thoracolumbar fascia
the multifidus, longissimus, and iliocostalis (figs. 2 and 3). (the transversalis fascia in the two-layer model) divides into
two layers. One layer is continuous with the endothoracic
Fascia fascia in the thorax, and the other layer blends with the dia-
phragm at the arcuate ligaments. Caudally, this fascial layer
The quadratus lumborum muscle is surrounded by a fibrous is continuous with the fascia iliaca.2–4
composite of aponeurotic and fascial tissue: the thoraco- The three-layered model is the most commonly used.
lumbar fascia. The thoracolumbar fascia is part of a myofas- Regardless of which model is accepted, the fascial planes
cial girdle that surrounds the lower torso and is important in the abdominal compartment follow the quadratus lum-
for posture, load transfer, and stabilization of the lumbar borum and psoas muscles through the medial and lateral
spine. The thoracolumbar fascia comprises multilayered fas- arcuate ligaments and the aortic hiatus of the diaphragm,
cia and aponeuroses, with two proposed models. forming the endothoracic fascia. This provides a potential
The two-layered model incorporates a posterior layer pathway for spread of injectate, such as local anesthetic,
surrounding the erector spinae muscles and an anterior from the abdominal to the thoracic cavity and paravertebral
layer lying between the erector spinae and the quadratus space, thereby achieving clinical effect.2–4

This article has been selected for the Anesthesiology CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of
this issue. This article is featured in “This Month in Anesthesiology,” page 5A.
Submitted for publication April 12, 2018. Accepted for publication October 18, 2018. From the Departments of General Anesthesiology and Outcomes Research, Anesthesiology
Institute, Cleveland Clinic, Cleveland, Ohio (H.E.); Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
(H.E.); Department of Anaesthesia, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, United Kingdom (K.E.-B.); King’s College, London, United Kingdom
(K.E.-B.); Department of Anaesthesia and Acute Pain Medicine, St. Vincent’s Hospital, Melbourne, Australia (M.B.); and Melbourne Medical School, Faculty of Medicine, Dentistry
and Health Sciences, University of Melbourne, Melbourne, Australia (M.B.).
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322 FEBRUARY 2019 ANESTHESIOLOGY, V 130 • NO 2

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<zdoi;10.1097/ALN.0000000000002524>
 Quadratus Lumborum Block

Lateral Raphe and Lumbar Interfascial Triangle from it by para- and perinephric fat, the posterior layer of
renal fascia, and the transversalis fascia.
The paraspinal retinacular sheath is the deep lamina of the
posterior layer of the thoracolumbar fascia extending from the Neural Structures
spinous to transverse processes.1 The lateral raphe is a dense
connective tissue complex formed where the abdominal The iliohypogastric and ilioinguinal nerves (ventral ramus
myofascial structures (aponeurotic sheaths of the transversus of L1 with occasional contributions from T12, L2, and L3)
abdominis and internal oblique muscles) join the paraspi- depart through the proximal and lateral aspect of the psoas
nal retinacular sheath at the lateral border of the paraspinal major muscle and traverse the ventral surface of quadratus
muscles. At this point, the myofascial structures separate into lumborum (fig. 1B).7,8 In four cadaver studies, the iliohypo-
two laminae, which join the anterior and posterior paraspinal gastric and ilioinguinal nerves were consistently involved in
retinacular sheath layers. This creates the lumbar interfascial spread of injectate.4,9–11 In published cases the reported der-
triangle, situated along the lateral border of the paraspinal matomal sensory blockade frequently includes the T12–L2,
muscles from the twelfth rib to the iliac crest (fig. 3).5 The indicating consistent involvement of iliohypogastric and ili-
lumbar interfascial triangle provides a theoretical pathway for oinguinal nerves using different approaches.12–21 The lateral
injectate spread deep to the thoracolumbar fascia. femoral cutaneous, obturator, and femoral nerves exit the
psoas major muscle at more caudal levels (fig. 1B).22–24 The
Vascular Structures dorsal rami of the spinal nerves traverse the medial aspect of
the middle thoracolumbar fascia posterior to the quadratus
The abdominal branches of the lumbar arteries arise from the lumborum muscle and then enter the erector spinae muscles.
abdominal aorta and run laterally and posterior to the quadratus
lumborum muscle. One exception is the fourth lumbar artery
that may be located anterior to the quadratus lumborum.6 Spread of Injectate and Mechanisms of Action

Viscera Endothoracic Fascia Pathway

Intraabdominal viscera are located in close proximity to It is plausible that local anesthetic injected anterior to the
where quadratus lumborum block is performed. However, quadratus lumborum muscle and posterior to the trans-
the transversalis fascia separates the muscle layers from the versalis fascia will spread to the thoracic paravertebral
retroperitoneal abdominal contents. The kidney lies ante- space, posterior to the medial and lateral arcuate ligaments
rior to the quadratus lumborum muscle and is separated of the diaphragm, along the endothoracic fascia to block

