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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 391 - 397
Comparison of Quadratus Lumborum Block (QLB) versus Thoracic Paravertebral Block for analgesia in patients of Laparoscopic Nephrectomy: A Prospective Randomized Controlled Trial
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1
Senior Resident, Department of Anaesthesia & Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar (India).
2
Professor, Department of Anaesthesia & Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar (India).
3
Assistant Professor, Department of Surgery, Netaji Subash Medical College and Hospital, Amhara, Bihta, Bihar (India).
4
Consultant, Department of Critical Care, Asian City Hospital, Patliputra, Patna, Bihar (India)
Under a Creative Commons license
Open Access
Received
Dec. 29, 2024
Revised
Jan. 3, 2025
Accepted
Jan. 20, 2025
Published
Jan. 30, 2025
Abstract

Background: Effective pain management is a crucial aspect of postoperative care for minimally invasive surgeries, such as laparoscopic nephrectomy. Regional anesthesia techniques like the transmuscular quadratus lumborum block (TMQLB) and thoracic paravertebral block (TPVB) have gained attention as part of multimodal analgesia strategies aimed at minimizing opioid use and enhancing recovery. While TPVB is a well-established technique, TMQLB has emerged as a promising alternative due to its ease of administration and potential for broader sensory coverage. This study aimed to compare the analgesic efficacy, opioid-sparing effects, and postoperative recovery outcomes of TMQLB and TPVB in patients undergoing laparoscopic nephrectomy through a prospective randomized controlled trial. Materials and Methods: This prospective, randomized, double-blind, single-center study was conducted to compare the analgesic efficacy and recovery outcomes of transmuscular quadratus lumborum block (TMQLB) and thoracic paravertebral block (TPVB) in laparoscopic nephrectomy patients. A total of 68 participants, aged 17–80 years and classified as ASA I–III, were enrolled and randomized into two groups. All blocks were performed under ultrasound guidance using 0.5% ropivacaine at a dose of 0.4 ml/kg. The primary outcome was 48-hour postoperative cumulative morphine consumption, while secondary outcomes included sensory block dermatomes, intraoperative hemodynamic changes, Numerical Rating Scale (NRS) pain scores, postoperative recovery data, and quality of recovery scores. Data analysis was performed using GraphPad software, with a significance threshold of p < 0.05. Results: A total of 68 patients were randomized into two groups (n=34 each), with 30 patients per group included in the final analysis. Both groups had similar baseline characteristics. Postoperative cumulative morphine consumption was significantly lower in the TPVB group at all time points (p < 0.05), though pain scores were comparable. The postoperative pain NRS at rest and on movement, incidences of side effects, anesthesia-related satisfaction, and quality of recovery scores were similar between the two groups (all P > 0.05). The TMQLB group achieved a broader sensory block (p = 0.002). Intraoperative hemodynamics were stable, with no significant differences between groups. The TMQLB group required more sevoflurane and fentanyl. Postoperative recovery, including gas passing, urination, mobilization, and length of stay, showed no significant differences. Complication rates and quality of recovery were similar, with high patient satisfaction in both groups. Conclusion: The present study demonstrated that transmuscular quadratus lumborum block (TMQLB) provides a comparable postoperative analgesic effect to T10-level thoracic paravertebral block (TPVB), as reflected by similar 48-hour cumulative morphine consumption in patients undergoing laparoscopic partial nephrectomy. TMQLB shows promise as a viable alternative to TPVB in select surgical settings and patient populations, warranting further research to explore its potential applications and benefits.

