Quadratus Lumborum Block

Quick Answer

Quadratus lumborum block (QLB) involves injection of local anaesthetic into the fascial planes surrounding the quadratus lumborum muscle, providing somatic and visceral analgesia through spread to the thoracolumbar fascia, lumbar plexus, and sympathetic chain. Three approaches: QL1 (lateral/QL muscle at transverse process), QL2 (posterior/QL muscle at posterior border), QL3 (anterior/QL muscle at anterior border near psoas). Anatomy: Quadratus lumborum muscle extends from 12th rib and L1-L4 transverse processes to iliac crest; thoracolumbar fascia encloses erector spinae and QL muscle. Indications: Abdominal surgery (laparotomy, laparoscopic procedures), thoracic surgery (rib fractures, thoracotomy), chronic back pain, hip surgery. Coverage: Unilateral or bilateral abdominal wall (T7-L1), partial lumbar plexus (with QL2/QL3), potential visceral analgesia. Technique: Ultrasound-guided - curved probe in coronal plane at flank; identify QL muscle, transverse process, psoas; inject 20-30 mL at target plane. Advantages: Extensive coverage, potential visceral analgesia, catheter suitable, alternative to TAP/paravertebral. Complications: LAST, vascular puncture, renal injury (deep injection), epidural spread, bowel perforation (anterior). [1-20]

Anatomy

Quadratus Lumborum Muscle

Structure: The quadratus lumborum (QL) is a thick, quadrilateral muscle located in the posterior abdominal wall, extending between the 12th rib and the iliac crest.

Origin:

• Iliolumbar ligament: Between L5 transverse process and iliac crest
• Iliac crest: Outer lip of posterior iliac crest

Insertion:

• 12th rib: Inferior border (medial half)
• L1-L4 transverse processes: Anterior aspects

Relations:

• Anterior: Psoas major muscle, lumbar plexus, aorta (left), inferior vena cava (right), kidneys
• Posterior: Erector spinae muscles, thoracolumbar fascia
• Superior: 12th rib, diaphragm
• Inferior: Iliac crest, iliolumbar ligament
• Medial: Psoas major, vertebral column
• Lateral: Transversus abdominis, internal oblique muscles

Function:

• Bilateral contraction: Extends lumbar spine, fixes 12th rib during inspiration
• Unilateral contraction: Lateral flexion of spine to same side
• Stabilizes diaphragm and 12th rib during respiration

Thoracolumbar Fascia

Composition: The thoracolumbar fascia (TLF) is a complex, multilayered fascial system enclosing the deep muscles of the back.

Layers:

1. Posterior layer: Most superficial, encloses erector spinae posteriorly

   • Attachments: Spinous processes to transverse processes
   • Blends with latissimus dorsi, gluteal fascia

2. Middle layer: Between erector spinae and quadratus lumborum

   • Attachments: Transverse processes to tips
   • Fusion with posterior layer at lateral border of erector spinae

3. Anterior layer: Covers quadratus lumborum anteriorly

   • Attachments: Transverse processes to 12th rib
   • Continuous with fascia over psoas major

Function:

• Muscle compartmentalization
• Load transfer between trunk and limbs
• Proprioceptive function
• Clinical relevance: Conduit for local anaesthetic spread

Lumbar Plexus

Formation: The lumbar plexus is formed within the psoas major muscle from the ventral rami of L1-L4 nerves.

Terminal Branches:

1. Iliohypogastric nerve (L1): Skin of suprapubic and gluteal region
2. Ilioinguinal nerve (L1): Skin of groin, genitalia
3. Genitofemoral nerve (L1-L2): Skin of upper anterior thigh, genitalia
4. Lateral femoral cutaneous nerve (L2-L3): Skin of lateral thigh
5. Femoral nerve (L2-L4): Anterior thigh muscles, knee extensors, skin of anterior thigh and medial leg
6. Obturator nerve (L2-L4): Medial thigh muscles (adductors), skin of medial thigh

Relation to QL Block:

• QL1: Minimal lumbar plexus involvement
• QL2: Moderate lumbar plexus coverage (femoral, obturator, lateral cutaneous)
• QL3: Extensive lumbar plexus coverage (within psoas, near QL anterior border)

Three Approaches to QL Block

QL1 (Lateral/Transverse Process Approach):

• Location: Lateral to QL muscle, at level of transverse process
• Target plane: Between transversus abdominis/internal oblique and QL muscle
• Mechanism: Spreads within thoracolumbar fascia to posterior abdominal wall
• Coverage: Abdominal wall (T7-L1), minimal lumbar plexus
• Safety: Safest approach, away from major vessels and kidneys

QL2 (Posterior Approach):

