# Quadratus Lumorum post operative pain block



## bam0913 (May 3, 2016)

Has anyone ever coded a Quadratus Lumborum post operative pain block?   According to our provider it is a Fascia plane block of the abdominal wall similar in complexity/coverage to a TAP block.  I am not sure if we use the TAP block codes or 64450.  We have only seen single injections so far, no continuous catheters.  

Thank you in advance for any insight anyone has on this! 
Beth


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## dwaldman (May 7, 2016)

Looking at different information regarding this block on the internet it seems like it is separate technique from the TAP block so I believe you might have to stick with CPT 64450. But another forum member might have more information regarding coding for this procedure.
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The Quadratus Lumborum block (QLB) was first described by Blanco in 2007. The main advantage of QLB compared to the Transversus Abdominis Plane block (TAP) is the extension of local anesthetic agent beyond the TAP plane to the thoracic paravertebral space. The wider spread of the local anesthetic agents may produce extensive analgesia and prolonged action of the injected local anesthetic solution.

Previous studies showed that both TAP block and QLB may reduce morphine requirements in the postoperative period in patients who had cesarean section under spinal anaesthesia. However there are no published reports comparing the 2 techniques.

The aim of this randomised controlled, double blinded study is to compare the analgesic efficacy of QLB compared to TAP block in patients who had cesarean section under spinal anesthesia.

Full Title of Study: “Quadratus Lumborum Block vs Tranversus Abdominis Plane Block for Post Cesarean Section Analgesia. A Randomised Controlled Study”


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.9. USG Quadratus Lumborum (QL) block – the “new kid on the block”

As we are approaching the end of the description of the various USG truncal blocks we would like to introduce the reader to the “new kid on the block”. The so-called Blanco block (as it is known by some anaesthetists in the United Kingdom) is an USG block administered to the quadratus lumborum space first described by Professor R. Blanco in May 2007 during his presentation at ESRA 2007 at the XXVI Annual ESRA Congress in Valencia, Spain. Professor Blanco describes a potential space posterior to the abdominal wall muscles and lateral to the quadratus lumborum muscle. Thus, this new block has also been called the Quadratus lumborum (QL) block. It has been used in abdominoplasties, caesarean sections and lower abdominal operations since 2006 providing complete pain relief in the distribution area from Th6 to L1 dermatomes. Apparently, in operations with peritoneal involvement the morphine consumption was significantly reduced to less than 30% of the control groups. It is hard however, to find any solid scientific evidence to support these findings in the literature, and much of the knowledge of the QL block relies regrettably to this day on personal communication, which is certainly not the best of documentation. Much research effort at many centres is currently directed towards the description and qualification of this new block, and we have found it highly relevant to include the block in this chapter, since the block holds some very positive potential benefits. If may well be seen as a lumbar approach to the TPVS. The block apparently produces distribution of the local anaesthetic extending proximally and over both sides of the surface of the QL muscle, in between the anterior and intermediate layers of the thoracolumbar fascias. It also pushes the fascia transversalis and the perinephric fat towards the peritoneum without the risk of intrabdominal puncture. The block does not rely on the feeling of any pops or fascial clicks because depending of the angle of the needle several pops can be felt without reaching the target zone, which is lateral to the quadratus lumborum muscle. Actually, the block has never been intended to be conducted without the use of US guidance, and the block is thus a purely USG block. In an absolutely brilliant paper by Carney et al. the block is compared to other TAP block techniques using volunteers rather than patients (Carney 2011). Dr. Carney found that there was a non-contiguous paravertebral, epidural and lymphatic contrast enhancement Th5-Th10 in one subject, and similarly contrast at Th6-Th10 in two other subjects (Carney 2011). Carney et al. concluded that the posterior USG approach (as they have named the QL block in their recent publication) produced a more extensive, predictable and posterior spread of contrast, similar to that seen with their own landmark-based and blind approach at the triangle of Petit. The contrast extended postero-medially to the paravertebral region from the 5th thoracic vertebral level rostrally, to the first lumbar vertebral level caudally, indicating that this US guidance approach is the optimal site for injection to reproduce the analgesia of the blind landmark TAP block favoured by Dr. McDonnell and Dr. Carney. Fig. 7 depicts one method to administer the USG guided QL block as we have found it most easy to perform in our daily clinical practise (Jensen 2012). Again, the patient rests in a supine position. We have found it easier to conduct the block using a low frequency transducer (2-6 MHz) as compared to a linear transducer. The low frequency transducer is placed on the lateral abdomen above the iliac crest and below the thoracic cage. The transducer is then gradually aligned in a more posterior and lateral direction parallel to the inter-crista line. It is always possible to observe, that the TA muscle becomes aponeurotic, and this aponeurosis is followed until the QL muscle is clearly visualized. Thus, it is indeed possible to visualize the QL muscle lateral and posterior to the abdominal wall muscles. It is also clearly possible to visualize the thoracolumbar fascia at the lateral edge of the QL muscle. We have set this to be the point of injection of local anaesthetic. Following the injection we could observe the local anaesthetic spread along the ventral side of the QL muscle. Apparently this block results in a block that is longer lasting and more extensive than what we have previously observed with the BD-TAP block, but it remains to be further elucidated in RCT trials.


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