Keywords
INTRODUCTION

A novel abdominal truncal block known as the quadratus lumborum block (QLB) provides analgesia for various abdominal surgeries, including pyeloplasty, laparoscopy, colostomy, cesarean section, and hernia repair [1–5]. Currently, there are four distinct methods for performing the quadratus lumborum block, each involving an injection of local anesthetic at different angles around the quadratus lumborum (QL) muscle. The quadratus lumborum block (QLB) technique was originally introduced by Blanco in 2007 and is referred to as QLB 1. This method involves inserting a needle into the space between the quadratus lumborum and psoas major muscles and injecting the anesthetic into the anterolateral edge of the quadratus lumborum muscle, also known as the lateral QLB [6]. QLB 2, or posterior QLB, involves injecting the anesthetic posterolateral to the quadratus lumborum muscle [7]. Subsequently, Borglum et al. established another method called the transmuscular quadratus lumborum block (TMQLB), or QLB 3, which entails advancing the needle anteriorly through the latissimus dorsi and quadratus lumborum muscle to deliver the anesthetic in a posterior-anterior direction. Lastly, there is the intramuscular quadratus lumborum block, where the anesthetic is injected directly into the quadratus lumborum muscle [5]. The primary intention behind the transmuscular quadratus lumborum block is to alleviate pain during intraperitoneal and retroperitoneal surgeries. Initially, it was theorized that the anesthetic would spread cranially to the thoracic paravertebral region, providing analgesic effects if injected within the plane between the quadratus lumborum and psoas major muscles. Recent anatomical studies have provided evidence to support this theory. In a cadaveric study, examining the spread of dye solution following the transmuscular quadratus lumborum block, Borglum et al. convincingly demonstrated that the injectate could reach the ventral rami of the lower thoracic spinal nerves (T9–T12) in the thoracic paravertebral space as well as the thoracic sympathetic trunk [9]. The injectate traveled cranially from the lumbar administration site, passing posteriorly to the medial and lateral arcuate ligaments, to reach the paravertebral region. Given that both the transmuscular quadratus lumborum block and thoracic paravertebral block (TPVB) penetrate the sympathetic and thoracic somatic nerves in the thoracic paravertebral space, it is reasonable to infer that their analgesic effects may be similar. Although thoracic paravertebral block (TPVB) is generally safe, it carries risks such as pneumothorax, vascular or dural puncture, and the potential for epidural or intrathecal dissemination. Additionally, being a deep block performed in a non-compressible region, thoracic paravertebral block (TPVB) poses significant bleeding risks in the thoracic paravertebral space, which can be challenging to manage, particularly given that clotting depends on the patient’s hemostatic status [10].

According to the American Society of Regional Anesthesia and Pain Medicine's (ASRA) anticoagulant guidelines, thoracic paravertebral block (TPVB) is typically contraindicated for patients on anticoagulation therapy. In contrast, the transmuscular quadratus lumborum block presents minimal risk of harm because the needle and endpoint pass through muscle and fascial planes, far from the peritoneal cavity, major blood vessels, and abdominal organs. If clinical data demonstrate that transmuscular quadratus lumborum (TMQLB) provides analgesia comparable to thoracic paravertebral block (TPVB), this technique could offer a way to avoid the complications associated with thoracic paravertebral block (TPVB). Unfortunately, there are a limited number of high-quality randomized clinical trials (RCTs) assessing the safety and efficacy of transmuscular quadratus lumborum (TMQLB) in abdominal and retroperitoneal surgeries, and no direct comparisons between transmuscular quadratus lumborum (TMQLB) and thoracic paravertebral block (TPVB). The aim of this study is to design a prospective randomized controlled trial comparing the effectiveness of transmuscular quadratus lumborum block with thoracic paravertebral block in alleviating pain and improving recovery in laparoscopic renal surgery.

MATERIALS AND METHODS

This was a prospective, randomized, single-center, double-blind, noninferiority study aimed at assessing pain relief and recovery quality in laparoscopic renal surgery utilizing transmuscular quadratus lumborum block (TMQLB) in comparison to thoracic paravertebral block (TPVB). The comprehensive trial framework is depicted in Figure 1. Approval from the Institutional Research Ethics Committee was obtained from the Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar (India). The trial was executed at IGIMS in accordance with the International Conference on Harmonisation (ICH) guidelines for Good Clinical Practice (GCP).

Full written informed consent was obtained from each participant before the intervention. Participants were randomized into two groups receiving TMQLB or TPVB for postoperative pain control.