Fig. 1. (A) A posterior schematic illustration of the musculature of the posterior abdominal wall. The quadratus lumborum muscle origi-
nates from medial border of the twelfth rib and lumbar vertebrae transverse processes and inserts into the posteromedial iliac crest. (B)
An anterior schematic illustration of the musculature of the posterior abdominal wall. On the left, the psoas muscle has been removed to
reveal the ventral rami of the spinal nerve roots and branches passing anterior to the quadratus lumborum muscle. ES, erector spinae; LD;
latissimus dorsi; QL, quadratus lumborum; TP, transverse process. Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography © 2018. All Rights Reserved.

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 Clinical Focus Review

Fig. 2. A schematic illustration of cross-section at L4 level showing the quadratus lumborum muscle with the different layers of the
thoracolumbar fascia. On the left, the two-layer model is depicted, where the purple dashed line represents the anterior layer of the
thoracolumbar fascia, and the green dashed line represents the transversalis fascia. On the right, the three-layer model is depicted, where
the purple dashed line represents the middle layer of the thoracolumbar fascia, and the green dashed line represents the anterior layer
of the thoracolumbar fascia. The blue dashed line represents the posterior thoracolumbar fascia. IL, iliocostalis; LD, latissimus dorsi; Lo,
longissimus; Mu, multifidus; PM, psoas major; QL, quadratus lumborum; TLF, thoracolumbar fascia. Reprinted with permission, Cleveland
Clinic Center for Medical Art & Photography © 2018. All Rights Reserved.

Fig. 3. A schematic illustration of cross-section at L4 level showing the detailed descriptions of the three-layered model of the thoracolum-
bar fascia and its sublayers (left) and the anatomical relations of the three approaches to quadratus lumborum block (right) at L4 level. The
dark blue dashed line represents the superficial lamina of the posterior layer of the thoracolumbar fascia encircling the latissmus dorsi and
erector spinae muscles. The light blue dashed line represents the deep lamina of the posterior layer of the thoracolumbar fascia, also termed
as paraspinal retinacular sheath, encircling the erector spinae muscles. The red dashed lines represent the epimysium-investing fascia of qua-
dratus lumborum and psoas major muscles. The white (gray dashed) layer represents the aponeurosis of the internal oblique and transversus
abdominis muscles. IL, iliocostalis; LD, latissimus dorsi; Lo, longissimus; Mu, multifidus; PM, psoas major; PTLF, posterior thoracolumbar fascia;
QL, quadratus lumborum. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2018. All Rights Reserved.

324 Anesthesiology 2019; 130:322–35 Elsharkawy et al.

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 Quadratus Lumborum Block

the somatic nerves and thoracic sympathetic trunk of the sympathetic afferents could theoretically induce changes to
lower thoracic levels (fig. 1B). In addition to existing sup- both the local circulation and the general autonomic tone.28
porting anatomical2,25 and clinical literature,3 two recent This might potentially contribute to the analgesic efficacy
cadaveric studies support this mechanism of action in of posterior quadratus lumborum block.29
anterior quadratus lumborum block.4,10 Dam et al.4 repli-
cated an anterior quadratus lumborum block in a cadav-
eric model at the iliac crest (L4) and L2 and documented Approaches, Sonography, and Technical
thoracic paravertebral spread involving somatic nerves Performance
and the thoracic sympathetic trunk to the T9–T10 level.
Similarly, Elsharkawy et al.10 replicated a subcostal ante- We have proposed that quadratus lumborum block be
rior quadratus lumborum approach at L1–2 level using a named based on the anatomical location of needle tip
parasagittal oblique approach and found cranial spread to placement in relation to the quadratus lumborum muscle
involve T7–12. In contrast, Sondekoppam et al.11 demon- (fig. 3).30 Therefore we recommend the following termi-
strated, with an anterior approach at L3, dye spread in the nology: lateral, posterior, and anterior quadratus lumborum
lateral part of the thoracic paravertebral space (T11–12) block approaches. Figure 4 illustrates examples of in-plane
with no clear craniocaudal spread. Adhikary et al.9 per- approaches with anterior–posterior, posterior–anterior, and
formed anterior quadratus lumborum blocks at L3–L4 caudal–cranial trajectories.
levels and also demonstrated no evidence of thoracic para-
vertebral spread. However, Elsharkawy et al.10 investigated Needle Length and Gauge
the posterior quadratus lumborum approach at the L3–4
level found staining up to T10 inside the lateral thoracic Typical needle length would range from 80 to 150 mm
paravertebral space (table 1). Overall, local anesthetic depending on patient body habitus. The exact gauge would
injected between the transversalis fascia and the quadratus depend on single injection technique versus continuous
lumborum muscle may spread to the thoracic paraverte- technique.
bral space, and the vertebral level of injection will influ-
ence the extent of cranial spread. Injectate