• Location: Posterior to QL muscle, at posterior border
• Target plane: Between QL and erector spinae (middle layer TLF)
• Mechanism: Spreads to paravertebral space, lumbar plexus
• Coverage: Abdominal wall, partial lumbar plexus, visceral analgesia
• Safety: Moderate risk, deeper than QL1

QL3 (Anterior Approach):

• Location: Anterior to QL muscle, at anterior border
• Target plane: Between QL and psoas major
• Mechanism: Lumbar plexus block (within psoas), sympathetic involvement
• Coverage: Extensive lumbar plexus, abdominal wall, visceral analgesia
• Safety: Highest risk (near kidneys, major vessels, psoas/intrathecal)

Ultrasound Anatomy

Probe Position:

• Transducer: Curved array (2-5 MHz) required for depth (5-10 cm)
• Orientation: Coronal plane (longitudinal) at flank/posterior axillary line
• Level: L3-L4 (typically), or T12-L1 for upper abdominal coverage

Sonographic Appearance:

Lateral to Medial:

1. Peritoneal cavity: May see bowel (stay posterior)
2. Transversus abdominis muscle: Thin, lateral
3. Internal/external oblique muscles: Anterolateral
4. Quadratus lumborum muscle:
   • Shape: Thick, hypoechoic, quadrilateral
   • Extends from 12th rib superiorly to iliac crest inferiorly
   • Lies lateral to psoas, posterior to peritoneum
5. Psoas major muscle: Anteromedial to QL, deeper
6. Erector spinae muscles: Posteromedial to QL
7. Transverse processes: Hyperechoic shadowing structures (L1-L4)
8. Lumbar plexus: Not typically visualized (within psoas)

Landmark Identification:

• 12th rib: Superior limit, curved hyperechoic structure
• Iliac crest: Inferior limit
• QL muscle: Between rib and crest, thick muscle belly
• Transverse processes: Posterior acoustic shadowing "signposts"

Approach-Specific Targets:

• QL1: Lateral edge of QL (between QL and abdominal wall muscles)
• QL2: Posterior edge of QL (between QL and erector spinae)
• QL3: Anterior edge of QL (between QL and psoas)

Indications and Contraindications

Indications

Abdominal Surgery:

• Laparotomy: Open abdominal procedures
• Laparoscopic surgery: Cholecystectomy, appendectomy, colectomy
• Cesarean section: Postoperative analgesia (bilateral QL blocks)
• Hernia repair: Inguinal, ventral, incisional hernia
• Renal surgery: Donor nephrectomy, partial nephrectomy (avoid QL3)
• Bariatric surgery: Gastric bypass, sleeve gastrectomy

Thoracic Applications:

• Thoracotomy: Open thoracic surgery
• VATS: Video-assisted thoracoscopic surgery
• Rib fractures: Unilateral or bilateral analgesia
• Chest wall surgery: Tumor resection, chest wall reconstruction
• Sternotomy: Bilateral QL blocks for cardiac surgery (alternative to sternal infiltration)

Hip and Lower Limb Surgery:

• Total hip arthroplasty: QL2/QL3 for lumbar plexus coverage
• Hip fracture surgery: Analgesia and lumbar plexus block
• Anterior thigh procedures: Femoral nerve distribution

Chronic Pain:

• Chronic abdominal wall pain: Diagnostic and therapeutic
• Post-herpetic neuralgia: Thoracic/lumbar dermatomes
• Complex regional pain syndrome: Lower extremity involvement
• Chronic back pain: Lumbar facet syndrome, myofascial pain

Pediatric Applications:

• Abdominal surgery: Appendectomy, hernia repair
• Thoracic surgery: Congenital diaphragmatic hernia
• Advantage: Alternative to neuraxial techniques

Contraindications

Absolute Contraindications:

• Patient refusal: Unable to consent
• Infection at site: Cellulitis, abscess at flank
• Allergy to local anaesthetics: True allergy (rare)
• Local anaesthetic toxicity: Current or recent
• Coagulopathy: Severe bleeding disorder (relative, see below)

Relative Contraindications:

Anticoagulation (ASRA Guidelines):

• QLB considered intermediate risk (closer to neuraxial than peripheral)
• QL1: Lower risk (more peripheral)
• QL2/QL3: Higher risk (near lumbar plexus, major vessels)
• Warfarin: INR <1.5 (QL1), <1.4 (QL2/QL3)
• Therapeutic LMWH: Delay 12-24 hours
• DOACs: Hold 2-3 days

Anatomical Concerns:

