Access to the PPM Journal and newsletters is FREE for clinicians.
15 Articles in Volume 20, Issue #6
Using Photobiomodulation to Treat Trigeminal Neuralgia
20/20 with Mark Wallace: Where Cannabis Fits into Pain Practice
A Commentary on Opioid Stewardship: Fentanyl, Sufentanil, and Perioperative Pain
Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions
Advanced Practice Matters with Theresa & Jeremy: COVID, Pain, and Power
Analgesics of the Future: Janus Kinase Inhibitors
Case Report: Quadratus Lumborum Block for Managing Pathologic Pain to the Hip
Chronic Pain and the Short-term Effects of Medical Cannabis
Differential Diagnosis: Polymyalgia Rheumatica or Rheumatoid Arthritis
Genicular Nerve Blocks: Field Tips on Prognostic Value and Technical Considerations
Guideline Update: ACR Promotes Pharmacologic Treatment for Osteoarthritis
Navigating New York's Medical Marijuana Program: A Patient Handout
Person-Centered Care: Lessons from the VA’s Whole Health Model
Psychedelics for Chronic Pain: Is It Time?
Resident’s Corner: What Pain Medicine Education is Missing in the COVID Era

Case Report: Quadratus Lumborum Block for Managing Pathologic Pain to the Hip

The relatively simple technique could be a reliable, opioid-sparing analgesic with widespread applications, including to treat severe and chronic hip pain.

A Review of QL Blocks and Techniques

Ultrasound guided fascial plane blocks have an extensive variety of applications in acute perioperative pain management as well as in the chronic pain management setting. The quadratus lumborum (QL) plane block under ultrasound guidance (USG) is a fascial plane block that is garnering increased attention due to its relative ease to perform, reliable analgesic effect, and widespread applications. Since its introduction by Blanco, et al, the QL block has been utilized primarily in abdominal surgeries as an alternative to the transverse abdominis plane (TAP) block.1 More recently, Colla described the QL block as an alternative to femoral nerve and lumbar plexus blocks for postoperative pain control in patients undergoing total hip replacement.2

Three ultrasound guided approaches to the QL plane block have been described, each with a potential for different clinical applications. The three distinct QL blocks are obtained by varying the position of the needle with respect to the QL muscle:

  • lateral (QL1)
  • posterior (QL2)
  • anterior, also referred to as transmuscular (TM QL or QL3)

Several USG techniques have been described for QL blocks. The most promising technique seems to be the shamrock model described by Sauter, et al, which is based on recognizing three muscles around the transverse process (TP) of L4:

  • QL
  • Erector Spinae (ES)
  • Psoas Major (PM)

The L4 transverse process makes up the stem, ES as the posterior leaflet, PM as the anterior leaflet, and the QL as the lateral leaflet. Together these form a “shamrock” sign.3.

At the time of this writing, there is no literature to elucidate the usefulness of the QL block in patients with intractable pathologic pain of the hip or pelvis. Herein, we report a successful case of the TM QL block used as an alternative analgesic technique in a patient with severe pain to the iliac crest secondary to metastases while awaiting radiation therapy. We propose that the QL block can be used as an analgesic technique for patients with severe pathologic pain in the hip or pelvis, as well as a regional technique for certain procedures, such as bone marrow biopsy. The most common site for bone marrow biopsy in adults is the posterior iliac crest, which can be covered by QL3 block.


Case Report

The Patient

A middle-aged male presented with a medical history of metastatic colon cancer status post left hemicolectomy and chemotherapy complicated by recurrent metastases to the lung and bone. He presented to the ED with severe right-sided hip pain despite his home regimen of hydrocodone-acetaminophen 5-325 mg every 8 hours. He reported the pain was a 10 out of 10 in severity, affecting his ability to ambulate and perform activities of daily living. Imaging revealed progression of pulmonary nodules, local recurrence of the tumor, and a new lytic lesion within the right iliac crest (see Figures 1a and 1b).