Involvement of the Lumbar Spinal Nerve Roots and Local anesthetic dosage in the range of 0.2 to 0.4 ml/kg of
Branches 0.2 to 0.5% ropivacaine31–33 or 0.1 to 0.25% bupivacaine34–36
per side is recommended. The operator will need to adjust
Cadaveric data also support a possible mechanism of action dosage to ensure toxic thresholds are not exceeded, par-
via direct spread of dye to the roots and branches of the lum- ticularly when bilateral blocks are performed. There is no
bar plexus.4,9–11 L1–3 nerve roots were consistently involved comparative data on the efficacy of adjuvants in quadratus
in an anterior quadratus lumborum cadaveric injection study lumborum blocks; however, the use of epinephrine may
at the L3–4 level.26 Three cadaveric studies9–11 also demon- have benefits in reducing the rate of absorption and in
strated involvement of the upper lumbar plexus nerves and detecting and limiting inadvertent intravascular injection.
subcostal nerve after anterior quadratus lumborum block. Standard safety precautions for performing regional anes-
Elsharkawy et al.10 and Dam et al.4 did not observe direct thetic blocks should be followed.
lumbar plexus involvement within the psoas major muscle in
all approaches. It is notable that the spread of local anesthetic Positioning
in living humans may be different from that of cadavers, and
cadaveric evidence may not forecast clinical outcomes.Thus, The patient can be positioned supine with a lateral tilt, lat-
careful analysis of translational data is needed. eral, sitting or prone, largely depending on physician pref-
erence, patient mobility, and planned needle trajectory. For
Peripheral Sympathetic Field Block example, a posterior–anterior trajectory will require the
patient to be lateral, prone, or in the sitting position.
Recent evidence suggests that rather than being a “pas-
sive” scaffold, fascial tissue is more complex, with rich vas- Lateral Quadratus Lumborum Block
cular and sensory innervation. The thoracolumbar fascia
has extensive sensory innervation by both A- and C-fiber This can be performed using an in-plane approach, with a
nociceptors and mechanoreceptors.27 Sympathetic nerve needle insertion lateral (anterior) to the ultrasound trans-
fibers related to the abdominal branches of the lumbar ducer with an anterior-to-posterior needle trajectory. Local
arteries, located posterior to the quadratus lumborum mus- anesthetic is deposited at the lateral border of quadratus lum-
cle, innervate the thoracolumbar fascia.28 Because these borum muscle after the needle tip penetrates the transver-
nerves have a strong vasomotor component, blocking these sus abdominis aponeurosis.37 Lateral quadratus lumborum

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 326
Table 1. Cadaveric Studies Conducted Investigating Quadratus Lumborum Block
Quadratus Lumborum
Article N Block Approach Objectives Injectate Main Finding Other Findings or Comments
Clinical Focus Review

Carline et al.26 5 (10 sides)* Anterior quadratus Document injectate spread 20 ml of India ink and latex Lateral quadratus lumborum block (n = 3): Difficult to interpret intramuscular spread,
lumborum block transversus abdominis plane, subcutaneous perhaps technique- or tissue-related
Lateral quadratus tissue or muscular spread
lumborum block Posterior quadratus lumborum block (n = 3):
Posterior quadratus transversus abdominis plane, subcutaneous
lumborum block tissue or muscular spread
Anterior quadratus lumborum block (n = 4) L1
and L3 nerve root spread; within psoas major
and quadratus lumborum muscles
Dam et al.4 8 (16 sides)† Anterior quadratus Document injectate spread 30 ml of dye mixture (poly- Above diaphragm: dye spread into the thoracic Dye did not involve lumbar plexus or sympathetic
lumborum block and involvement of ven- mers, latex, acrylates, paravertebral space involving somatic and trunk, femoral nerve, with limited involvement

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tral rami, sympathetic acrylic esters, alcohols sympathetic nerves (upper limit T9–10) of genitofemoral and lateral femoral cutaneous
trunk, and peripheral all mixed to control Below diaphragm: dye staining of subcostal, nerves
nerves viscosity) iliohypogastric, and ilioinguinal nerves
Adhikary et al.9 5 (10 sides) Anterior quadratus Document injectate spread 20 ml of methylene blue Cranial extent of radiographic spread reached Injectate spread to the psoas major muscle and
lumborum block and peripheral nerve with iodinated contrast the L1 transverse process in all specimens, to included the upper branches of the lumbar
involvement using mixture the T12 transverse process in two (25%); no plexus: ilioinguinal (100%), iliohypogastric
dissection and com- visible injectate spread into the thoracic cavity (80%), subcostal (50%)