• Prior retroperitoneal surgery: Scarring, altered anatomy
• Kidney abnormalities: Horseshoe kidney, pelvic kidney (avoid QL3)
• Lumbar plexus neuropathy: Pre-existing (document)
• Severe scoliosis: Technical difficulty
• Morbid obesity: Depth >10 cm, technical difficulty

Approach-Specific Contraindications:

QL1:

• Generally safest; few specific contraindications

QL2:

• Renal pathology: Avoid if kidney abnormal position
• Lumbar plexus disorders: Risk of exacerbation

QL3:

• Renal disease: High risk of kidney injury
• Aortic aneurysm: Risk of rupture
• Coagulopathy: High bleeding risk (major vessels)
• Psoas abscess: Risk of spread
• Lumbar neuraxial blocks: Recent (risk of spread to neuraxis)

Technique

Pre-Block Assessment

Mandatory Checks:

1. Informed consent (risks vary by approach: QL1 lowest, QL3 highest)
2. Medical history (coagulation, kidney disease, prior surgery)
3. Physical examination (baseline neurological, spine deformity)
4. Review imaging (if prior retroperitoneal surgery)
5. Monitoring: ECG, NIBP, SpO2
6. IV access
7. Lipid emulsion available
8. Urinalysis (if renal injury suspected post-block)

Ultrasound-Guided Technique

Patient Position:

• Lateral decubitus: Operative side up (preferred for unilateral)
• Sitting: Leaning forward, supported
• Prone: For posterior approaches (less common)

Equipment:

• Curved array probe (2-5 MHz): Essential for depth (6-10 cm typical)
• Needle: 100-150 mm, 22G, echogenic (long needle required)
• Local anaesthetic: 20-30 mL (volume depends on approach)
• Extension tubing: For aspiration

General Scanning Protocol:

1. Position probe: Coronal plane at posterior axillary line, L3-L4 level
2. Identify landmarks:
   • 12th rib (superior, curved)
   • Iliac crest (inferior)
   • QL muscle (thick, between rib and crest)
   • Psoas (anteromedial to QL)
   • Erector spinae (posteromedial to QL)
3. Select approach based on surgical indication
4. Identify target plane for chosen approach

QL1 Technique (Lateral Approach):

Target:

• Lateral border of QL muscle
• Plane between transversus abdominis/internal oblique and QL

Needle Insertion:

• In-plane from anterior to posterior
• Advance through abdominal wall muscles
• Target lateral edge of QL

Injection:

• Volume: 20-30 mL
• Confirmation: Lateral spread between muscle layers, cranio-caudad spread
• Similar to posterior TAP block but more posterior

QL2 Technique (Posterior Approach):

Target:

• Posterior border of QL muscle
• Plane between QL and erector spinae (middle TLF layer)

Needle Insertion:

• In-plane from posterior to anterior
• Advance through erector spinae or posterior to QL
• Target posterior edge of QL

Injection:

• Volume: 20-25 mL
• Confirmation: Spread between QL and erector spinae, potential paravertebral spread
• Higher risk than QL1; monitor for lumbar plexus effects

QL3 Technique (Anterior Approach):

Target:

• Anterior border of QL muscle
• Plane between QL and psoas major (anterior TLF layer)

Needle Insertion:

• In-plane from lateral to medial or anterior to posterior
• Requires precise needle placement
• Visualize needle tip at all times (near kidney, vessels)

Injection:

• Volume: 15-20 mL (smaller due to proximity to psoas/lumbar plexus)
• Confirmation: Spread between QL and psoas, lumbar plexus blockade
• Highest risk approach: Incremental injection, frequent aspiration

Catheter Techniques

Indications:

• Major abdominal or thoracic surgery
• Multiple rib fractures
• Chronic pain management

Technique:

• Insert catheter 3-5 cm beyond needle tip (QL1 or QL2 preferred)
• Tunnel subcutaneously (5-10 cm)
• Secure with adhesive dressings
• Infusion: Ropivacaine 0.2% at 8-12 mL/h (QL1/QL2), 6-8 mL/h (QL3)
• Duration: 2-5 days typically

Local Anaesthetic Selection and Dosing

Single-Shot Block

Bilateral Blocks:

• Volume per side: Reduce by 25% (15-20 mL QL1, 12-15 mL QL2, 10-12 mL QL3)
• Total volume: Monitor for LAST
• Risk: Higher with bilateral (large total dose)

Additives:

• Dexamethasone: 4-8 mg IV (prolongs 6-10 hours)
• Clonidine: 0.5-1 mcg/kg (prolongs, sedation side effect)

Continuous Infusion

Infusion Regimens:

Duration:

• Typical: 2-5 days
• Maximum: 7 days with meticulous care
• Daily site inspection essential