His pain was managed in the ED with IV pushes of morphine and hydromorphone. Upon transfer to the wards, he was transitioned to morphine patient-controlled-analgesia (PCA), extended-release (ER) morphine, ketorolac, acetaminophen, gabapentin, and amitriptyline. His pain remained refractory to this multimodal pharmacologic approach. 


Figure 1a. Axial and sagittal view of the iliac crest.Figure 1b. A right iliac crest osteolytic lesion depicted.

Treatment with USG QL Block

The following day, the decision was made to bring the patient to the pain clinic for an USG QL fascial plane block. Written informed consent was obtained and standard monitors were applied.

The patient was placed in the left lateral decubitus position. After sterile preparation and with standard aseptic technique, a low-frequency curved US transducer was placed transversely at the L3/L4 level and the three layers of abdominal wall muscles were identified. The transducer was then traced antero-posteriorly until the deep fascia of the transversus abdominis merged with the thoraco-lumbar fascia.

The three QL planes were identified (QL1, QL2, QL3) along with the psoas muscle, latissimus dorsi muscle, and erector spinae muscle. Using the in-plane approach and while maintaining visualization of the shamrock sign, a 21G x 4-inch Stimuplex (Braun) needle was advanced into the fascial plane between QL and psoas muscle (see Figures 2a and 2b). Needle positioning was confirmed by hydro-dissection. After negative aspiration, 20 mL of 0.2% ropivacaine and dexamethasone 8 mg were injected.


Figure 2a. US guided image of TM QL block.Figure 2b. US guided image highlighting the “shamrock” sign.


The procedure resulted in immediate and complete resolution of the patient’s pain. The patient was able to walk from the procedure room to the recovery area without motor weakness or discomfort. He was discharged home the following day with plans to begin radiation therapy. Upon his follow-up visit in clinic, he reported 100% pain relief that lasted for one week and significant relief lasting over two weeks. The procedure was repeated as an outpatient one more time with the goal of improving patient quality of life until radiation therapy was initiated.


Discussion and Related Data

QL Anatomy

The quadratus lumborum muscle originates from the posterior border of the iliac crest and inserts into the medial edge of the twelfth rib and the transverse processes of L2-L5. The QL muscle is surrounded by the thoracolumbar fascia (TLF), which is made up of the anterior, middle, and posterior layers.  The layers of the TLF extend to the aponeurosis of the transversus abdominis and internal oblique muscles. The posterior layer of the TLF surrounds the ES, the middle layer divides the QL and ES muscles, and the anterior layer is anterior to the QL muscle.

The transversalis fascia (TF) encapsulates the transversus abdominis, QL, and PM muscles. The TF is continuous with the endothoracic fascia and possibly allows for the spread of local anesthetic from the fascia between the QL and PM muscles (TM QL) to the thoracic paravertebral space. Karmakar et al, postulated that the QL block might act as an indirect paravertebral block because of this spread of the injectate to the paravertebral space.4

The anterior layer of the TLF connects to the TF. This space includes the iliohypogastric, ilioinguinal, and subcostal nerves. Placing local anesthetic into this space, therefore, results in a T12-L2 sensory block. The TLF also invests the superior cluneal nerves (branches of the dorsal rami of L1-L3). The superior cluneal nerves and the lateral branch of the iliohypogastric nerve are part of the periosteal sensory innervation of the iliac crest, which explains the pain relief in our patient. Saito et al, theorized the spread of the local anesthetic into the psoas compartment leading to analgesic effect through the lumbar plexus nerve roots.5 TM QL blocks reliably spread to L1-L3 nerve roots.6

Shamrock Sign Technique

As discussed, the three QL blocks are obtained by varying the position of the needle with respect to the QL muscle: lateral (QL1), posterior (QL2), or anterior (TM QL or QL3) (see Figures 3a and 3b). We utilized the USG shamrock sign technique, which is based on recognizing three muscles around the TP of L4, with the muscles as the three “leaves” and the TP of L4 as the “stem” forming the “shamrock sign:”3

  • QL (lateral leaflet)
  • ES (posterior leaflet)
  • PM (anterior leaflet)
  • TP of L4 (stem)