Anesthesiology 2019; 130:322–35

puterized tomography
imaging
Elsharkawy 6 (12 sides) Posterior quadratus Document injectate spread 30 ml of 0.5% methylcellu- Spread of dye with posterior injection (T10–L1) For both techniques, ilioinguinal, iliohypogastric,
et al.10 lumborum block lose with India ink was different from anterior subcostal (T6–L3) subcostal, T11–L1 nerve roots were deeply
Anterior subcostal stained in all specimens; there were two levels
quadratus lumborum of difference between two approaches (ante-
block rior subcostal at L1–L2, posterior quadratus
lumborum at L3–L4)
Sondekoppam 5 (10 sides) Anterior quadratus Document injectate spread 20 ml of 0.5% methylcellu- Consistent involvement of ilioinguinal, Clinical correlations in case series showed
et al.11 lumborum block to subcostal, iliohy- lose with India ink ­iliohypogastric, and subcostal nerves reliable coverage of T9–L2 dermatomes
pogastric, ilioinguinal, Inconsistent spread to the lateral femoral
and lateral femoral cutaneous nerve
cutaneous nerves

*Thiel embalmed cadavers. †Preserved cadavers so that ultrasound images can be acquired. QL, quadratus lumborum; TAP, transversus abdominis plane.

Elsharkawy et al.
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 Quadratus Lumborum Block

Fig. 4. Photographs and ultrasound images for different quadratus lumborum block approaches. (A–C) Lateral or posterior quadratus
lumborum blocks. Transverse transducer and anteroposterior needle trajectory are shown. The external image and ultrasound images show
the ultrasound probe position with a solid arrow indicating the needle trajectory for a lateral quadratus lumborum block and the dashed
line indicating the needle trajectory for a posterior quadratus lumborum block approach. The red-/blue-shaded area represents the spread
of the local anesthetic. (D–F) Anterior quadratus lumborum block: transverse oblique paramedian approach. Transverse transducer and
posteroanterior needle trajectory are shown. The external image and ultrasound images show the ultrasound probe position with an arrow
indicating the needle trajectory. The blue-shaded area represents the spread of the local anesthetic. (G–I) Anterior quadratus lumborum
block: subcostal approach. Parasagittal oblique transducer and caudal-to-cranial needle trajectory are shown. The external image and
ultrasound images show the ultrasound probe position with an arrow indicating the needle trajectory. The blue-shaded area represents the
spread of the local anesthetic. EO, external oblique; ES, erector spinae; IO, internal oblique; PM, psoas major; QL, quadratus lumborum; TA,
transversus abdominus; TP, transverse process.

block has been shown to be opioid-sparing compared with opioid-sparing effect of quadratus lumborum block com-
placebo for post–cesarean section analgesia.31,32 pared with placebo34 or transversus abdominis plane block35
after caesarean section.
Posterior Quadratus Lumborum Block
Anterior Quadratus Lumborum Block
This can be performed using an in-plane approach using
an anterior-to-posterior or posterior-to-anterior trajectory. This can be performed using an in-plane approach, with
Local anesthetic is injected on the posterior surface of qua- a needle insertion medial to the ultrasound transducer,
dratus lumborum muscle, between the quadratus lumbo- using a posterior-to-anterior trajectory.38 Alternatively an
rum and erector spinae muscles. This approach was used in-plane approach, with an anterior-to-posterior trajec-
in two randomized controlled trials that documented an tory can be used. A further option is with the subcostal

