A Comparative Study Between Two Approaches of Ultrasound-Guided Transmuscular Quadratus Lumborum Block on Post-Operative Analgesia After Total Hip Arthroplasty
Phase: NA
Conditions: Quadratus Lumborum Block
Sponsor: Tanta University

A Comparative Study between two approaches of 
ultrasound‑guided transmuscular quadratus 
lumborum block on post‑operative analgesia after  
total hip arthroplasty. 
 
 
 
 
DOCUMENT DATE (DATE OF APPROVAL OF TANTA ETHICAL 
COMMITTEE)  (34800/7/21)   on 25/07/2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
                                            Introduction 
The demand for total hip arthroplasty (THA) continues to increase, 
with the obvious goals of improving physical function. However, THA is 
associated with significant post-operative pain, which remains a serious 
concern for patients (1, 2). Further, post-operative ambulation may be 
delayed by poorly treated post-operative pain, increasing the risk of 
pulmonary complications and venous thrombosis(3). 
Effective postoperative pain management can improve patient comfort, 
increase patient satisfaction, promote earlier mobilization and ensure early 
participation in rehabilitation. Otherwise, patients may suffer chronic pain 
and disability, with a poor quality of life(4).  
 Multimodal 
analgesia 
including 
opioids, 
nonsteroidal 
anti-
inflammatory drugs, patient-controlled analgesia, and regional anesthesia (5, 
6) have been shown to reduce pain and opioid consumption after THA (7). 
Regional anesthetic techniques provides dense analgesia, decrease opioid 
related side effects (nausea, vomiting, sedation, itching, urinary retention, 
respiratory depression) by decreasing reliance on opioid medications and 
decrease pain scores compared with systemic analgesia alone (8, 9). 
Quadratus lumborum block (QLB) is a fascial plane block where local 
anesthetic is injected into the fascial plane around the quadratus lumborum 
muscle(10). QLB was initially reported for postoperative pain control by 
Blanco in 2007 (11).It initially described as an analgesic modality for 

abdominal surgery. Depending on the needle tip positioning in relation to 
quadratus lumborum muscle and local anesthetic (LA) injection location, 
there are several QLB variations using anterior (transmuscular), lateral 
(QL1), and posterior QL (QL2) approaches (12). 
Transmuscular (anterior) QL block involves injection in the plane 
between the psoas major (PM) and the QL muscles. Cadaveric studies have 
reported spread of the injectate to the somatic nerves in the thoracic 
paravertebral space, as well as the spinal nerve which runs anterior to the QL 
muscle(13-15).  
Previous studies have shown that QL1 and QL2 blocks may generate 
analgesia from T7 to L1,and the transmuscular block( QL3) may cause caudal 
spread to the L2–L3 dermatomes (16). Thus, the QL3 approach may be more 
suitable for hip surgery than the other approaches. (17, 18). Recent evidence 
of the anterior QL block performed at the L3–L4 level in cadavers has shown 
spread to branches of the lumbar plexus(19, 20), which may account for the 
analgesia observed after hip surgery(16, 21).  
Paraspinous Sagittal Shift QL block is a modification of the anterior 
QL block, done at L4 transverse process level in a sagittal orientation, 
involving a craniocaudal approach of LA injection between the QL and PM 
muscles just after piercing QL fascia. This may allow LA spread behind the 
anterior thoracolumbar fascia (ATLF) at the level of L4. This approach may 
achieve better caudal spread to the nerves covered with the fascia iliaca, with 
a potential for medial spread to the ventral rami of L2 and L3, in addition to 
a possibility of blocking the nerves passing anterior to the QL muscle, 
including subcostal, ilioinguinal and iliohypogastric nerves (22). 
 