QL 1 Block in Abdominal Surgery

Since its introduction, the QL1 block has mainly been utilized in abdominal surgeries as an alternative to the TAP block. In the QL1 block, the needle is positioned lateral to the QL muscle. The QL1 block has been shown to reduce opioid consumption for 48 hours after cesarean section7 and have reduced postoperative pain after laparoscopic gynecological and lower abdominal surgery.8,9 This approach involves injection of local anesthetic lateral to the QL muscle. The QL1 block results in anesthesia to the lateral cutaneous branches of the iliohypogastric, ilioinguinal, and subcostal nerves (T12-L1).10

In case reports of QL1 blocks, a patient with right sub capital femoral neck fracture was able to walk hours after surgery, and another patient with a revision total hip arthroplasty reported pain relief for 30 hours.2

QL 1 Block for Hip Surgery

More recently, the QL 1 block has been described as an alternative to femoral nerve and lumbar plexus blocks for postoperative pain control in patients undergoing total hip replacements,2 anterior iliac crest bone graft,11 and total hip arthroplasty.12

The posterior approach is achieved by injection into the middle layer of the TLF, with the needle posterior to the QL muscle. Similar to the QL1, the QL2 can be used as an alternative to the TAP block for abdominal surgeries below the umbilicus.10 It has also been shown to have opioid-sparing effects after cesarean section.1

TM QL Block

The TM QL block is obtained by local anesthetic injection into the fascial plane between the QL and PM muscles. As discussed previously, the spread into the TLF results in a paravertebral like block as well as a lumbar plexus block.10 This results in both somatic and visceral analgesia from the thoracic to lumbar dermatomes, whereas the TAP block provides somatic analgesia only.11 TM QL block can be used for analgesia in surgeries both above and below the umbilicus. It is more frequently being used for hip surgeries.11,13-15 Although both the posterior and anterior approaches can be used as alternatives to femoral or lumbar plexus blocks, the anterior approach has been shown to be more reliable.10

Options for Osteolytic Metastases

Various options for the management of osteolytic metastases have been described apart from chemotherapy and radiotherapy. Surgical options for treatment include acetabular reconstruction, such as the Harrington procedure, mega prosthesis, saddle prosthesis, and total hip replacement. However, these invasive options carry a high complication rate.16,17

Acrylic cement18 and vertebroplasty or kyphoplasty are additional treatment considerations.19 Percutaneous acetabuloplasty is another treatment that has been shown to have a clinically significant reduction in pain for an average of 7.3 months.20 A study of 25 patients undergoing ethanol injections under CT guidance resulted in complete pain relief in 16% of patients and reduced analgesic needs in 74% of patients.21

Thermotherapy has been shown to reduce pain by 45%22  while cryoablation has resulted in 100% pain relief.23  A study of 43 patients with radiofrequency ablation showed a 95% clinically significant reduction in pain and a mean pain score reduction of 7.9 prior the procedure to 4.5, 3.0, and 1.4 at 4, 12, and 24 weeks, respectively.24,25

QL3 Block

All of above approaches remain valid options for treatment of pain secondary to metastatic lesions to the bones of the hip. However, the QL3 block as an analgesic technique has not been described in case reports thus far. The authors believe that the QL3 block used as either a temporizing measure for pain relief while awaiting more definitive treatment or as a regional technique for procedures such as bone biopsies may become very useful given its ease and reliability.



Quadratus L=lumborumblocks have been shown to be successful in perioperative analgesia in abdominal and hip surgeries. They are also simple and effective techniques for pain control in cancer pain due to metastatic lesions to the bones of the hip or pelvis. The QL block offers a reliable alternative form of analgesia for patients with intractable pathologic pain as a bridge to definitive therapy. When using the shamrock sign technique, the QL block has the advantage of allowing full needle control and easy visualization of anatomic structures, resulting in reliable analgesia with minimal risks.

We propose that QL3 block is a reasonable analgesic option for patients undergoing iliac crest bone marrow aspiration and biopsy in outpatient hematology-oncology clinics.

Continue Reading:
Genicular Nerve Blocks: Field Tips on Prognostic Value and Technical Considerations
close X