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Different approaches have been described to perform a quadratus lumborum block:
- QLB 1 or lateral: Target is deep to the aponeurosis of the transversus abdominis but superficial to the fascia transversalis at the lateral margin of the QL muscle.
- QLB 2 or posterior: Targets the posterior fascial plane of the QL muscle, deep to the middle layer of the thoracolumbar fascia (TLF).
- Transmuscular or anterior block: Targets the fascial plane between the QL and psoas major muscles (the anterior aspect of the QL).
QL1 (Lateral)
Target is deep to the aponeurosis of the transversus abdominis but superficial to the fascia transversalis at the lateral margin of the QL muscle.
Transducer position
- Place the transducer in a transverse orientation just above the iliac crest on the midaxillary line (same initial position for the three approaches can be used).
Scanning
Slide the transducer posteriorly until the posterior aponeurosis of the transversus abdominis muscle is identified followed by the QL muscle.
Needle insertion
- Insert the needle in-plane, in an anterior to posterior direction, until the needle tip pierces the posterior aponeurosis of the transversus abdominis muscle, medial to the QL muscle.
- The injection should result in a visible spread along the lateral side of the quadratus lumborum muscle at the union with the transversalis fascia.
- A volume of 0.2-0.3 mL/Kg has been described for this approach.
Fig. Transducer position and sonoanatomy for a QL1 block. Needle insertion in-plane showing injection point for a QL 1 block (white arrow). EO, External oblique; IO, Internal oblique; TA, Transversus abdominis; QL, Quadratus lumborum muscles.
QL2 (Posterior)
Target is the posterior fascial plane of the QL muscle, deep to the middle layer of the thoracolumbar fascia (TLF).
Transducer position
- Place the transducer in a transverse orientation at the midaxillary line and slide it posteriorly (similar to the QL1 block).
Scanning
Identify the fascial plane between the posterior aspect of the QL muscle and the middle layer of the TLF.
Needle insertion
- Insert the needle in-plane from an anterior to posterior direction.
- Direct the needle toward the posterior (dorsal) surface of QL.
- Inject 2-3 mL of local anesthetic to confirm pooling along the posterior aspect of the QL and complete the block with a volume of 0.2-0.3 mL/Kg.
Fig. Reverse ultrasound anatomy with needle insertion points for a QL1, and QL2 blocks. Ideal local anesthetic spread (blue area) for QL1 – lateral to the QL muscle, and for QL2 – posterior to the QL muscle. EO, External oblique; IO, Internal oblique; TA, Transversus abdominis; QL, Quadratus lumborum; ESP, Erector spinae muscles.
QL3 (Transmuscular)
Target is the fascial plane between the QL and psoas major muscles (anterior aspect of the QL).
Transducer position
- Place the transducer in a transverse orientation on the patient’s flank just cranial to the iliac crest.
Scanning
Identify the acoustic shadow of the L4 transverse process, the erector spinae muscles posteriorly, the QL muscle laterally, and psoas major muscle anteriorly (i.e., the shamrock sign).
Needle insertion
- Insert the needle in a posterior-to-anterior direction through the QL.
- Direct the needle tip toward the plane between the QL and psoas major muscles.
- Inject 2-3 mL to confirm spread in between the muscles and complete the block with 0.2-0.3 mL/Kg.
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