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“The Science Behind the Art” 
Volume 10 - No.3 2022 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 9

Comparison of Quadratus Lumborum Block and Transversus Abdominis Plane Block for 
Postoperative Pain Management 
Kristina Alexis Whitely, BSN, RN, CCRN

Affiliation:
Texas Christian University 

Grant/Financial Support: 
None 

KEYWORDS: Regional anesthesia, abdominal, quadratus lumborum block, transversus abdominis plane block, interfascial plane 
block

Abstract
Enhanced recovery after surgery (ERAS) protocols for open abdominal cases suggest preoperative epidural, wound 
catheter, or transversus abdominis plane (TAP) block placement can be effective for postoperative pain management.1 
This case-based poster presents a middle-aged woman who undergoes a pancreatoduodenectomy (PD) and receives a 
postoperative fascial plane block, a quadratus lumborum (QL) block, rather than the currently recommended TAP block, 
wound infiltration, or neuraxial anesthesia. Based on quality evidence regarding the benefits of the QL block, expanding 
ERAS protocols to regional anesthesia beyond wound infiltration and TAP blocks has the potential to produce increased 
pain management postoperatively, aiding in enhanced recovery and improved outcomes.

AEJ
Volume 10- No. 3 2022

About the Author: Kristina “Alexis” Whiteley is a doctoral student at Texas Christian University School of Nurse 
Anesthesia, Class of 2022. She has an ADN from Victoria, Texas, 2016, as well as a BSN from University of Texas at 
Arlington, 2018. Alexis has worked in the MICU/SICU and CVICU in Arlington, Texas. The author currently lives in 
the Fort Worth area with primary residency at John Peter Smith ( JPS) Level 1 trauma center, Fort Worth, Texas.



Texas Christian University 
“The Science Behind the Art” 
Volume 10 - No.3 2022 

Anesthesia eJournal - Online
ISSN 2333-2611 

Page 10

P o w e rP o in t  T e m p la te  © 2 0 0 9  T e x a s  C h r is t ia n  U n iv e rs it y ,  C e n te r  fo r  In s t ru c t io n a l S e rv ic e s .  F o r  E d u c a t io n a l U s e  O n ly .  C o n te n t  is th e  p ro p e r ty  o f  th e  p re s e n te r  a n d  th e ir  r e s o u rc e s .

Figure 1. Cross Section of TLF and Muscles Viewed 
During US for QL Block6

Figure 2. Demonstration of Posterior, QL2 block. LA Injected 
Posterior to QL and Adjacent to/or within the LIFT6

Figure 3. Demonstration of Anterior, QL3 block. LA Injected 
Between QL and Psoas Major Muscles6

Figure 4. 
Cross Section 
of Antero-
lateral Muscles, 
Myofascial 
Planes, and 
Surrounding 
Tissues for TAP 
Block6

Introduction

• Enhanced recovery after surgery (ERAS) guidelines
for pancreatoduodenectomy surgery suggests preop
epidural, wound infiltration (WI), or transversus
abdominis plane (TAP) block for postop pain
management1

• Although TAP block reduces overall opioid
consumption and enhances rapid recovery when
compared with neuraxial anesthesia,2 TAP blocks
only provide somatic analgesia

• Quadratus Lumborum (QL) blocks are an alternative
fascial plane block, aside from TAP block, that
provides substantially increased analgesia spread

• QL block spread shown to aid in visceral and somatic
analgesia due to injected local anesthetic (LA) 
spreading to thoracolumbar fascia (TLF), targeting 
sympathetic fibers and paravertebral space3

Transversus Abdominis Plane Block

• TAP approaches: subcostal, lateral, anterior & posterior
• Blocks ventral rami of spinal nerves T7-T10 located in

plane between internal oblique muscle (IOM) and
transversus abdominis muscle (TAM)6

• Blocks anterolateral skin, muscles, and parietal peritoneal
sensory nerve fibers of abdominal wall4

• No inhibitory effect on visceral pain, only somatic
• Complications researched include abdominal organ injury,

nerve injury, vascular injury4

• Compared to the gold standard epidural, TAP blocks result
in significantly less opioid consumption, postop pain, and
incidences of hypotension, with no difference in opioid
consumption at 72 hrs2

• When compared to QL blocks, TAP blocks are shown to
have increase patient pain scores, opioid
consumption, and number of patients requiring
analgesia postoperatively3

Quadratus Lumborum Block vs. Transversus Abdominis Plane Block
Kristina “Alexis” Whiteley, BSN, RN, Texas Christian University

Case Summary

Pre-Anesthetic Evaluation
• 58-year-old disabled female, NKDA, ASA 2, BMI 31.2
• History of pancreatic head mass & obstructive

jaundice status post biliary stent
• Medical history: anxiety & GERD
• Surgical history: EGD & ERCP
• Home medications: pantoprazole 40 mg PO q

morning
• Preoperative medications: acetaminophen 650 mg

PO, celecoxib 200 mg PO, gabapentin 300 mg PO,
transdermal scopolamine  & midazolam 2 mg IV