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 Clinical Focus Review

oblique anterior approach; the needle insertion is caudal to can be imaged at its point of insertion on the lower border
the transducer, and the trajectory is in-plane, caudal–lateral of the twelfth rib, and the erector spinae muscle is seen
to cranial–medial. The point of injection of local anesthetic posterior (superficial) to the quadratus lumborum muscle.
lies in the tissue plane between the quadratus lumborum The psoas major muscle, diaphragmatic zone of apposition,
and psoas muscles.38–40 These variants differ in the needle the kidney and perinephric fat and renal fascia are anterior
trajectory used (anterior-to-posterior; posterior-to-ante- (deep) to the quadratus lumborum muscle. The needle tra-
rior; caudal-to-cranial) but have the same plane of injection. jectory for the anterior approach to quadratus lumborum
According to cadaveric and clinical reports, it is reason- block is deep and close to the abdominal and retroperito-
able to conclude that different quadratus lumborum blocks neal viscera; therefore a high level of vigilance and technical
have different mechanisms of action. Anterior quadratus competency is required.
lumborum block injectate may spread to the lumbar nerve
roots and branches in addition to the thoracic paravertebral
space.4,9–11 Posterior quadratus lumborum blocks appear to Indications and Clinical Relevance
demonstrate their clinical effect by injectate spread along
the middle thoracolumbar fascia intertransverse area.10,26 To date, two randomized controlled trials demonstrated
Lateral quadratus lumborum blocks are associated with that quadratus lumborum block reduces cumulative opioid
injectate spread to the transversus abdominis muscle plane consumption for 48 h after caesarean section.31,32 Two fur-
and to subcutaneous tissue,26 although clinical reports refer ther randomized controlled trials have demonstrated that
to a more extensive distribution.31,32,35,41 At present, there posterior quadratus lumborum block has an opioid-spar-
is insufficient evidence to recommend one approach and ing effect after caesarean section (table 2).34,35 Posterior
transducer positioning over another for individual patient quadratus lumborum block is associated with reduced
populations and specific surgical types. postoperative pain scores after laparoscopic gynecological
surgery33 and reduced rescue analgesia requirements after
Sonography lower abdominal surgery.36 Successful use of quadratus
lumborum block with all approaches has been published in
Because identifying the quadratus lumborum muscle is case reports for the following surgical procedures: procto-
critical to performing quadratus lumborum block, it is sigmoidectomy,18 hip surgery,12 above-knee amputation,43
important to note the following landmarks and relation- abdominal hernia repair,44 breast reconstruction,13 colos-
ships: the aponeuroses of the abdominal wall muscles (exter- tomy closure,14 radical nephrectomy,15 lower extremity
nal oblique, internal oblique, transversus abdominis) are vascular surgery,45 total hip arthroplasty,16,17,20 laparotomy,19
located posterolateral to the quadratus lumborum muscle and colectomy.46 Several other case reports with a vari-
(fig. 2); the quadratus lumborum muscle is often hypoechoic ety of indications for quadratus lumborum block docu-
relative to psoas major muscle, which is found anteromedi- ment sensory blockade to include the T7–L2 dermatomes
ally; and the lumbar transverse processes are apparent with (table 3).9,19,20,24,44,47–66
their hyperechoic curved appearance (fig. 4E).
A curvilinear low-frequency transducer is often required,
facilitating tissue penetration of ultrasound and a wide field Contraindications
of view.The transducer is placed in transverse orientation at
the posterior or midaxillary line at the L2–L4 level with the Because of the ongoing investigative nature of this tech-
objective of imaging the quadratus lumborum and erector nique, empirical contraindications apply. Absolute contrain-
spinae muscles, together with a transverse process forming dications include local infection, allergy to local anesthetics,
the “shamrock sign” (fig. 4E).42 A variation is maintaining and a known bleeding diathesis because it is a deep block.
the transducer in transverse orientation but placing it more Relative contraindications include anatomical abnormalities,
medially, approximately 3 cm lateral to the L2 spinous pro- hemodynamic instability, and known neurologic disorders.
cess (fig. 4D). This has been referred to as the transverse
oblique paramedian placement, and the image is enhanced
with medial rocking of the transducer and slight caudal Complications
rotation of the lateral aspect of the transducer.38 A further
option is to place the transducer in a parasagittal oblique Local Anesthetic-related Complications
plane tilted medially (subcostal oblique anterior approach)
at the level of the twelfth rib approximately 6 to 8 cm from Quadratus lumborum block may result in local anesthetic
the spinous process (fig. 4G). This view corresponds to the distribution to the lumbar plexus and prolonged motor
transverse oblique paramedian view but with the transducer block, delaying mobilization and hospital discharge. Lower-
rotated to a parasagittal oblique plane. With the subcostal limb weakness has been reported after use of all quadratus
oblique anterior approach, the quadratus lumborum muscle lumborum block approaches.67,68 Hypotension has been

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 Elsharkawy et al.
Table 2. Randomized Controlled Trials with Quadratus Lumborum Block Interventions
Quadratus
Article N Surgery Lumborum Block Comparator Injectate Primary Outcome Results

Blanco et al.34 50 Caesarean section Posterior quadratus Posterior quadratus 0.2 ml/kg 0.125% 48-h morphine consumption Morphine requirements (mg) reduced at 6 and 12 h (2, 8 vs.
lumborum block ­lumborum block ­bupivacaine or saline 7, 14, respectively) in quadratus lumborum block group
(bupivacaine) (saline)
Blanco et al.35 76 Caesarean section Posterior quadratus Lateral transversus 0.2 ml/kg 0.125% 48-h morphine consumption Morphine requirements (mg) reduced at 12, 24, and 48 h
lumborum block ­abdominis plane ­bupivacaine (bilateral)