 

Figure 1: Flow diagram of the study

 

[TMQLB: Transmuscular quadratus lumborum block; TPVB: Thoracic paravertebral block]

 

Eligibility criteria:

Participants enrolled in this trial were aged between 17 and 80 years, categorized as American Society of Anaesthesiologists (ASA) class I–III, and undergoing laparoscopic nephrectomy. Patients were excluded if they had a known allergy to the anaesthetics used, an infection at the injection site, coagulopathy or a history of anticoagulant use, were taking analgesics for a chronic illness, or had a history of substance abuse, or were unable to appropriately describe their postoperative pain or recovery due to factors such as a language barrier or neuropsychiatric disorder.

 

Interventions:

All blocks were performed in a specialized procedural room before surgery. After the application of conventional monitors, supplemental oxygen, and IV access, patients were positioned in the lateral decubitus position with the operative side facing upward.

 

In the transmuscular quadratus lumborum block (TMQLB) group, the procedure was executed according to the methodology described by Borglum et al. [8]. A curved array transducer was placed on the transverse plane in the abdominal flank, posterior to the rib. The transducer was then repositioned dorsally while maintaining the transverse orientation until the "shamrock sign" appeared. A 22-G needle was inserted into the plane with the tip directed from the dorsal to the ventral, entering the ventral fascia of the quadratus lumborum muscle. After verifying the needle tip placement using hydro dissection, 0.4 ml/kg of 0.5% ropivacaine was administered between the quadratus lumborum and psoas muscles.

 

In the thoracic paravertebral block (TPVB) group, the procedure followed the protocol established by Renes et al. [11]. A curved array transducer was placed on the paramedian sagittal plane to locate the T10 intercostal region. The transducer was subsequently moved to align with the intercostal space and calibrated to find the paravertebral space between the sliding pleura and the inner intercostal membrane. A 22-G needle was inserted into the plane and moved medially until its tip reached the paravertebral space. After confirming the appropriate needle tip placement using hydro dissection, 0.4 ml/kg of 0.5% ropivacaine was administered into the space, resulting in a pleural depression sign. Sensory block dermatomes were assessed 30 minutes post-nerve block. A cold stimulus was applied along the midclavicular line to evaluate bilateral sensory changes. A diminished cold sensation compared to the contralateral side in the same dermatome was considered a successful block. The total quantities and degrees of sensory block dermatomes were documented and compared between the two groups. Preoperative vital signs, including heart rate and blood pressure, were recorded.

 

Complications associated with the blocks, such as bleeding, organ damage, pneumothorax (related to TPVB), local anesthetic toxicity, and infections at the injection site, were also documented. All patients received standardized general anesthesia with tracheal intubation. Anesthesia was initiated with 2 mg/kg propofol, 1 µg/kg fentanyl, and 0.8 mg/kg rocuronium, and maintained with sevoflurane in an air-oxygen mixture, targeting a Bispectral Index (BIS) value of 40 to 60. The baseline heart rate and blood pressure were established as the average values recorded over three consecutive days before the operation. The intraoperative heart rate was maintained within ±10 bpm of the baseline and documented every ten minutes. Intraoperative blood pressure was sustained within ±20% of the baseline and documented every ten minutes. Fentanyl was provided as needed at a dosage of 1 µg/kg per bolus. Anaesthesiologists documented all intraoperative medications and fluids used during surgery. Sevoflurane was discontinued, and neostigmine was administered following the closure of the innermost layer of the wound.

 

Post-surgery, both cohorts received electronic patient-controlled intravenous analgesia (PCIA) pumps. Morphine was administered via a self-dosing button as needed, with parameters set at 1.5-2 mg per bolus, a 5-minute lockout interval, and a maximum limit of 6–8 mg per hour, without continuous background infusion. Parecoxib was provided as a rescue for inadequate analgesia if patients reported discomfort with a Numerical Rating Scale (NRS) of 4 or higher after utilizing the PCIA. An experienced anaesthesiologist, blinded to group allocation, conducted the postoperative follow-up and outcome assessment.