Intraoperative Course
• General anesthesia induction: RSI with IV ketamine

50 mg, lidocaine 100 mg, & propofol 150 mg; muscle
relaxation via succinylcholine 120 mg

• Antibiotics & adjuncts: cefepime 2 g, dexamethasone
8 mg, magnesium sulfate 2 g bolus, lidocaine drip
2000 mg/500 mL at 2 mg/min

• Maintenance: isoflurane, rocuronium titrated to
twitches, 1 PRBC & 2 PLT received

• Opioids & pain adjuncts: fentanyl 200 mcg,
hydromorphone 2 mg, ketamine 10 mg/hr for a total
of 50 mg

Postoperative Course
• Postoperative QL block: Ultrasound (US) guided, QL2

technique with 25 mL 0.25% bupivacaine bilaterally
• Awake extubation, patient transferred to PACU

comfortably post-extubation, with 8 L/min oxygen via
simple facemask

• 24-hr follow-up: 4/10 pain at rest, 5/10 pain during
movement & patient verbalizes pain ”relatively well
controlled”

References

1.Melloul E, Lassen K, Roulin D, et al. Guidelines for perioperative care for 
pancreatoduodenectomy: Enhanced recovery after surgery (ERAS) recommendations.
2019. World J of Surg. 2020;44:2056-2084.

2.Desai N, El-Boghdadly K, Albrecht E. Epidural vs transversus abdominis plane block for
abdominal surgery: a systematic review, meta-analysis and trial sequential analysis.
Anaesthesia. 2021;76(1):101-117.

3. Liu X, Song T, Chen X, et al. Quadratus lumborum block versus transversus abdominis plane
block for postoperative analgesia in patients undergoing abdominal surgeries: a systematic
review and meta-analysis of randomized controlled trials. BMC Anesthesiology. 2020;20:53-
53.

4.Wang Y, Wang X, Zhang K. Effects of transversus abdominis plane block versus quadratus
lumborum block on postoperative analgesia: a meta-analysis of randomized controlled
trials. BMC Anesthesiology. 2020;20:103. https://doi.org/10.1186/s12871-020-01000-2

5.Akerman M, Pejcic N, Velickovic I. A review of the quadratus lumborum block and
ERAS. Frontiers in Medicine. 2018;5:44. doi: 10.3389/fmed.2018.00044

6.Block Buddy Pro. Version 1.0.7. Newbury, OH: Block Buddy, LLC; 2019.

Quadratus Lumborum Block

• QL approaches: QLB 1, QLB 2, QLB 3
• Blocks dorsal rami—somatic analgesia to skin &

muscles of posterior abdominal wall6

• Blocks ventral rami—somatic analgesia to skin &
muscles of anterolateral abdominal wall6

• Blocks sympathetic trunk within TLF—visceral
analgesia of the abdomen6

• LA spread within TLF potentially reaches
paravertebral space, generating indirect
paravertebral block3

• Needle passage is further from abdominal organs,
great vessels, and peritoneal cavity4

• Fascial plane blocks require volume for adequate
spread; current practice suggests a max LA dose
of 2.5 mg/kg5

Discussion
• A systemic review (SR) & meta-analysis of 22

RCTs comparing postop analgesia of TAP & QL
blocks showed a statistical decrease in opioid
consumption, visual analogue scale (VAS) scores
at 24 hrs postop, number of patients requiring
postop analgesia within QL group

• In lieu of current ERAS guidelines, QL blocks
tout clinical superiority in postoperative
analgesia when compared to TAP blocks

Case Critique
• After 6-hour, open abdominal case, outcomes

demonstrated stark similarities to current
literature over QL efficacy

• ERAS guidelines for PD procedure were
followed, with alternative interfascial plane
block—QL block—used instead of WI, TAP block,
or epidural

• Patient was ambulating the day after surgery,
with well managed pain of 4/10 at rest and 5/10
upon activity

Conclusions & Recommendations
• Regional anesthesia, specifically truncal blocks, are 

a major component of multimodal pain 
management for enhanced postoperative recovery

• QL blocks have proven clinically superior to TAP 
blocks for multiple major surgeries involving 
anterior & lateral abdominal wall3,4

• Based on quality evidence, ERAS protocols for PD 
and other open abdominal cases should be 
expanded to QL blocks for postoperative analgesic 
management

Recommendations for Research
• Larger RCTs with ASA I-IV, as well as BMIs > 30 

kg/m2 should be considered for increased 
generalizability of data

• Evaluation of LA diffusion via the TLF & adjacent 
structures to validate mechanism of action

Figure 5. 
Demonstration 
of TAP Block via 
Anterolateral 
Approach. LA is 
Injected 
Between IOM 
and TAM6




