P091: QUADRATUS LUMBORUM BLOCKS FOR IMPROVED POSTOPERATIVE PAIN
Cara Esser, MD; Mohammed F Malik, MD; William Grubb, MD, DDS; Rutgers Robert Wood Johnson University Hospital
In the past, the ‘gold standard’ for any kind of hip surgery has been general anesthesia. However, there is increased utilization of neuraxial and regional anesthesia. Quadratus lumborum block (QLB) has emerged over the past 15 years to assist with a vast range of analgesia coverage. This type of block is done under ultrasound guidance for the posterior abdominal wall and spreads along the thoracolumbar fascia into the paravertebral space to provide analgesia. QLB's have often been used for gynecological cases or abdominal cases instead of utilizing an epidural and removing it the next day, but are becoming more popular for hip and femur procedures.
17 y/o female presented for left surgical hip dislocation with femoral head osteotomy. No significant medical problems, no medications. Denies alcohol, smoking or illicit drug use. No drug allergies or previous problem with anesthesia. UPT negative. Patient consented for general endotracheal anesthesia with a QBL.
All ASA monitors were applied. General anesthesia (GA) was induced with lidocaine, propofol, sufentanil and rocuronium. 6.5cm ETT was placed without difficulty and secured. GA was maintained with Sevoflurane at 1.8 and Sufentanil 0.004 mg/kg/min. Patient was placed in the right lateral decubitus position. The ultrasound transducer was placed in the transverse plane on the patient’s left flank area. The layers of muscle of the abdominal wall were visualized and transducer was moved posteriorly to visualize transversus abdominis muscle aponeurosis. 21G, 100mm needle was advanced in plane anterior to posterior through the abdominal wall muscles, positioned at the lateral border of the QBL. 15cc of Exparel and 15cc of 0.25% Bupivicaine were injected in this location, aspirating every 5 cc’s. No blood aspirated.
Patient woke up comfortably from GA with no immediate complaints of L hip pain. Follow up the next day showed the patient ambulating well with no significant pain protests.
The innervation of the hip has made it quite challenging to provide adequate analgesia for hip surgeries/procedures. The quadratus lumborum muscle (QLM) extends in the posterior abdominal wall from the posteromedial iliac crest to the medial border of the twelfth rib and 1st-4th lumbar vertebrae. The QLM is surrounded by thoracolumbar fascia which consists of aponeuroses and fascial tissue. Research has shown that injection of local anesthetic in this area has direct spread to roots and branches of the lumbar plexus which would be beneficial for hip surgeries. There are different subtypes of quadratus lumborum blocks (QLB) but the QLB1 was used in this case. However most providers must have a strong understanding of the relevant anatomy related to a QLB for this type of block to be efficient and safe. Studies show that patients who received the QLB had diminished pain post-op and prior to discharge in comparison to those who did not receive QLB. Additionally, the application of regional anesthesia has shown to decrease opioid use in the postoperative period in addition to decreased operative blood loss and prevention of DVTs. Studies have shown that patients who receive QLB have decreased pain overall which improves early mobilization and the effects of the block last from 24-48 hours.