The Quadratus Lumborum Block

Anatomy
The quadratus lumborum muscle is located in the posterior abdominal wall. It originates from
the iliac crest and inserts into the transverse processes of L1 to L4 and the inferior surface of
the 12th rib. It thickens inferiorly and so is visualized best on ultrasound at the L4 transverse
process. At this level it is related to the psoas muscle anteriorly, the erector spine muscle
posteriorly and the transverse process medially. It is invested by the thoracolumbar fascia
which is continuation of the common aponeurosis formed by the continuation of the fascia
surrounding the internal oblique and transversus adominus after these muscle taper off.
Anterior to this is the transversalis fascia. At the level of the diaphragm, the transversalis fascia
split in two. One sheet becomes the inferior diaphragmatic fascia. The second passes superior
to the diaphragm to blend with the endothoracic fascia. This creates a potential route for spread
of local anaesthetic to the thoracic paravertebral pace following quadratus lumborum block
(QLB).

Figure showing the anatomical relationship of the transversus abdominis plane (TAP), fascia
transversalis and the fascia of the quadratus lumborum (quadratus lumborum fascia) and psoas (psoas
fascia / sheath) muscles in retroperitoneal space. Note the subcostal and ilioinguinal nerves are located
on the anterior surface of the quadratus lumborum muscle. Ao, aorta, IVC, inferior vena cava, PM,
psoas major muscle, ESM, erector spine muscle, TAM, transversus abdominis muscle, IO, internal
oblique muscle, EOM, external oblique muscle.
 Figure showing the facial planes in the posterior abdomen where the local anesthetic is
injected during a quadratus lumborum block (QLB). TAM, indicates transversus abdominis
muscle, IOM, internal oblique muscle, EOM, external oblique muscle, QLM, quadratus
lumborum muscle, VB, verterbal body, Ao, aorta, and IVC, inferior vena cava.

Ultrasound Guided QLB Techniques

A. QLB 1 + QLB 2
QLB 1 – With the patient in the supine position, a low frequency transducer is placed on
the lateral aspect of the abdominal wall just superior to the iliac crest. It is moved posteriorly
until the transversus abdominus muscle can be seen tapering off to form its common
aponeurosis. At this point the quadratus lumborum muscle can be identified. Using an in-
plane technique, the needle is inserted and aimed towards the lateral edge of quadratus
lumborum and the thoracolumbar fascia. This is the final injection point.
QLB 2 – This technique is a modification of the QLB 1 in which the needle is passed through
the latissimus dorsi muscle. Local anesthetic is injected posterior to the quadratus lumborum
muscle outside the fascia. As the injection point is more superficial, the ultrasound images
obtained are of higher quality which may make the QLB 2 safer and more reliable than the
QLB 1.
B. Transmuscular approach
The patient is placed in the lateral position with the side to be anesthetized upwards. A
curved array transducer (5-2 MHz) is palced in the transverse plane at the abdominal flank
immediately superior to the iliac crest. The first approach described by Prof. Borglum was
an anterior to posterior approachwith the needle tip being positioned anterior to the QL
muscle. This was refined in the subsequent two posterior approaches. In the first
transmuscular approach, Borglum et al describe the ‘Shamrock sign’ as the ultrasound
guidelines to this approach. The three leaves of the shamrock are represented by the erector
spine, the QL and the Psoas muscle; with the transverse process of L4 representing the stem.
Figure showing the position of the patient, ultraosund transducer and the plane of ultrasound imaging
during a quadratus lumborum block (QLB) with the patient in the lateral decuibtus position. Note the
anatomical relationship of the psoas major (PM), quadratus lumborum (QLM) and erector spine
(ESM) muscles to the transverse process and the transversus abdominis plane. TM QLB, indicates
transmuscular quadratus lumborum block.

Figure highlighting the various approaches for quadratus lumborum block (QLB). Simulated needle
insertion paths (in red) have been superimposed on to a transverse sonogram of the lumbar
paravertebral region at the level of the L4 transverse process (Shamrock view). TMQLB, indicates
transmuscular QLB, QLM, quadratus lumborum muscle, TP, transverse process, EOM, external
oblique muscle, IOM, internal oblique muscle, TAM, transversus abdominis muscle, LDM, latissimus
dorsi muscle, ESM, erector spine muscle.
Transverse sonogram of the lumbar paravertebral region, acquired with a curvilinear transducer (C5-
1MHz), showing the anatomy relevant for quadratus lumborum block (QLB) at the level of the
transverse process (Shamrock view). Note the site for local anesthetic injection during a QLB 1 and
QLB 2 injection. Accompanying photograph on the right is demonstrating the position of the patient
and the ultrasound transducer during a QLB. EOM, external oblique muscle, IOM, internal oblique
muscle, TAM, transversus abdominis muscle, VB, vertebral body, TP, transverse process, ESM,
erector spine muscle, AP, articular process.

Transverse sonogram of the lumbar paravertebral region, acquired with a curvilinear transducer (C5-
1MHz), showing the anatomy relevant for quadratus lumborum block (QLB) at the level of the
articular process (AP) of the lumbar vertebra. Note the site for local anesthetic during a QLB 1 and
QLB 2 injection. The lumbar plexus nerves are visualized on the psoterior aspect of the psoas muscle.
Also the spinal canal is visualized through the interverterbal foramen (IVF). EOM, external oblique
muscle, IOM, internal oblique muscle, TAM, transversus abdominis muscle, VB, verterbral body,
ESM, erector spine muscle.
 Figure illustrating the (A) position of the patient (supine), ultrasound transducer and (B) direction of
needle insertion during a quadratus lumborum1 and 2 block, especially for bilateral injections. Having
an assistant to retract the abdominal skin away from the needle insertion site can help with the
needling.

Ultrasound guided QLB injection with the patient in the supine position. (A). The kidney is initially
identified to define the anterior surface of the psoas major (PM) and quadratus lumborum muscle
(QLM), (B). Scout scan, (C). In-plane needle (arrow heads) insertion in a postero-medial direction,
(D) The needle tip has been placed at the junction between the PM and QLM, (E & F). Note the
spread of the local anesthetic (LA) in the retroperitoneal apsce and on the anterolateral surface of the
PM and anterior aspect of QLM.
Ultrasound guided transmuscular QLB injection with the patient in the lateral position. (A) Scout scan
– shamrock view, (B) In-plane needle (short arrow heads) insertion ina a postero-anterior direction,
(C) Saline test bolus with needle tip positioned in the QLB plane between the psoas major (PM) and
quadratus lumborum muscle (QLM), (D – F), Spread of the local anesthetic (LA) in the QLB plane.
VB, indicates verterbral body, TP, transverse process.