Departments of General Anesthesia and Pain Management, Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Mail Code E31, Cleveland, OH, 44195, USA.
Anesthesiology CCLCM of Case Western Reserve University, Cleveland, OH, USA.
Can J Anaesth. 2019 Aug;66(8):894-906. doi: 10.1007/s12630-019-01312-z. Epub 2019 Mar 11.
The local anesthetic injectate spread with fascial plane blocks and corresponding clinical outcomes may vary depending on the site of injection. We developed and evaluated a supra-iliac approach to the anterior quadratus lumborum (QL) block and hypothesized that this single injection might successfully block the lumbar and sacral plexus in cadavers and provide analgesia for patients undergoing hip surgery.
Ultrasound-guided bilateral supra-iliac anterior QL blocks were performed with 30 mL of India ink dye in six fresh adult cadavers. Cadavers were subsequently dissected to determine distribution of the dye. In five patients undergoing hip surgery, a unilateral supra-iliac anterior QL block with 25 mL ropivacaine 0.5% followed by a continuous catheter infusion was performed. Patients were clinically assessed daily for block efficacy.
The cadaveric injections showed consistent dye involvement of the majority of the branches of the lumbar plexus, including the femoral nerve, lateral femoral cutaneous nerve, ilioinguinal nerve, and iliohypogastric nerve. The majority of cadaveric specimens (83%) also exhibited thoracic paravertebral spread of dye to the T10 level. No specimens showed L5 or sacral nerve root staining or caudal spread below L5. All patients had effective analgesia for total hip surgery and a T11-L3 sensory level following the initial bolus of local anesthetic as well as during the period of continuous catheter infusion.
This cadaveric study and case series show that a supra-iliac approach to the anterior QL block involved T10--L3 nerve territories and dermatomal coverage with no sacral plexus spread. This technique may have clinical utility for analgesia in hip surgery.
筋膜平面阻滞时局部麻醉剂的扩散及其相应的临床效果可能因注射部位而异。我们开发并评估了一种经髂嵴上方入路至前锯肌（QL）阻滞的方法，并假设这种单次注射可能成功阻滞腰椎和骶丛，为接受髋关节手术的患者提供镇痛。
在 6 具新鲜成人尸体中，超声引导双侧髂嵴上方前锯肌阻滞，注入 30ml 印度墨水染料。随后对尸体进行解剖，以确定染料的分布。在 5 例行髋关节手术的患者中，进行单侧髂嵴上方前锯肌阻滞，注入 25ml 0.5%罗哌卡因，随后行连续导管输注。患者每天进行临床评估以确定阻滞效果。
尸体注射显示，染料广泛涉及腰丛的大多数分支，包括股神经、股外侧皮神经、髂腹股沟神经和髂腹下神经。大多数尸体标本（83%）还显示出胸椎旁的染料向 T10 水平的扩散。没有标本显示 L5 或骶神经根染色或 L5 以下的尾部扩散。所有患者在接受初始局部麻醉冲击剂量和连续导管输注期间，均对全髋关节手术有效镇痛，且感觉平面达到 T11-L3。
这项尸体研究和病例系列研究表明，经髂嵴上方入路至前锯肌阻滞可涉及 T10-L3 神经区域和皮节覆盖，而无骶丛扩散。这种技术可能对髋关节手术的镇痛具有临床应用价值。