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(5, 6, 9 vs. 8, 13.5, 17.5, respectively) in quadratus lumbo-
rum block group
Krohg31 40 Caesarean section Lateral quadratus Lateral quadratus 0.4 ml/kg 0.2% 24-h analgesia requirement Number of patients requiring postoperative analgesia lower
lumborum block ­lumborum block ropivacaine or saline, (3 vs. 7) in quadratus lumborum block group
(ropivacaine) (saline) bilaterally
Mieszkowski 58 Caesarean section Lateral quadratus No block 24 ml of 0.375% 48-h morphine consumption Morphine requirements (mg) reduced at 48 h (15.0 vs. 30.0) in
et al.32 lumborum block ­ropivacaine, bilaterally quadratus lumborum block group
Parras and 97 Hip hemiarthroplasty for Lateral quadratus Femoral nerve block 30 ml of 0.125% 24-h visual analog scale pain Visual analog scale reduced at 6, 12, 18, and 24 h (3.7, 1.4,

Anesthesiology 2019; 130:322–35

Blanc41 femoral neck fracture lumborum block levobupivacaine score; postanesthesia care 0.8, 0.7 vs. 5.2, 4.6, 3.4, 2.6, respectively) in the quadratus
unit opioids; 24-h opioid lumborum block group; 24-h opioid consumption (mg) lower
consumption (9.7 vs. 16.9) in the quadratus lumborum block group
Ishio et al.33 70 Laparoscopic Posterior quadratus No block 20 ml of 0.375% Numeric rating scale pain Numeric rating scale pain scores reduced at 1, 3, and 24 h
gynecological surgery lumborum block ropivacaine scores (1.4, 1.8, 1.5 vs. 3.1, 4.0, 4.4, respectively) in quadratus
lumborum block group
Oksüz et al.36 53 Pediatric: inguinal hernia Posterior quadratus Lateral transversus 0.5 ml/kg 0.2% Analgesic requirements Reduced need for rescue analgesia in quadratus lumborum
repair or orchiopexy lumborum block ­abdominis plane bupivacaine group
Quadratus Lumborum Block

329
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 330
Table 3. Case Reports of Quadratus Lumborum Block
Timing/
Case Types N Surgery Indication Site of Injection Injectate Results

Abdominal surgery 1 Laparotomy (duode- Perioperative Posterior quadratus lumborum 25 ml of 0.5% ropivacaine Initial sensory block T8–L1; first analgesic request
Kadam19 nal tumor) analgesia block at 3 h, patient-controlled analgesia fentanyl 720 µg
on postoperative day 1, 1,000 µg on postoperative
day 2
Clinical Focus Review

Kadam61 1 Hemicolectomy Perioperative Posterior quadratus lumborum 5 ml/h 0.2% ropivacaine Perioperative opioids: 500 µg of fentanyl (intraoper-
analgesia block ative, postanesthesia care unit combined); 10 mg
of oxycodone as rescue in first 48 h
Shaaban et al.18 1 Proctosigmoidec­ Postoperative Posterior quadratus lumborum Bilateral bolus: 15 ml of 0.5% Numeric rating scale improved from 10/10 to
tomy, colorectal day 1, after block bupivacaine; bilateral infusion, 2–3/10
anastomosis opioid-induced 8 ml/h 0.1% bupivacaine
hypoventilation
and respiratory
failure, surgical
team refusal of
thoracic epidural
analgesia

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Elsharkawy et al.46 1 Colectomy Perioperative Anterior quadratus lumborum Bilateral: 25 ml of 1.3% liposo- Anterior quadratus lumborum block: T7–L1; sensory
analgesia block compared with transver- mal bupivacaine blockade, 48 h transversus abdominis plane:
sus abdominis plane on same T10–L1; sensory blockade, 24 h; 190 mg of IV
patient morphine equivalent in first 72 h
Spence et al.13 1 Breast reconstruction Perioperative Posterior quadratus lumborum Bilateral bolus through catheter, Sensory block T7–L1, postoperatively numeric
using transverse analgesia block 20 ml of 1.5% mepivacaine; rating scale 0–3; minimal postoperative opioid
rectus abdominis bilateral infusion, 10 ml/h use: 15 mg of oxycodone (to postoperative day
myocutaneous 0.2% ropivacaine 3); patient-controlled analgesia hydromorphone