Complications and Management

Local Anaesthetic Systemic Toxicity (LAST)

Risk Factors:

• Large volumes: 40-60 mL for bilateral blocks
• Vascular injection: Lumbar arteries, aorta, IVC (QL3)
• Rapid injection
• Absence of ultrasound guidance
• Low body weight/lean body mass

Prevention:

• Incremental injection with frequent aspiration
• Ultrasound visualization of vessels
• Epinephrine-containing solution (1:200,000)
• Dose based on lean body weight
• Avoid excessive volumes for bilateral blocks

Management:

• ASRA LAST protocol
• Lipid emulsion 20%: 1.5 mL/kg bolus, 0.25 mL/kg/min infusion
• Airway support, seizure control

Vascular Puncture

Risk by Approach:

• QL1: Low risk (lateral, away from major vessels)
• QL2: Moderate risk (segmental lumbar arteries)
• QL3: High risk (aorta, IVC, lumbar arteries, renal vessels)

Complications:

• Hematoma: Retroperitoneal, flank
• Hematuria: Renal injury (QL3)
• Hypotension: Major vessel puncture

Prevention:

• Ultrasound visualization of vessels
• Color Doppler if available (identify aorta, IVC)
• Incremental injection with aspiration
• Avoid QL3 if anticoagulated

Management:

• Firm pressure 10-15 minutes
• Monitor for retroperitoneal hematoma (flank pain, falling Hb)
• CT scan if suspected
• Transfusion if significant

Renal Injury (QL2/QL3)

Risk:

• QL2: Kidney posterior to QL at upper levels
• QL3: Kidney immediately anterior to target plane

Recognition:

• Hematuria (immediate or delayed)
• Flank pain
• Falling hematocrit
• CT: Perirenal hematoma, laceration

Prevention:

• Know anatomy: Kidney typically T11-L3, posterior to QL upper part
• Stay lateral/posterior (QL1/QL2) to avoid kidney
• Visualize kidney on ultrasound (anechoic structure anterior to QL upper portion)
• Avoid QL3 if kidney in path
• QL2 only at lower levels (L3-L4, below kidney)

Management:

• Urology consultation
• Monitor renal function
• Imaging (CT urogram)
• Conservative vs surgical management
• Document as serious complication

Neuraxial Spread

Intrathecal Injection (Rare):

• Risk: QL3 approach (near dural sleeves)
• Mechanism: Needle through intervertebral foramen
• Prevention: Stay lateral, visualize needle tip

Epidural Spread:

• Risk: QL2/QL3 (paravertebral spread to epidural)
• Effects: Bilateral block, lower limb motor weakness, hypotension
• Incidence: 1-5%

Management:

• Supportive care
• Monitor respiratory function (bilateral block)
• Vasopressors if hypotensive
• Usually self-limiting

Lumbar Plexus Blockade (Expected with QL2/QL3)

Characteristics:

• QL1: Minimal (<10% femoral/obturator)
• QL2: Moderate (30-50% lumbar plexus)
• QL3: High (60-80% lumbar plexus)

Effects:

• Femoral nerve: Quadriceps weakness, anterior thigh numbness
• Obturator nerve: Adductor weakness, medial thigh numbness
• Lateral femoral cutaneous: Lateral thigh numbness

Management:

• Expected effect with QL2/QL3
• Warn patient about leg weakness
• Fall prevention strategies
• Unilateral vs bilateral weakness (if bilateral blocks)

Other Complications

Bowel Perforation:

• Risk: QL1 if too anterior (needle enters peritoneum)
• Prevention: Stay posterior to QL, ultrasound visualization
• Management: Surgical consultation, antibiotics, observation

Infection:

• Incidence: <0.1% single shot, 1-3% catheters
• Prevention: Aseptic technique
• Management: Antibiotics, catheter removal

Block Failure:

• Incidence: 10-20%
• Causes: Superficial injection, inadequate volume, anatomical variation
• Management: Repeat block, supplemental analgesia

Clinical Scenarios and SAQs

SAQ 1: QL Anatomy and Approaches (12 marks)

Question: Describe the anatomy of the quadratus lumborum muscle and the three approaches to quadratus lumborum block.

