In a typical adult undergoing abdominal or retroperitoneal surgery, should I use a quadratus lumborum block or an erector spinae plane block for postoperative analgesia?

Quadratus Lumborum Block vs Erector Spinae Plane Block for Abdominal Surgery

For postoperative analgesia after abdominal or retroperitoneal surgery, both quadratus lumborum block (QLB) and erector spinae plane block (ESPB) provide comparable analgesic efficacy, but ESPB is technically easier and faster to perform, making it the preferred first-line choice when both options are available. 1

Evidence-Based Comparison

Analgesic Efficacy

• Pain control and opioid consumption are essentially equivalent between ESPB and QLB for abdominal surgery, with ESPB showing only a statistically insignificant reduction in 24-hour morphine consumption (2.3 mg difference) that does not reach clinical significance 1

• Both blocks provide somatic and visceral analgesia, unlike traditional TAP blocks which only address somatic pain 2, 3

• Pain scores at rest and with movement show no significant differences between the two techniques at any postoperative time point 1, 4

• Time to first rescue analgesia is comparable between both blocks 1

Technical Considerations

• ESPB is significantly faster to perform than QLB, with QLB requiring approximately 3 additional minutes of procedure time 1

• ESPB is technically less challenging and easier to learn, as the erector spinae muscle provides a more superficial and readily identifiable ultrasound target 1

• QLB has multiple approach variations (anterior/QLB-1, lateral/QLB-2, posterior/QLB-3, intramuscular) with variable anesthetic spread patterns, adding complexity to standardization 2, 5

• Both blocks require ultrasound guidance for safety and accuracy 6, 7

Safety Profile

• No block-related complications have been identified with either technique in comparative studies 1

• Incidence of postoperative nausea and vomiting is similar between both blocks 1

• Both are safer alternatives to epidural analgesia, avoiding risks of hypotension, urinary retention, and lower limb weakness that can delay mobilization 8

Clinical Decision Algorithm

Choose ESPB when:

• Rapid block performance is needed for surgical workflow efficiency 1
• The anesthesiologist has limited experience with fascial plane blocks 1
• Standardization of technique across providers is a priority 1
• Performing blocks at T7 level for visceral abdominal analgesia in bariatric or major abdominal surgery 3

Choose QLB when:

• Specific dermatomal coverage is required and the QLB-2 or QLB-3 approach provides optimal spread for the surgical site 2
• The provider has extensive experience with QLB and prefers this technique 2
• Pediatric patients undergoing procedures like pyeloplasty or laparoscopic appendectomy where QLB has established efficacy 2

Consider TAP block instead when:

• Surgery involves lower abdominal wall incisions only (T10-L1 coverage) 6
• Visceral pain is minimal and only somatic analgesia is needed 8
• The patient has coagulopathy requiring the lowest-risk compressible block 6

Integration into Multimodal Analgesia

• Always combine either block with scheduled acetaminophen and NSAIDs for enhanced analgesic effectiveness 6

• Avoid relying solely on regional techniques; incorporate them into a comprehensive multimodal regimen 8

• For trauma laparotomy in elderly patients, QLB is specifically recommended as part of multimodal analgesia to reduce opioid-related complications 8

• Calculate maximum safe local anesthetic dose before performing either block, especially when combining with wound infiltration 6

Common Pitfalls to Avoid

• Do not assume QLB is superior simply because it is newer or more complex; evidence shows equivalence 1

• Do not perform these blocks without ultrasound guidance; this increases toxicity risk and requires larger anesthetic volumes 6

• Do not exceed total local anesthetic dose limits when combining multiple infiltration techniques 6

• Do not choose epidural over these blocks for routine abdominal surgery, as peripheral blocks avoid sympathectomy-induced hypotension and urinary retention 8, 6

• Verify block adequacy before surgical incision to avoid intraoperative conversion to general anesthesia 6

Guideline Context

• The 2024 World Society of Emergency Surgery guidelines specifically endorse both TAP and QLB for abdominal trauma surgery 8

• The 2024 European Society for Paediatric Anaesthesiology guidelines recognize ESPB as having a place in specialized centers for particular indications, while advocating for well-established blocks like QLB in routine practice 8

• The 2021 PROSPECT guidelines for cesarean section found QLB superior to TAP but similar to intrathecal morphine, and noted that ESPB improved analgesia compared to both TAP and intrathecal morphine 8