 

Outcomes:

The primary outcome was postoperative 48-hour cumulative morphine consumption.

The secondary outcomes included:

  • Sensory block dermatomes 30 min after blockade.
  • Intra-operative hemodynamic changes and medications used.
  • NRS (Numerical Rating Scale) pain scores at rest and during movement at postoperative 0, 4, 12, 24 and 48 hours.
  • Cumulative morphine consumption at postoperative 4, 12, and 24 hours.
  • Postoperative recovery data, including gas passing, urination and off-bed times, and incidences of postoperative nausea and vomiting (PONV), pruritus, and dyspnea.
  • Anesthesia-related satisfaction scores evaluated by a 1- to 5-point Likert scale, [1 point defined as very unsatisfied, 2 points defined as unsatisfied, 3 points defined as acceptable, 4 points defined as satisfied, and 5 points defined as very satisfied] [12,13].
  • Quality of recovery evaluated by the self-assessment15-item quality of recovery scale [14, 15].
  • Length of hospital stay.

 

Sample Size: A power analysis was made by using G*power software, version 3.0.1(Franz Foul Universitat, Kiel, Germany). A sample size of 30 patients required in each group would yield 80% power to detect significant differences, with an effect size of 0.50 and a significance level of 0.05. Assuming a 10% dropout rate, we enrolled 34 patients in both groups.

 

Statistical Analysis: The collected data was organized into a table using Microsoft Excel 2019. Subsequently, the data was transferred to GraphPad version 8.4.3 for further statistical analysis. A difference was deemed significant if the p-value was less than 0.05

RESULTS

A total of seventy-three patients scheduled for laparoscopic partial nephrectomy were evaluated for eligibility to participate in the study. Five patients who declined to participate were excluded from the analysis. Among the enrolled patients (n=68), they were randomly assigned to one of two treatment groups (n=34 each). Eight patients were later excluded due to changes in the surgical approach (n=5) and missing data (n=3). Ultimately, thirty patients from each group were included in the final analysis (see Figure 1). The baseline data are presented in Table 1. The mean age, sex ratio, body mass index, preoperative pain score (NRS), surgical side, and surgical time were comparable between the two groups (all P > 0.05).

 

Table 1: Showing the different demographic profiles of the patients of both groups.

Demographic

characteristics

Group 1 [TMQLB]

(n = 30)

Group 2 [TPVB]

(n = 30)

Age (years)

50.51±7.43

53.12±9.62

Gender

(Male/Female)

20/10

18/12

Body mass index (kg/m2)

26.43±3.21

24.41±3.18

Mean pre-op NRS in points

0.11±0.51

0.14±0.46

Side of the surgery (Right/Left)

17/13

14/16

The mean duration of surgery (minutes)

105±20

116±26

 

The comparison of postoperative cumulative morphine use and pain NRS scores between the TMQLB and TPVB groups demonstrated distinct analgesic profiles (Table 2). The TPVB group consistently showed significantly lower cumulative morphine consumption at all postoperative time points, indicating superior opioid-sparing effects. However, pain NRS scores at rest and on movement were comparable between the two groups, with no statistically significant differences observed. The sensory block ranges for the Transmuscular Quadratus Lumborum Block (TMQLB) and the Thoracic Paravertebral Block (TPVB) extended from the T2 to L3 levels and from T2 to L1 levels, respectively. This indicates that the TMQLB group achieved a broader sensory block coverage, suggesting its potential to provide a larger area of analgesia. Although TPVB may more effectively reduce opioid consumption, both techniques offer similar pain relief, though they exhibit different sensory block characteristics.

 

Table 2: Showing the comparison of postoperative cumulative morphine consumption and pain NRS of transmuscular quadratus lumborum block and paravertebral block groups at different time points.