Model Answer:

a) QL muscle anatomy (4 marks):

• Origin: Iliolumbar ligament, iliac crest
• Insertion: 12th rib, L1-L4 transverse processes
• Relations: Anterior to psoas/kidneys, posterior to erector spinae, lateral to abdominal wall muscles
• Function: Spine extension, lateral flexion, stabilizes 12th rib

b) Three approaches (6 marks):

• QL1 (lateral): Between abdominal wall muscles and QL; coverage: abdominal wall; lowest risk
• QL2 (posterior): Between QL and erector spinae; coverage: abdominal wall + partial lumbar plexus; moderate risk
• QL3 (anterior): Between QL and psoas; coverage: abdominal wall + extensive lumbar plexus; highest risk (near kidney, vessels)

c) Thoracolumbar fascia relevance (2 marks):

• Three layers (posterior, middle, anterior) compartmentalize back muscles
• Conduit for LA spread to paravertebral space and multiple dermatomes

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SAQ 2: Clinical Application (10 marks)

Question: A 45-year-old patient is undergoing laparoscopic cholecystectomy. The surgeon requests effective postoperative analgesia covering port sites and visceral pain.

a) Which QL approach would you choose, and why? (3 marks)

b) What are the advantages of QL block over TAP block for this patient? (3 marks)

c) What volume and concentration of local anaesthetic would you use? (2 marks)

d) What specific complications should you monitor for with your chosen approach? (2 marks)

Model Answer:

a) Approach selection (3 marks):

• QL2 or QL1 (accept either with justification) (1 mark)
• QL2 rationale: Provides both somatic and some visceral analgesia through paravertebral spread (1 mark)
• Safer than QL3 (avoids kidney/vessels) while providing better coverage than QL1 (1 mark)

b) Advantages over TAP (3 marks):

• More extensive cranio-caudad spread (4-6 dermatomes vs 2-3) (1 mark)
• Potential visceral analgesia through paravertebral/sympathetic spread (1 mark)
• Better coverage for upper abdominal/gallbladder pain (1 mark)

c) Local anaesthetic (2 marks):

• Ropivacaine 0.5% or bupivacaine 0.375%, 20-25 mL (1 mark per element)

d) Complications to monitor (2 marks):

• LAST (large volume), lumbar plexus block (leg weakness, falls), vascular puncture (accept any 2)

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SAQ 3: Safety and Technique (8 marks)

Question: You are planning to perform a QL3 block for a patient undergoing total hip arthroplasty who has a history of chronic kidney disease (eGFR 45 mL/min).

a) What are the specific risks of QL3 approach in this patient? (3 marks)

b) What modifications would you make to your technique? (3 marks)

c) What alternative approaches might you consider? (2 marks)

Model Answer:

a) Specific risks (3 marks):

• Renal injury/puncture (kidney anterior to QL3 target plane) (1 mark)
• LAST (reduced LA clearance with CKD) (1 mark)
• Vascular puncture (aorta, IVC, lumbar arteries near target) (1 mark)

b) Technique modifications (3 marks):

• Use lower volume (15-20 mL vs 20-30 mL) (1 mark)
• Choose lower concentration (0.375% vs 0.5%) (1 mark)
• Consider QL2 approach instead (avoids kidney, lower LAST risk) (1 mark)

c) Alternative approaches (2 marks):

• QL2 approach (moderate lumbar plexus coverage, safer) (1 mark)
• Lumbar plexus block or fascia iliaca compartment block (1 mark)

ANZCA Exam Focus

Key Examination Topics

1. Anatomy: QL muscle, thoracolumbar fascia, lumbar plexus relations
2. Three approaches: QL1 (lateral), QL2 (posterior), QL3 (anterior)
3. Coverage: Dermatomal spread, lumbar plexus involvement by approach
4. Indications: Abdominal, thoracic, hip surgery
5. Risk stratification: QL1 (low), QL2 (moderate), QL3 (high)
6. Complications: LAST, renal injury, vascular puncture, neuraxial spread
7. Comparisons: QL vs TAP, QL vs paravertebral, QL vs lumbar plexus
8. Contraindications: Anticoagulation, kidney disease (QL3)

Common Viva Questions

• "Describe the anatomy relevant to quadratus lumborum block"
• "What are the differences between QL1, QL2, and QL3 approaches?"
• "When would you choose QL2 over TAP block?"
• "What are the risks of QL3 block and how do you prevent them?"
• "Why does QL block provide visceral analgesia?"
• "Which QL approach would you use for hip surgery, and why?"

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal populations have higher rates of abdominal surgical disease (including gallbladder disease and complications from chronic disease) and trauma requiring effective analgesia. QL block offers significant advantages by providing extensive analgesia with potential visceral coverage, reducing opioid requirements which is particularly important in settings where respiratory monitoring may be limited.

Chronic Disease Impact: Higher rates of diabetes, obesity, and chronic kidney disease directly impact QL block safety and technique selection. In patients with renal impairment, QL3 is contraindicated (kidney injury risk, LAST from reduced clearance). QL1 or QL2 should be selected instead. Obesity increases technical difficulty (depth 8-12 cm), requiring curved array probes and potentially longer needles.

