Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Original Investigation

Quadratus lumborum or transversus abdominis plane block for postoperative analgesia after cesarean: a double-blinded randomized trial

Bloqueio do plano do quadrado lombar ou transverso do abdome para analgesia pós-operatória após cesariana: um estudo randomizado duplo-cego

Ashok Jadon, Mohammad Amir, Neelam Sinha, Swastika Chakraborty, Asif Ahmad, Sudeshna Mukherjee

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Multimodal analgesia (MMA) is the current standard practice to provide post-cesarean analgesia. The aim of this study was to compare the analgesic efficacy of quadratus lumborum (QL) block and transversus abdominis plane (TAP) block as an adjunct to MMA.

Eighty mothers undergoing cesarean delivery under spinal anesthesia were randomized to receive either TAP or transmuscular QL block (QLB) with 20 mL 0.375% ropivacaine on each side. Postoperatively, all the subjects were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcomes were the pain scores during rest and movement, number of doses of tramadol, postoperative nausea-vomiting, sedation, and mother’s satisfaction with the pain management.

The median (IQR) time to first analgesic request was 12 (9.25, 13) hours in the QL group and 9 (8.25, 11.37) hours in the TAP group (p = 0.0008). Patients in QL group consumed less doses of tramadol than TAP group (p < 0.0001). Pain scores were significantly lower in the QL group at all time points (p < 0.0001) except at 8th h where at rest, p = 0.0024, and on movement, p = 0.0028. The maternal satisfaction was significantly higher in the QL group (p = 0.0017).

Our study showed the significant delay in time to first analgesic request in QL group patients. Patients in the QL group had lower pain scores, required fewer analgesic supplements, and had more satisfaction. Nausea-vomiting and sedation were comparable.


Quadratus lumborum block;  Transversus abdominis plane block;  Cesarean;  Postoperative pain;  Multimodal analgesia


Introdução: A analgesia multimodal (AMM) é a prática padrão atual para fornecer analgesia pós-cesariana. O objetivo deste estudo foi comparar a eficácia analgésica do bloqueio do quadrado lombar (QL) e do bloqueio do plano transverso abdominal (PTA) como adjuvante à AMM. Métodos: Oitenta mães submetidas a cesariana sob raquianestesia foram randomizadas para receber PTA ou bloqueio QL transmuscular (QL) com 20 mL de ropivacaína 0,375% de cada lado. No pós-operatório, todos os indivíduos foram avaliados em 2, 4, 6, 8, 12, 18 e 24 horas. O desfecho primário foi o tempo até a primeira solicitação de analgésico. Os desfechos secundários foram os escores de dor em repouso e movimento, número de doses de tramadol, náuseas-vômitos pós-operatórios, sedação e satisfação da mãe com o manejo da dor. Resultados: O tempo mediano (IQR) para a primeira solicitação de analgésico foi de 12 (9,25, 13) horas no grupo QL e 9 (8,25, 11,37) horas no grupo TAP (p = 0,0008). Os pacientes do grupo QL consumiram menos doses de tramadol do que o grupo TAP (p < 0,0001). Os escores de dor foram significativamente menores no grupo QL em todos os momentos (p < 0,0001), exceto na 8ª h onde em repouso, p = 0,0024, e em movimento, p = 0,0028. A satisfação materna foi significativamente maior no grupo QV (p = 0,0017). Conclusão: Nosso estudo mostrou o atraso significativo no tempo para a primeira solicitação de analgésico em pacientes do grupo QL. Os pacientes do grupo QL apresentaram escores de dor mais baixos, necessitaram de menos suplementos analgésicos e tiveram mais satisfação. Náusea-vômito e sedação foram comparáveis.


Bloqueio do quadrado lombar; Bloqueio do plano transverso do abdome; Cesariana; Dor pós-operatória; Analgesia multimodal


1 RA Farragher, JG Laffey Postoperative pain management following Cesarean G Shorten, D Carr, D Harmon, et al. (Eds.), Postoperative pain management: an evidence based guide to practice (1st ed.), Saunders Elsevier, Philadelphia, PA (2006), pp. 225-228

2 N Sujata, VM Hanoora Pain control after Cesarean birth – What are the options? J Gen Pract., 02 (2014), Article 1000164

3 A. Jadon, R. Bagai Effective pain relief after cesarean; Are we on the right path or still on the crossroad J Obstet Anaesth Crit Care., 9 (2019), pp. 3-6

4 P. Madadi, C.J. Ross, M.R. Hayden, et al. Pharmacogenetics of neonatal opioid toxicity following maternal use of codeine during breastfeeding: a case–control study Clin Pharmacol Ther., 85 (2009), pp. 31-35

5 A. Jadon, P. Jain, S. Chakraborty, et al. Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment cesarean section: a randomized double-blind clinical study BMC Anesthesiol., 18 (2018), p. 53

6 M.R. Siddiqui, M.S. Sajid, D.R. Uncles, et al. A meta-analysis on the clinical effectiveness of transversus abdominis plane block J Clin Anesth., 23 (2010), pp. 7-14