 
 
 

 
 
 
 
 
 
Aim of work 
 
The aim of this study is to compare between the post-operative analgesic 
effect of two approaches of transmuscular quadratus lumborum block 
(transverse versus paraspinous sagittal transmuscular QLB) in total hip 
replacement surgery. 
The primary outcome of this study is the postoperative morphine 
consumption. Secondary outcome will be the postoperative pain score 
which will be assessed by visual analogue scale (VAS). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
Patients and methods   
 
This prospective, randomized, controlled double blind study will be 
carried out at Tanta University Hospital on 75 patients scheduled for total 
hip replacement surgery for a period of one year from September 2021 to 
August 2022 after approval of institutional ethical committee, and 
obtaining written informed consent from each patient. 
All data of patients will be confidential with secret codes and private 
file for each patient. All given data will be used for the current medical 
research only. Any unexpected risks appeared during the course of the 
research will be cleared to the participants and ethical committee on time 
and managed. 
*NOTE (The study Protocol was approved from Tanta ethical 
committee  with approval number (34800/7/21)   on 25/07/2021. 
Every patient will receive an explanation to the purpose of the study 
and have secret code number to ensure privacy to participants and 
confidentiality of data, an informed written consent will be taken from all 
patients. 
  
Inclusion criteria: 
75 patients, aged between 21- 80 years old, of both sex ASA I - III 
scheduled for total hip replacement surgery. 
Exclusion criteria: 
• Patient refusal . 

• Coagulopathy  
• Spinal deformities 
• Peripheral neuropathy; sensory disorders in the leg requiring 
surgery and chronic pain. 
• Mental 
dysfunction, 
psychiatric 
illnesses 
and 
cognitive 
dysfunction. 
• History of drug abuse &chronic analgesic use 
• History of allergy to local anesthetic.  
•  Local skin infection at the site of block. 
• Body Mass Index >40Kg/m2. 
• Patients with severe cardiac disease, liver disease or renal 
dysfunction.  
Preoperative preparation: 
Preoperative assessment will be done by: 
          History 
taking, 
clinical 
examination, 
routine 
laboratory 
investigations including: CBC, coagulation profile, random blood sugar, 
renal function test. 
During the preanesthetic assessment, all patients will be educated 
about the visual analogue scale (VAS) for pain assessment, with scores 
ranging from 0 to 10 (0 represent no pain, while10 represent maximum 
intolerable pain). 
The patients will be randomly classified into three equal groups (25 
patients each). Group allocation will be done by computer generated 
random numbers and closed opaque sealed envelopes. The study will be 
designed to be double blind as all patients and postoperative assessor will 
be blinded to group assignment. 

 
 Patients will be randomized to one of three equal groups: 
o Group I: Control group (n= 25 patients): Patients in this group 
will receive ipsilateral sham ultrasound-guided block via 
subcutaneous injection of 1 ml of normal saline after surgery.  
o Group II (n= 25 patients): Patients in this group will receive 
an ipsilateral single shot of transverse transmuscular approach 
of QLB (30 ml of plain bupivacaine 0.25%) after surgery 
using ultrasonographic guidance. 
o Group III (n= 25 patients): patients in this group will receive 
an ipsilateral single-shot of paraspinous sagittal approach of 
QLB (30 ml of plain bupivacaine 0.25%) after surgery using 
ultrasonographic guidance. 
Intraoperative: 
On arrival of the patient to operating room, an intravenous access 
will be established with intravenous cannula and starting routine 
monitoring (pulse oximetry, electrocardiogram and noninvasive blood 
pressure). 
Spinal anesthesia will be the anesthetic choice in sitting position and 
under complete aseptic conditions. Local anesthetic skin infiltration with 3 
ml lidocaine 1% at intervertebral space will be done then spinal anaesthesia 
will be performed using a 25-gauge spinal needle. Once intrathecal 
placement will be confirmed, a mixture of 2.5 ml of hyperbaric bupivacaine 
(12.5 mg) and 0.5 ml of fentanyl (25 µg) will be injected. Moreover, 
sensory and motor blockade will be assessed. Oxygen will be provided to 
the patient through a nasal canula at a flow rate of 3 L/min. 
Block description: 

