Journal of Anesthesia

, Volume 33, Issue 1, pp 148–154 | Cite as

Subcostal approach to anterior quadratus lumborum block for pain control following open urological procedures

  • Hesham ElsharkawyEmail author
  • Sanchit Ahuja
  • Sean DeGrande
  • Kamal Maheshwari
  • Vincent Chan
Clinical Report


In the case of open urological surgeries, analgesic coverage at mid thoracic dermatomal levels is required. As shown in cadaveric studies, the site of QL block injection is an important determinant of the extent of dye spread and presumably local anesthetic dermatomal coverage. In this case series, we evaluated dermatomal blockade and analgesic efficacy of a subcostal approach to anterior QL block following open urological surgeries. Twenty-two adult patients undergoing renal transplant surgery (60%) and open nephrectomy (40%) received unilateral ultrasound-guided subcostal anterior QL block with catheter insertion. Sensory level, pain score (numeric rating scale, NRS), local anesthetic consumption, and opioid consumption (morphine equivalent dose, MED) were assessed daily for 3 days. The block achieved sensory blockade between T6-7 and L1-2. The most frequently affected dermatomes were T8 -T12 and the number of blocked segments was 3 (mean 2.8). The median (interquartile range Q1, Q3) of NRS pain score was 3.7 (2.8–5.5), 3.3 (2.4–4.7), 2.9 (1.9–3.6), and 2.3 (1.0–4.2) on POD0, POD1, POD2, and POD3, respectively. Our preliminary data showed that the subcostal approach to anterior QL block provides appropriate thoracic dermatome level needed for analgesia following open urological surgical procedures between T6-7 and L1-2.


Quadratus lumborum block Regional anesthesia Urological procedures 



Dr. Elsharkawy has received unrestricted educational funding from PAJUNK (GA, USA), and consultant for PACIRA (Troy Hills, NJ, USA). Those companies had no input into any aspect of the present project design or manuscript preparation.

Conflict of interest

The other authors declare no conflicts of interest.

Ethical approval

Dr. Vincent Chan received honorarium from BBraun, Aspen Pharma, and SonoSite and was on the medical advisory board of Smiths Medical.

Figures’ permissions

Permission to use images was obtained from the Cleveland Clinic Department of Art Photography.

Clinical reports

This report describes human research. Cleveland Clinic Institutional Review Board (IRB 15–573) (date of approval—12 May 2015). The requirement for written informed consent was waived by the Institutional Review Board.

Supplementary material

540_2018_2605_MOESM1_ESM.pptx (16.3 mb)
Supplementary material 1 (PPTX 16656 KB)


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Copyright information

© Japanese Society of Anesthesiologists 2019

Authors and Affiliations

  • Hesham Elsharkawy
    • 1
    • 2
    Email author
  • Sanchit Ahuja
    • 3
  • Sean DeGrande
    • 4
  • Kamal Maheshwari
    • 1
  • Vincent Chan
    • 5
  1. 1.Department of General Anesthesiology, Pain Management and Outcomes Research, Anesthesiology InstituteCleveland Clinic, Cleveland Clinic FoundationClevelandUSA
  2. 2.Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland ClinicClevelandUSA
  3. 3.Department of Anesthesiology, Pain Management & Perioperative MedicineHenry Ford Health SystemDetroitUSA
  4. 4.Anesthesiology InstituteCleveland Clinic FoundationClevelandUSA
  5. 5.Department of AnesthesiaUniversity of TorontoTorontoCanada

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