Characteristics

Group 1 [TMQLB]

(n = 30)

Group 2 [TPVB]

(n = 30)

p-value

Mean postoperative cumulative morphine consumption (in mg) [Mean±SD]

4 Hours

1.54±1.11

1.13±1.24

0.001

12 Hours

4.21±3.45

2.86±2.15

0.015

24 Hours

7.42±4.11

4.65±2.37

0.001

48 Hours

10.32±4.76

6.33±3.34

0.001

Pain NRS at rest (in points) [Mean±SD]

0 Hour

0.68±1.06

0.51±1.11

0.356

4 Hours

1.48±1.19

1.39±1.44

0.895

12 Hours

2.89±1.69

2.99±1.15

0.769

24 Hours

1.87±1.17

1.38±1.12

0.572

48 Hours

1.09±1.56

0.96±1.04

0.615

Pain Numerical Rating Scale (NRS) on movement (in points) [Mean±SD]

0 Hour

1.56±1.76

0.58±0.91

0.081

4 Hours

3.17±1.62

2.81±1.48

0.432

12 Hours

3.63±1.59

3.44±1.01

0.775

24 Hours

3.31±1.18

1.28±1.11

0.964

48 Hours

2.45±1.36

2.34±1.08

0.689

Mean sensory block dermatomes (in segments) [Mean±SD]

Segments

8±5

5±4

0.002

 

In Table 3, we compare intraoperative hemodynamic changes and medication use between the transmuscular quadratus lumborum block (TMQLB) and thoracic paravertebral block (TPVB) groups. The analysis revealed no significant differences in intraoperative mean arterial pressure (MAP) and heart rate (HR) between the two groups at various time points, suggesting that both blocks maintained stable hemodynamic parameters during laparoscopic nephrectomy. The TMQLB group used more sevoflurane and fentanyl than the TPVB group. However, the requirement for intraoperative rescue analgesics and vasopressors was similar across both groups, indicating comparable efficacy in achieving adequate pain control and hemodynamic stability. These findings highlight that both TMQLB and TPVB are equally effective in managing intraoperative hemodynamic changes and minimizing the need for additional medications during surgery. The fluid input and output volumes were similar between the two groups.

 

Table 3: Showing the comparison of intraoperative hemodynamic changes and medication used in transmuscular quadratus lumborum block and paravertebral block groups.

Characteristics

Group 1 [TMQLB]

(n = 30)

Group 2 [TPVB]

(n = 30)

p-value

Mean heart rate (beats per minute) [Mean±SD]

Baseline

78±8

74±7

0.152

Pre-op

80±13

72±11

0.059

Intra-op

68±11

66±8

0.491

Mean systolic blood pressure (in mm Hg) [Mean±SD]

Baseline

128±16

126±14

0.434

Pre-op

141±22

134±24

0.174

Intra-op

114±10

114±12

0.263

Mean diastolic blood pressure (in mm Hg) [Mean±SD]

Baseline

79±8

77±7

0.917

Pre-op

86±13

82±11

0.038

Intra-op

76±11

73±8

0.179

Medications [Mean±SD]

Sevoflurane in %

1.31±0.26

1.11±0.28

0.029

Fentanyl in μg

248±76

219±47

0.036

 

In Table 4, we compare postoperative recovery data between the transmuscular quadratus lumborum block (TMQLB) and thoracic paravertebral block (TPVB) groups. The time to first gas passing, urination, and mobilization off the bed, as well as the overall hospital length of stay, were comparable between the two groups, with no statistically significant differences observed (p > 0.05). The incidence of postoperative complications, including nausea, vomiting, pruritus, and dyspnea, was also similar across both groups. The mean quality of recovery scores on postoperative days 3 and 5 did not differ significantly between the groups. Additionally, patient satisfaction with anesthesia-related care, including preoperative information, emergence, postoperative analgesia, management of nausea and vomiting, and overall anesthesia care, was comparable, with high satisfaction scores in both groups. These results suggest that TMQLB and TPVB provide equivalent postoperative recovery outcomes and patient satisfaction following laparoscopic nephrectomy.