Anesthesiology 2019; 130:322–35

flaps use to postoperative day 2 was 1.4 mg
Carvalho et al.44 1 Multiple abdominal Chronic neuropathic Posterior quadratus lumborum 25 ml of 0.2% ropivacaine + Immediate pain relief lasting up to 6 months
wall surgeries pain block 20 mg of methylprednisolone
Corso et al.47 1 Open nephrectomy Perioperative Anterior quadratus lumborum 30 ml of 0.375% ropivacaine Good analgesia
analgesia block
Garg et al.48 1 High inguinal Perioperative Posterior quadratus lumborum 20 ml of 0.2% ropivacaine Sensory level T8–L1
orchidectomy analgesia block
Suri et al.49 6 Open radical Perioperative Lateral quadratus lumborum 20 ml of 0.2% ropivacaine Sensory level T5–L1
nephrectomy analgesia block (surgeon-assisted
injection)
Ueshima and Hiroshi50 2 Lower abdominal Perioperative Anterior subcostal quadratus Bolus through catheter: 20 ml of Good analgesia
surgery analgesia lumborum block 0.375% levobupivacaine
Ueshima and Otake51 2 Open nephrectomy Perioperative Anterior subcostal quadratus Bolus through catheter: 20 ml of Sensory block T8–12
analgesia lumborum block 0.5% levobupivacaine
Sindwani et al.52 1 Laparoscopic Perioperative Posterior quadratus lumborum Bilateral bolus through catheter: Excellent analgesia without opioid
nephrectomy analgesia block 15 ml of 0.2% ropivacaine
Sá et al.53 2 Gastrectomy and Perioperative Posterior quadratus lumborum Bilateral 20 ml of 0.25% Good analgesia, postblock hypotension
colectomy analgesia block levobupivacaine
(Continued )

Elsharkawy et al.
Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Table 3. (Continued)

Elsharkawy et al.
Timing/
Case Types N Surgery Indication Site of Injection Injectate Results

Obstetric and gynaecological surgery 1 Hysterectomy Perioperative Anterior quadratus lumborum Bilateral bolus through catheter: Good analgesia
Jadon54 analgesia block 25 ml of 0.3% ropivacaine
Sebbag et al.55 3 Cesarean delivery Perioperative Posterior quadratus lumborum Bilateral 30 ml of 0.25% Good analgesia
analgesia block ropivacaine
Wikner68 1 Gynecological Perioperative Lateral quadratus lumborum 40 ml of 0.25% levobupivacaine Motor block on left side involving hip and knee for
laparoscopy analgesia block 18 h, delaying discharge; sensory block right:
T7–L1; left: T7–L2
Ben-David et al.56 1 Uterine artery Perioperative Lateral quadratus lumborum Bilateral 20 ml of 0.375% Excellent analgesia
embolization analgesia block ropivacaine
Lower limb surgery 1 Total hip arthroplasty Perioperative Posterior quadratus lumborum Bolus through catheter: 15 ml T10–L2, oxycodone 50 mg until postoperative day 2
Hockett et al.16 analgesia block of 0.5% lidocaine; infusion:
7 ml/h 0.2% ropivacaine
Johnston and Sondekoppam20 1 Revision hip Perioperative Anterior quadratus lumborum Bolus: 30 ml of 0.5% ropiva- T12–L2 sensory block, oxycodone 80 mg in first
arthroplasty analgesia block caine; infusion: 10 ml/h 0.2% 48 h
ropivacaine

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Watanabe et al.45 1 Femoral–femoral Analgesia/anesthesia Posterior quadratus lumborum 15 ml of 0.125% levobupivacaine General anesthesia abandoned because of hemo-
bypass and block (combined with lumbar dynamic instability; remainder of case performed
bilateral foot plexus branch and parasacral under regional anesthesia
amputation sciatic blocks)
La Colla et al.12 2 Hip surgery (open Perioperative Lateral quadratus lumborum 0.5% ropivacaine + 20 µg Initial numeric rating scale 0/10, mean 4–5/10 on
reduction and analgesia block dexmedetomidine + 4 mg postoperative day 1; sensory block T6–L2 to 24 h
internal fixation, dexamethasone: 20 or 30 ml postoperatively
femoral neck

Anesthesiology 2019; 130:322–35

fracture); total hip
arthroplasty
Ohgoshi et al.57 2 Hip arthroplasty Perioperative Anterior subcostal quadratus Bolus through catheter: 20 ml of Sensory block T9–L2 dermatomes
analgesia lumborum block 0.375% ropivacaine
Ueshima et al.17 2 Total hip arthroplasty Perioperative Anterior quadratus lumborum Bolus: 25 ml of 0.3% levobupiva- T11–L4; T12–L2
analgesia block caine Infusion: 6 ml/h 0.125%
levobupivacaine + 3 ml of
bolus
Ueshima and Otake43 2 Above knee Surgical anesthesia Anterior quadratus lumborum 20 ml of 0.375% levobupivacaine No supplemental sedation or analgesics required
amputation block (combined with sciatic
nerve block)
Segura-Grau et al.58 1 Iliac and acetabulum Perioperative Posterior quadratus lumborum Bolus through catheter: 20 ml of Excellent analgesia without additional opioid
fracture analgesia block 0.25% levobupivacaine requirements
Spinal surgery 3 Spinal fusion Perioperative Posterior quadratus lumborum Bilateral bolus through Excellent analgesia without opioid
Iwamitsu et al.66 analgesia block catheter: 20 ml of 0.375%
levobupivacaine
Ueshima et al.66 2 Lumbar laminectomy Perioperative Posterior quadratus lumborum Bilateral 20 ml of 0.375% Excellent analgesia without opioid
analgesia block levobupivacaine
(Continued )
Quadratus Lumborum Block