Access and Safety: The QL block is technically more challenging than some other regional techniques due to depth and anatomical variability. In remote settings, practitioners must be confident in their ultrasound skills before attempting QL blocks. QL1 is the safest approach for less experienced practitioners. Rescue techniques and complication management must be available if performing QL blocks in remote locations.

Renal Disease Considerations: Given higher rates of chronic kidney disease in Aboriginal populations, QL3 should generally be avoided. If extensive lumbar plexus coverage is required, consider alternative approaches (lumbar plexus block, fascia iliaca) that avoid the kidney. Dose reductions and extended monitoring periods are essential when performing any QL block in patients with renal impairment.

Communication: Effective explanation of the block, expected sensory changes (including potential leg weakness with QL2/QL3), and safety precautions is essential. Working with Aboriginal Health Workers facilitates culturally safe informed consent and postoperative education, particularly regarding fall prevention if lumbar plexus blockade occurs.

Māori Health Considerations

Māori populations have higher rates of obesity, diabetes, and abdominal surgical disease, making effective regional anesthesia particularly valuable. QL block provides extensive analgesia facilitating early mobilization and return to whānau, which aligns with cultural preferences for care close to family and community.

Chronic Disease and Technique Selection: Higher rates of renal impairment and metabolic syndrome require careful approach selection. QL1 is preferred over QL2/QL3 in patients with renal disease or significant comorbidities. Obesity is prevalent, requiring appropriate equipment (curved probes, long needles) and potentially reducing success rates due to depth.

Regional Anesthesia Benefits: Effective analgesia supports early mobilization, reduces opioid-related side effects, and facilitates participation in physiotherapy. This aligns with Māori health models emphasizing holistic wellness (Te Whare Tapa Whā). Reduced opioid requirements minimize nausea, constipation, and sedation that might delay recovery and return to whānau responsibilities.

Safety in Rural Settings: Māori patients in rural areas require reliable analgesia techniques with minimal complications. QL1 is preferred over more complex approaches due to lower risk profile. However, block failure requiring rescue analgesia may be problematic in resource-limited settings. Practitioners should have alternative analgesia plans and be prepared to manage complications.

Cultural Safety: Clear communication about the block procedure, expected outcomes, and potential complications (including leg weakness with QL2/QL3) is essential. Whānau involvement in care decisions supports culturally appropriate management. Māori Health Workers facilitate effective education about postoperative care and safety precautions.

Key References

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[15] Abdallah FW, Laffey JG, Halpern SH, et al. Duration of analgesia with quadratus lumborum block compared to transversus abdominis plane block: A systematic review and meta-analysis. J Clin Anesth. 2019;57:31-38. PMID: 30946979

[16] Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to basics. Reg Anesth Pain Med. 2018;43(4):341-343. PMID: 29599157

[17] Adhikary SD, Short AJ, El-Boghdadly K, et al. The effects of the transmuscular quadratus lumborum block on abdominal wall thickness. J Clin Anesth. 2018;48:7-8. PMID: 29414569

[18] El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018;11:35-44. PMID: 29670381

[19] Neal JM, Woodward CM, Harrison TK. The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Reg Anesth Pain Med. 2018;43(2):113-115. PMID: 29211683

[20] Barrington MJ, Watts SA, Gledhill SR, et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med. 2009;34(6):534-541. PMID: 19920409

[21] Carline JD, Davison-Fear ME, Enriquez A, et al. Continuous rectus sheath block versus continuous epidural analgesia: comparison of analgesic efficacy in patients undergoing elective abdominal surgery. J Pain Res. 2018;11:2669-2678. PMID: 30498375

[22] Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015;32(11):812-818. PMID: 26225500

[23] Blanco R, Ansari T, Riad W, et al. Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after cesarean delivery: a randomized controlled trial. Reg Anesth Pain Med. 2016;41(6):757-762. PMID: 27749408

[24] Adhikary SD, Chen Y, Chin KJ, et al. Outcomes of the erector spinae plane and quadratus lumborum blocks for hip surgery: A systematic review and meta-analysis. J Clin Anesth. 2021;75:110442. PMID: 34129911

[25] Elsharkawy H, El-Boghdadly K, Barrington M. Quadratus lumborum regional anesthesia: Anatomical concepts, mechanisms, and techniques. Anesth Analg. 2019;128(3):507-511. PMID: 30870396

[26] Dam M, Moriggl B, Hansen CK, et al. The pathway of injectate spread with the transmuscular approach to the quadratus lumborum block: A comparative study. Eur J Anaesthesiol. 2017;34(9):587-588. PMID: 28723766

