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The supra-iliac anterior quadratus lumborum block: a cadaveric study and case series

  • Hesham ElsharkawyEmail author
  • Kariem El-Boghdadly
  • Theresa J. Barnes
  • Richard Drake
  • Kamal Maheshwari
  • Loran Mounir Soliman
  • Jean-Louis Horn
  • Ki Jinn Chin
Reports of Original Investigations

Abstract

Purpose

The local anesthetic injectate spread with fascial plane blocks and corresponding clinical outcomes may vary depending on the site of injection. We developed and evaluated a supra-iliac approach to the anterior quadratus lumborum (QL) block and hypothesized that this single injection might successfully block the lumbar and sacral plexus in cadavers and provide analgesia for patients undergoing hip surgery.

Methods

Ultrasound-guided bilateral supra-iliac anterior QL blocks were performed with 30 mL of India ink dye in six fresh adult cadavers. Cadavers were subsequently dissected to determine distribution of the dye. In five patients undergoing hip surgery, a unilateral supra-iliac anterior QL block with 25 mL ropivacaine 0.5% followed by a continuous catheter infusion was performed. Patients were clinically assessed daily for block efficacy.

Results

The cadaveric injections showed consistent dye involvement of the majority of the branches of the lumbar plexus, including the femoral nerve, lateral femoral cutaneous nerve, ilioinguinal nerve, and iliohypogastric nerve. The majority of cadaveric specimens (83%) also exhibited thoracic paravertebral spread of dye to the T10 level. No specimens showed L5 or sacral nerve root staining or caudal spread below L5. All patients had effective analgesia for total hip surgery and a T11–L3 sensory level following the initial bolus of local anesthetic as well as during the period of continuous catheter infusion.

Conclusion

This cadaveric study and case series show that a supra-iliac approach to the anterior QL block involved T10-–L3 nerve territories and dermatomal coverage with no sacral plexus spread. This technique may have clinical utility for analgesia in hip surgery.

Le bloc du muscle carré des lombes antérieur par approche supra-iliaque : une étude cadavérique et une série de cas

Résumé

Objectif

La diffusion de l’anesthésique local injecté lors de la réalisation d’un bloc du fascia et les résultats cliniques qui en découlent peuvent varier selon le site d’injection. Nous avons mis au point et évalué une approche supra-iliaque pour la réalisation d’un bloc du muscle carré des lombes antérieur (quadratus lomburum) et émis l’hypothèse que cette injection unique pourrait suffire à bloquer les plexus lombaire et sacral de cadavres, offrant ainsi une analgésie aux patients subissant une chirurgie de la hanche.

Méthode

Des blocs bilatéraux du muscle carré des lombes antérieur ont été réalisés par approche supra-iliaque sous échoguidage à l’aide de 30 mL de teinture d’encre de Chine sur six cadavres adultes frais. Les cadavres ont par la suite été disséqués afin de déterminer la diffusion de la teinture. Nous avons réalisé un bloc unilatéral du muscle carré des lombes antérieur par approche supra-iliaque avec une solution de 25 mL de ropivacaïne 0,5 %, suivie d’une perfusion continue via cathéter, chez cinq patients subissant une chirurgie de la hanche. Une évaluation clinique quotidienne des patients a été réalisée afin de déterminer l’efficacité du bloc.

Résultats

Les injections sur les cadavres ont permis d’observer une diffusion constante de la teinture dans la majorité des branches du plexus lombaire, y compris dans le nerf fémoral, le nerf fémoral cutané latéral, le nerf ilio-inguinal et le nerf ilio-hypogastrique. Une diffusion paravertébrale thoracique de la teinture jusqu’au niveau T10 a également été retrouvée dans la majorité des spécimens cadavériques (83 %). Aucune coloration au niveau de la racine L5 ou des nerfs sacrés n’a été observée chez les spécimens, ni aucune diffusion caudale au-dessous de L5. Tous les patients ont reçu une analgésie efficace pour une arthroplastie totale de la hanche et obtenu un bloc sensitif au niveau T11–L3 après l’injection du bolus initial d’anesthésique local ainsi qu’au cours de la période de perfusion continue.

Conclusion

Cette étude cadavérique et cette série de cas montrent qu’une approche supra-iliaque pour réaliser un bloc du muscle du carré des lombes antérieur est parvenue à atteindre les territoires nerveux T10-–L3 et avec couverture de ces dermatomes et ce, sans diffusion au niveau du plexus sacré. Cette technique pourrait avoir une utilité clinique pour l’analgésie en cas de chirurgie de la hanche.

Notes

Conflict of interest

Dr. Elsharkawy has received unrestricted educational funding from PAJUNK (GA, USA), and is a consultant for PACIRA (Troy Hills, NJ, USA). Those companies had no input into any aspect of the present project design or manuscript preparation. The other authors declare no conflicts of interest.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

Hesham Elsharkawy, Ki Jinn Chin, and Kariem El-Boghdadly contributed substantially to all aspects of this manuscript, including study conception and design, acquisition, analysis, and interpretation of data, and drafting the article. Theresa J. Barnes contributed substantially to the conception and design of the manuscript. Richard Drake contributed substantially to the acquisition of data. Kamal Maheshwari, and Jean-Louis Horn contributed to the analysis of data. Loran Mounir Soliman contributed substantially to the interpretation of data.

Funding

Departmental funding.

Supplementary material

12630_2019_1312_MOESM1_ESM.pdf (90 kb)

eTABLE

Cadaveric studies investigating the anterior quadratus lumborum muscle block. (PDF 90 kb)

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Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  • Hesham Elsharkawy
    • 1
    • 2
    Email author
  • Kariem El-Boghdadly
    • 3
    • 4
  • Theresa J. Barnes
    • 5
  • Richard Drake
    • 6
  • Kamal Maheshwari
    • 1
    • 2
  • Loran Mounir Soliman
    • 7
  • Jean-Louis Horn
    • 8
  • Ki Jinn Chin
    • 9
  1. 1.Departments of General Anesthesia and Pain Management, Outcomes Research, Anesthesiology InstituteCleveland ClinicClevelandUSA
  2. 2.Anesthesiology CCLCM of Case Western Reserve UniversityClevelandUSA
  3. 3.Department of AnaesthesiaGuy’s & St Thomas’ NHS Foundation TrustLondonUK
  4. 4.King’s College LondonLondonUK
  5. 5.Department of AnesthesiologyEmory University School of MedicineAtlantaUSA
  6. 6.Cleveland Clinic Lerner College of MedicineClevelandUSA
  7. 7.Departments of General Anesthesia and Pain Management, Anesthesiology InstituteCleveland ClinicClevelandUSA
  8. 8.Department of Anesthesiology, Perioperative and Pain MedicineStanfordUSA
  9. 9.Department of Anesthesia, Toronto Western HospitalUniversity of TorontoTorontoCanada

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