331
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 Clinical Focus Review

reported, which may be related to local anesthetics spread

to the paravertebral space.53 Because of the doses used and

low pain scores, morphine 0.096 mg/kg required

the vascularity of the area, local anesthetic systemic toxicity

Sensory block T7–L2 maintained postoperatively,

Sensory level to T10 maintained postoperatively;

analgesics required (except for paracetamol)

pain numeric rating scale 2/10, no systemic
is a potential risk,69,70 although peak concentrations of local
anesthetic are lower after quadratus lumborum blocks than
transversus abdominis plane blocks.71
Results

NRS, numeric rating scale; ORIF, open reduction and internal fixation; PCA, patient controlled analgesia; POD, postoperative day; QL, quadratus lumborum; TAP, transversus abdominis plane; TEA, thoracic epidural analgesia.
Needle Trauma
on Postoperative day 1

The proximity of quadratus lumborum block to the pleura

Good Analgesia

and kidney in the subcostal anterior approach presents a risk

Good analgesia

Good analgesia

because of direct needle trauma.10 The risks of bleeding com-

plications are not yet known. There is no evidence for the
stratification of the risk of bleeding based on quadratus lum-
borum approaches. The posterior and lateral quadratus lum-
3 ml of 0.5% bupivacaine + 3 ml
Bolus through catheter: 10 ml of

borum block approaches use a fascial plane through which the

of 0.375% levobupivacaine
Bolus through catheter: 5 ml
20 ml of 0.25% bupivacaine

0.5 ml/kg 0.2% ropivacaine

abdominal branches of the lumbar arteries course. The ante-

Infusion: 5 ml/h 0.1%
Injectate

rior quadratus lumborum block is a deep block, close to the

0.5% ropivacaine

levobupivacaine
of 2% lidocaine

lumbar plexus and risks retroperitoneal spread of hematoma.

Therefore, the authors recommend that, for all approaches, the
American Society of Regional Anesthesia and Pain Medicine
guidelines for deep peripheral blocks be followed.
Anterior quadratus lumborum

Anterior quadratus lumborum

Anterior quadratus lumborum

Anterior quadratus lumborum

Anterior quadratus lumborum

Conclusions
Site of Injection

An understanding of the relevant anatomy and technical

aspects of quadratus lumborum block are essential for its
effective and safe use. Cadaveric studies demonstrate that
block

block

block

block

block

the iliohypogastric and ilioinguinal nerves are consistently

involved. Quadratus lumborum block approaches are
named in reference to injection location in relation to the
quadratus lumborum muscle. Current indications are based
Indication
Timing/

on few existing randomized controlled clinical trials and

Perioperative

Perioperative

Perioperative

Perioperative

Perioperative
analgesia

analgesia

analgesia

analgesia

analgesia

case reports (tables 2 and 3). Although the evidence base is

weak and still growing, the data thus far suggest that quadra-
tus lumborum block potentially results in extensive sensory
Pyeloplasty, pediatric
Extracorporeal shock

blockade (T7–L2). Quadratus lumborum block may lead to

Colostomy closure,

wave lithotripsy,
repair, pediatric

tomy, pediatric
Radical nephrec-

dermatomal coverage required for abdominal surgery and

Surgery

Inguinal hernia

hip surgery, representing an avenue for future research.

pediatric

pediatric

Acknowledgments

The authors acknowledge Jens Børglum, M.D., Ph.D.,

N

10
1

Department of Anesthesia and Intensive Care Medicine,

Zealand University Hospital, University of Copenhagen,
Denmark, and Rafael Blanco, M.D., Department of
Anesthesia, Corniche Hospital, Abu Dhabi, United Arab
Emirates, for their significant contributions in the develop-
Case Types
Table 3. (Continued)

Visoiu and Yakovleva14

ment of the presented theories.

Chakraborty et al.15
Aksu and Gürkan65
Pediatric surgery

Baidya et al.63
Yayik et al.60

Research Support
Support was provided solely from institutional and/or
departmental sources.

332 Anesthesiology 2019; 130:322–35 Elsharkawy et al.

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 Quadratus Lumborum Block

Competing Interests 9. Adhikary SD, El-Boghdadly K, Nasralah Z, Sarwani N,

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for PACIRA, Parsippany-Troy Hills, New Jersey. Those 72:73–9
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other authors declare no competing interests. DeGrande S, Soliman LM, Drake RL: Injectate spread
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Correspondence to the quadratus lumborum block: A comparative
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Medicine, Case Western Reserve University, 9500 Euclid al-medial transmuscular quadratus lumborum block for
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