Technique of transverse transmuscular quadratous lumborum 
block(23): 
At the end of the surgery, with the patient in a lateral decubitus 
position and under antiseptic precautions, the block area will be sterilized 
with povidone-iodine, a curvilinear ultrasound transducer (2–5 MHz) will 
be placed transverse to the abdominal flank in the anterior axillary line 
above the iliac crest to clearly visualise the three abdominal muscle layers. 
Then, the probe will be moved posteriorly with the external oblique and 
the internal oblique muscles disappearing into aponeurosis and the 
latissimus dorsi appearing with the QL muscle beneath. By moving the 
probe farther posteriorly, the transverse process of the lumbar vertebra, 
QL, PM and erector spinae muscles identified as a ‘Shamrock sign’. After 
subcutaneous local infiltration with 3 ml lidocaine 1%, the needle will be 
inserted using the in-plane technique from the posterior end of the 
ultrasound probe through the back muscles and then will be advanced 
through the QL muscle (transmuscular approach), targeting the fascial 
plane between the QL and PM muscles The right needle tip position will 
be confirmed by injection of 1-2 ml of normal saline solution that spread 
between the quadratus lumborum and psoas major muscles, then the local 
anaesthetic (30 ml of plain bupivacaine 0.25%) will be injected in the 
Group II( transverse trans muscular QL group). 
Technique of paraspinous sagittal approach of QLB(22):  
With the patient in  lateral decubitus and the block side independent, 
and under antiseptic precautions the block area will be sterilized with 
povidone-iodine, a curvilinear ultrasound transducer (2-5 MHz) will be 
directed caudally in a sagittal plane 3-4 cm lateral to the lumbar spinous 
process of L4, which is almost opposite to the iliac crest, producing a 
longitudinal scan of the lumbar paravertebral region; and thus identifying 

the transverse processes of L3 and L4, with PM muscle in-between and 
erector spinae muscle posteriorly. 
The probe will be shifted slowly to the lateral side until the 
transverse processes disappear and the QL muscle is evident in its long axis 
attached caudally to the iliac crest with a characteristic sonographic image 
of three muscle layers appearing from posterior to anterior as: erector 
spinae, QL, and PM muscles respectively. Here, anterior thoracolumbar 
fascia which is considered as continuation of fascia transversalis is seen 
separating QL and PM muscles. 
After subcutaneous local infiltration with 3 ml lidocaine 1% at the 
cephalic end of the probe, the block needle will be advanced in a cephalo-
caudal direction, through the erector spinae and QL muscles, until it 
pierces the QL. 30 ml of bupivacaine 0.25% will be injected anterior to 
the QL muscle, observing its spread in a caudal direction towards the iliac 
crest between the QL and psoas muscles. 
Technique of sham block: 
Subcutaneous injection of 1 ml sterile normal saline will be 
performed in  the control group at the same area using ultrasound 
transducer pressure that will be intended to simulate a real block 
procedure (24). 
Postoperative: 
           Postoperative pain will be assessed by the VAS (score for the 
severity of pain in the range 0–10, where 0 = no pain and 10 = severe pain) 
at 2,4,6,12,18,24 hours. If the VAS is 4 or more, 3 mg of intravenous 
morphine will be given as a rescue analgesia. All patients will receive 
paracetamol 1g intravenous infusion every 6 h and ketolac 30 mg every 
12h. 
 

Measurements: 
All measurements will be recorded by an investigator who will not be 
aware about the study design or intervention. 
• Demographic data (Age, sex and weight) 
• Postoperative pain will be assessed by VAS (score for the severity 
of pain in the range 0–10, where 0 = no pain and 10 = severe pain) 
at 2,4,6,12,18,24 hours. If the VAS is 4 or more, 3 mg of intravenous 
morphine will be given as a rescue analgesia.  
• Total Morphine consumption in the first 24 h of the post-operative 
period will be recorded. 
• Time of first analgesic request. 
• Incidence of post-operative complications during the first 24 hours 
will be recorded such as nausea and vomiting, bradycardia, 
hypotension, pruritus, manifestations of local anesthetic toxicity 
(cardiac dysrhythmias, convulsions, respiratory depression) will be 
recorded. 
• Patient satisfaction using subjective 5-level scale (1: not satisfied at 
all, 2: only slightly satisfied, 3: partly or somewhat satisfied, 4: fairly 
satisfied, 5: perfectly satisfied). 
After our study measurements will be complete, the study will be 
discontinued. 
Sample size calculation: 
Based upon previous study(23), sample size calculation revealed that at 25 
patients will be required in each group to detect a significant change in the 
postoperative morphine consumption of 2.9 mg at alpha value 0.05 and 
80% power of the study. 
 
 

 
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