 

Table 4: Showing the comparison of postoperative recovery data of transmuscular quadratus lumborum block and paravertebral block group.

Characteristics

Group 1 [TMQLB]

(n = 30)

Group 2 [TPVB]

(n = 30)

p-value

Meantime (in hours/days) [Mean±SD]

Gas passing (hours)

35±12

37±13

0.352

Urination (hours)

56±22

55±16

0.854

Off-bed (hours)

54±14

51±12

0.498

Length of stay (days)

7±2

7±1

0.597

Incidence (in percent) [Mean±SD]

Nausea

11 (36.67%)

10 (33.33%)

0.434

Vomiting

11 (36.67%)

10 (33.33%)

0.374

Pruritus

0 (0%)

2 (6.67%)

0.943

Dyspnea

3 (10%)

3 (10%)

0.958

Mean quality of recovery score (in points) [Mean±SD]

Post-op day 3

126±13

123±14

0.379

Post-op day 5

138±12

137±13

0.674

Anesthesia-related satisfaction (in points) [Mean±SD]

Pre-op information

4.12±0.26

4.22±0.28

0.413

Emergence

4.37±0.54

4.47±0.48

0.457

Post-op analgesia

4.35±0.41

4.61±0.43

0.061

Postoperative nausea and vomiting (PONV) treatment

4.39±0.48

4.32±0.87

0.267

Anesthesia care

4.81±0.81

4.77±0.31

0.812

DISCUSSION

This randomized controlled trial evaluated the analgesic effectiveness, intraoperative hemodynamic stability, and postoperative recovery outcomes of transmuscular quadratus lumborum block (TMQLB) versus thoracic paravertebral block (TPVB) in patients undergoing laparoscopic nephrectomy. The results indicated that whereas TPVB led to reduced total morphine usage, both methods offered similar pain management, consistent intraoperative hemodynamics, and equivalent postoperative recovery outcomes. These findings underscore the potential efficacy of both localized blocks as integral elements of multimodal analgesia in minimally invasive kidney procedures. No substantial discrepancies in postoperative recovery data between the two groups were seen. The perioperative discomfort associated with laparoscopic nephrectomy has both somatic and visceral components. Somatic pain resulting from gas distention of the abdominal wall, abdominal port installation, and dissection of the abdominal cavity originates from the spinal neurons T6 to T12. The intense pain in the renal pelvis is innervated by the sympathetic trunk from T12 to L2. This investigation demonstrated that 0.4 ml/kg of ropivacaine administered by TMQLB effectively blocked dermatomes from T2 to L3, consistent with the findings of Zhu et al. [17]. Additionally, TPVB resulted in an average blockade of 5 dermatomes, aligning with the outcomes of prior studies [18,19]. The sensory block areas of both TMQLB and TPVB encompassed the nerve distribution important for pain conduction during laparoscopic partial nephrectomy, which may elucidate the comparable analgesic efficacy of TMQLB relative to TPVB in this investigation. When administered identical dosages of ropivacaine, TMQLB resulted in a broader sensory blockade compared to TPVB. This phenomenon may be elucidated by the distinct spreading patterns of local anesthetics associated with these two procedures. TMQLB administers local anesthetics (LA) into a latent fascial compartment situated between the psoas major muscle (PM) and the quadratus lumborum muscle (QLM). The fascial planes traverse the psoas major muscle (PM) and quadratus lumborum muscle (QLM) superiorly via the medial and lateral arcuate ligaments and the aortic hiatus of the diaphragm, constituting the endothoracic fascia and inferior diaphragmatic fascia [9]. Consequently, local anesthetics (LA) may ascend cranially along the endothoracic fascia and permeate the ventral ramus of the thoracic spinal nerve, producing a sensory blockade adequate to alleviate the somatic pain associated with laparoscopic partial nephrectomy. The endo-thoracic fascia is a loose, mesh-like connective tissue around 250 µm thick, and local anesthetics injected via TMQLB can easily disseminate along it, producing an extensive sensory block range. The thoracic paravertebral space is wedge-shaped and possesses the capacity to store solutions. Consequently, local anesthetics (LA) administered by TPVB exhibit restricted diffusion, leading to a somewhat clustered blocking pattern. Notwithstanding the non-inferior postoperative analgesic efficacy of TMQLB during a 48-hour period in comparison to TPVB Our study observed substantial statistical differences in intraoperative and postoperative analgesic dosages at 24 and 48 hours between the TMQLB and TPVB groups. This result can be elucidated statistically and may suggest a potentially diminished analgesic impact, particularly the visceral analgesic effect of TMQLB in comparison to TPVB, attributable to variations in the sympathetic block effect. The reduced postblock diastolic blood pressure of TPVB in comparison to TMQLB further corroborates this conclusion. The sympathetic block effect of TPVB can be elucidated primarily through three mechanisms: (a) the injection of local anesthetics (LA) directly anterior to the endothoracic fascia and into the extrapleural compartment, where the sympathetic trunk is located; (b) the migration of local anesthetics (LA) from the subendothoracic compartment into the extrapleural compartment via fenestrations in the endothoracic fascia; and (c) the diffusion of local anesthetics (LA) into the epidural space, particularly when the injection is medial. The efficacy of TMQLB in producing sympathetic block remains contentious. Børglum et al.'s investigation of sixteen cadavers demonstrated that all dye administered via TMQLB could disseminate into the paravertebral space and permeate the sympathetic trunk, whereas Gadsden et al.'s examination of a single cadaver indicated that the transverse oblique paramedian approach QLB at L3 entirely preserved the paravertebral space [23]. A study including healthy volunteers using alternative QLB methods likewise demonstrated inconsistent outcomes [24]. Consequently, the sympathetic block and visceral analgesic effect associated with TMQLB were deemed less dependable than those achieved with TPVB.  The postoperative recovery outcomes, including adverse event occurrences, patient satisfaction with anesthetic ratings, and 15-item quality of recovery scores, were analogous across the two groups, suggesting an equivalent safety and recovery profile for both blocks.