7 F. Abdallah, J. Laffey, S. Halpern, et al. Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: a meta-analysis Br J Anaesth., 111 (2013), pp. 721-735

8 R. Blanco, T. Ansari, E. Girgis Quadratus lumborum block for postoperative pain after cesarean A randomized controlled trial Eur J Anaesthesiol., 32 (2015), pp. 812-818

9 R. Blanco, T. Ansari, W. Riad, et al. Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after cesarean delivery: a randomized controlled trial Reg Anesth Pain Med., 41 (2016), pp. 757-762

10 K. El-Boghdadly, H. Elsharkawy, A. Short, et al. Quadratus lumborum block nomenclature and anatomical considerations Reg Anesth Pain Med., 41 (2016), pp. 548-549

11 J. Børglum, B. Moriggl, K. Jensen, et al. Ultrasound-Guided Transmuscular Quadratus Lumborum Blockade BJA., 111 (2013), p. 22

12 S.D. Adhikary, K. El-Boghdadly, Z. Nasralah, et al. A radiologic and anatomic assessment of injectate spread following transmuscular quadratus lumborum block in cadavers Anesthesia., 72 (2017), pp. 73-79

13 A. Jadon, P. Jain, L. Dhanwani Bilateral transmuscular quadratus lumborum block performed in single lateral decubitus position without changing position to the contralateral side Indian J Anaesth., 62 (2018), pp. 314-315

14 B Carvalho, Se Cohen, Ss Lipman, et al. Patient preferences for anesthesia outcomes associated with cesarean delivery Anesth Analg., 101 (2005), pp. 1182-1187

15 American Society of Anesthesiologists Task Force on Obstetric Anesthesia Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia Anesthesiology., 106 (2007), pp. 843-863

16 D. Belavy, P.J. Cowlishaw, M. Howes, et al. Ultrasound guided transverse Abdominis Plane block for analgesia after cesarean delivery Br J Anaesth., 103 (2009), pp. 726-730

17 J. Baaj, R. Alsatli, H. Majaj, et al. Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for post-cesarean section delivery analgesia double-blind, placebo-controlled, randomized study Middle East J Anaesthesiol., 20 (2010), pp. 821-826

18 J. Costello, A. Moore, P. Wieczorek, et al. The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery Reg Anesth Pain Med., 34 (2009), pp. 586-589

19 R.C. McMorrow, R.J. Ni Mhuircheartaigh, K.A. Ahmed, et al. Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Cesarean Br J Anaesth., 106 (2011), pp. 706-712

20 J. Carney, O. Finnerty, J. Rauf, et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks Anesthesia., 66 (2011), pp. 1023-1030

21 C.J. Walter, C. Maxwell-Armstrong, T.D. Pinkney, et al. A randomized controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery Surg Endosc Other Interventional Tech., 27 (2013), pp. 2366-2372

22 R. Blanco The mechanism of the quadratus lumborum block: A peripheral sympathetic field block? BJA., 117 (2016), p. 13593

23 M.M. Mieszkowski, E. Mayzner-Zawadzka, B. Tuyakov, et al. Evaluation of the effectiveness of the Quadratus Lumborum Block type I using ropivacaine in postoperative analgesia after a cesarean section - a controlled clinical study Ginekol Pol., 89 (2018), pp. 89-96

24 N. Mænchen, C.K. Hansen, M. Dam, et al. Ultrasound-guided Transmuscular Quadratus Lumborum (TQL) Block for Pain Management after Cesarean Int J Anesthetic Anesthesiol., 3 (2016), p. 48

25 M. Dam, B. Moriggl, C.K. Hansen, et al. The pathway of injectate spread with the transmuscular quadratus lumborum block: A cadaver study Anesth Analg., 125 (2017), pp. 303-312

26 M. Sato, M. Hara, O. Uchida An antero-lateral approach to ultrasound-guided lumbar plexus block in supine position combined with quadratus lumborum block using single needle insertion for pediatric hip surgery Pediatr Anesth., 27 (2017), pp. 1064-1065

27 W. Kang, D. Lu, X. Yang, et al. Postoperative analgesic effects of various quadratus lumborum block approaches following cesarean section: a randomized controlled trial J Pain Res., 12 (2019), pp. 2305-2312

28 H Ueshima, H Otake, JA Lin Ultrasound-Guided Quadratus Lumborum Block: An Updated Review of Anatomy and Techniques BioMed Res Int. (2017), pp. 1-7

29 ER Salama Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after cesarean section: a randomized controlled trial Korean J Anesthesiol., 73 (2020), pp. 121-128

30 T. Murouchi, S. Iwasaki, M. Yamakage Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery Reg Anesth Pain Med., 41 (2016), pp. 146-150

31 C Almeida, JP Assuncao Hypotension associated to a bilateral quadratus lumborum block performed for post-operative analgesia in an open aortic surgery case Rev Bras Anestesiol., 68 (2018), pp. 657-660

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