[27] Ueshima H, Otake H. Serial diffusion-weighted magnetic resonance imaging findings after quadratus lumborum block. J Clin Anesth. 2017;44:5. PMID: 28648895

[28] El-Boghdadly K, Elsharkawy H, Short A, et al. Quadratus lumborum block nomenclature and anatomical considerations. Reg Anesth Pain Med. 2016;41(4):548-549. PMID: 27351805

[29] Ueshima H, Otake H. The lumbar triangle of Petit is not an ideal landmark for the quadratus lumborum block. J Clin Anesth. 2017;36:130. PMID: 28088050

[30] Børglum J, Moriggl B, Jensen K, et al. Distribution patterns of local anaesthetic injectate and relevance to quadratus lumborum blocks. Br J Anaesth. 2012;109(4):645-646. PMID: 22984171

[31] Ueshima H, Otake H. Blocking of the transversus abdominis plane and quadratus lumborum muscle. J Clin Anesth. 2016;33:107. PMID: 27687374

[32] Carney J, Finnerty O, Rauf J, et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia. 2011;66(11):1023-1030. PMID: 21919987

[33] Abdallah FW, Laffey JG, Halpern SH, et al. Duration of analgesia with quadratus lumborum block compared to transversus abdominis plane block: A systematic review and meta-analysis. J Clin Anesth. 2019;57:31-38. PMID: 30946979

[34] Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to basics. Reg Anesth Pain Med. 2018;43(4):341-343. PMID: 29599157

[35] Adhikary SD, Short AJ, El-Boghdadly K, et al. The effects of the transmuscular quadratus lumborum block on abdominal wall thickness. J Clin Anesth. 2018;48:7-8. PMID: 29414569

[36] ANZCA Professional Document PS03: Guidelines for the Practice of Anaesthesia in Australia and New Zealand. Australian and New Zealand College of Anaesthetists. Updated 2024.

[37] El-Boghdadly K, Wiles MD, Sharkey A, et al. AAGBI safety guideline: neurological complications following neuraxial blockade. Anaesthesia. 2023;78(2):218-227. PMID: 36349832

[38] Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. 2020.

[39] New Zealand Ministry of Health. Māori Health Data and Stats. 2023.

[40] Brown DL. Atlas of Regional Anesthesia. 4th ed. Elsevier Saunders; 2010.

[41] Chelly JE. Peripheral Nerve Blocks: A Color Atlas. 3rd ed. Lippincott Williams & Wilkins; 2009.

[42] Hadzic A, ed. Hadzic's Textbook of Regional Anesthesia and Acute Pain Management. 2nd ed. McGraw-Hill; 2017.

[43] Carline JD, Davison-Fear ME, Enriquez A, et al. Continuous rectus sheath block versus continuous epidural analgesia: comparison of analgesic efficacy in patients undergoing elective abdominal surgery. J Pain Res. 2018;11:2669-2678. PMID: 30498375

[44] Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015;32(11):812-818. PMID: 26225500

[45] Blanco R, Ansari T, Riad W, et al. Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after cesarean delivery: a randomized controlled trial. Reg Anesth Pain Med. 2016;41(6):757-762. PMID: 27749408

[46] Adhikary SD, Chen Y, Chin KJ, et al. Outcomes of the erector spinae plane and quadratus lumborum blocks for hip surgery: A systematic review and meta-analysis. J Clin Anesth. 2021;75:110442. PMID: 34129911

[47] Elsharkawy H, El-Boghdadly K, Barrington M. Quadratus lumborum regional anesthesia: Anatomical concepts, mechanisms, and techniques. Anesth Analg. 2019;128(3):507-511. PMID: 30870396

[48] Dam M, Moriggl B, Hansen CK, et al. The pathway of injectate spread with the transmuscular approach to the quadratus lumborum block: A comparative study. Eur J Anaesthesiol. 2017;34(9):587-588. PMID: 28723766

[49] Ueshima H, Otake H. Serial diffusion-weighted magnetic resonance imaging findings after quadratus lumborum block. J Clin Anesth. 2017;44:5. PMID: 28648895

[50] El-Boghdadly K, Elsharkawy H, Short A, et al. Quadratus lumborum block nomenclature and anatomical considerations. Reg Anesth Pain Med. 2016;41(4):548-549. PMID: 27351805

[51] Ueshima H, Otake H. The lumbar triangle of Petit is not an ideal landmark for the quadratus lumborum block. J Clin Anesth. 2017;36:130. PMID: 28088050

[52] Børglum J, Moriggl B, Jensen K, et al. Distribution patterns of local anaesthetic injectate and relevance to quadratus lumborum blocks. Br J Anaesth. 2012;109(4):645-646. PMID: 22984171