 

The current study has some significant limitations. The positioning of the ultrasonic transducer and needle injection sites varied between the TMQLB and TPVB groups, potentially compromising patient blinding to the injection techniques. Nonetheless, the likelihood of recognizing various blocking tactics was minimal in people lacking medical backgrounds. This investigation did not elucidate the variations in pharmacodynamics and systemic toxicity concerns between the two blocks, as serum concentrations of local anesthetics (LA) were not measured. Further investigations are required to ascertain the minimal dosage of local anesthetics (LA) that yields the optimal favorable therapeutic benefits, hence mitigating the risk of toxicity. Third, this investigation was conducted at a single center within a particular surgical context and was subject to the inherent limitations of such studies. Given that laparoscopic nephrectomy is a moderately invasive procedure with a less extensive incision compared to open surgery [25-27], the resultant pain may not be sufficiently pronounced to differentiate the analgesic efficacy between TMQLB and TPVB. Additional research is necessary to examine the analgesic effects of TMQLB in various surgical procedures and patient demographics.

CONCLUSION

The findings of this study highlight that the transmuscular quadratus lumborum block (TMQLB) offers a postoperative analgesic effect comparable to that of the T10-level thoracic paravertebral block (TPVB), as evidenced by similar cumulative morphine consumption over 48 hours in patients undergoing laparoscopic partial nephrectomy. This suggests that TMQLB can effectively manage postoperative pain while providing an alternative to TPVB, particularly in cases where TPVB may not be feasible due to technical or patient-related factors. The broader sensory block coverage observed with TMQLB further underscores its potential utility in certain surgical settings. Given its efficacy and possible advantages, TMQLB holds promise as an alternative regional anesthesia technique for multimodal pain management in minimally invasive surgeries. However, further investigations are warranted to validate these findings across diverse surgical procedures, evaluate their long-term outcomes, and optimize their application for different patient populations.

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