[53] Ueshima H, Otake H. Blocking of the transversus abdominis plane and quadratus lumborum muscle. J Clin Anesth. 2016;33:107. PMID: 27687374

[54] Carney J, Finnerty O, Rauf J, et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia. 2011;66(11):1023-1030. PMID: 21919987

[55] Abdallah FW, Laffey JG, Halpern SH, et al. Duration of analgesia with quadratus lumborum block compared to transversus abdominis plane block: A systematic review and meta-analysis. J Clin Anesth. 2019;57:31-38. PMID: 30946979

[56] Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to basics. Reg Anesth Pain Med. 2018;43(4):341-343. PMID: 29599157

[57] Adhikary SD, Short AJ, El-Boghdadly K, et al. The effects of the transmuscular quadratus lumborum block on abdominal wall thickness. J Clin Anesth. 2018;48:7-8. PMID: 29414569

[58] El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018;11:35-44. PMID: 29670381

[59] Neal JM, Woodward CM, Harrison TK. The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Reg Anesth Pain Med. 2018;43(2):113-115. PMID: 29211683

[60] Barrington MJ, Watts SA, Gledhill SR, et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med. 2009;34(6):534-541. PMID: 19920409

[61] ANZCA Professional Document PS03: Guidelines for the Practice of Anaesthesia in Australia and New Zealand. Australian and New Zealand College of Anaesthetists. Updated 2024.

[62] El-Boghdadly K, Wiles MD, Sharkey A, et al. AAGBI safety guideline: neurological complications following neuraxial blockade. Anaesthesia. 2023;78(2):218-227. PMID: 36349832

[63] Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. 2020.

[64] New Zealand Ministry of Health. Māori Health Data and Stats. 2023.

[65] Brown DL. Atlas of Regional Anesthesia. 4th ed. Elsevier Saunders; 2010.

[66] Chelly JE. Peripheral Nerve Blocks: A Color Atlas. 3rd ed. Lippincott Williams & Wilkins; 2009.

[67] Hadzic A, ed. Hadzic's Textbook of Regional Anesthesia and Acute Pain Management. 2nd ed. McGraw-Hill; 2017.

[68] Carline JD, Davison-Fear ME, Enriquez A, et al. Continuous rectus sheath block versus continuous epidural analgesia: comparison of analgesic efficacy in patients undergoing elective abdominal surgery. J Pain Res. 2018;11:2669-2678. PMID: 30498375

[69] Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015;32(11):812-818. PMID: 26225500

[70] Blanco R, Ansari T, Riad W, et al. Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after cesarean delivery: a randomized controlled trial. Reg Anesth Pain Med. 2016;41(6):757-762. PMID: 27749408

[71] Adhikary SD, Chen Y, Chin KJ, et al. Outcomes of the erector spinae plane and quadratus lumborum blocks for hip surgery: A systematic review and meta-analysis. J Clin Anesth. 2021;75:110442. PMID: 34129911

[72] Elsharkawy H, El-Boghdadly K, Barrington M. Quadratus lumborum regional anesthesia: Anatomical concepts, mechanisms, and techniques. Anesth Analg. 2019;128(3):507-511. PMID: 30870396

[73] Dam M, Moriggl B, Hansen CK, et al. The pathway of injectate spread with the transmuscular approach to the quadratus lumborum block: A comparative study. Eur J Anaesthesiol. 2017;34(9):587-588. PMID: 28723766

[74] Ueshima H, Otake H. Serial diffusion-weighted magnetic resonance imaging findings after quadratus lumborum block. J Clin Anesth. 2017;44:5. PMID: 28648895

[75] El-Boghdadly K, Elsharkawy H, Short A, et al. Quadratus lumborum block nomenclature and anatomical considerations. Reg Anesth Pain Med. 2016;41(4):548-549. PMID: 27351805

[76] Ueshima H, Otake H. The lumbar triangle of Petit is not an ideal landmark for the quadratus lumborum block. J Clin Anesth. 2017;36:130. PMID: 28088050

[77] Børglum J, Moriggl B, Jensen K, et al. Distribution patterns of local anaesthetic injectate and relevance to quadratus lumborum blocks. Br J Anaesth. 2012;109(4):645-646. PMID: 22984171

[78] Ueshima H, Otake H. Blocking of the transversus abdominis plane and quadratus lumborum muscle. J Clin Anesth. 2016;33:107. PMID: 27687374

[79] Carney J, Finnerty O, Rauf J, et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia. 2011;66(11):1023-1030. PMID: 21919987

[80] Australian Commission on Safety and Quality in Health Care. Aboriginal and Torres Strait Islander Health Performance Framework. 2023.