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Concept: Quadratus lumborum muscle


BACKGROUND:: Slipping rib syndrome (SRS) is a musculoskeletal cause of severe and recurrent thoracic or abdominal pain. The etiology of SRS is unknown, it seems to arise from costal hypermobility with a tendency of one of the ribs (usually from 8th to 10th but also 11th and 12th have been described) to slip under the superior adjacent rib. Its prevalence is underestimated because SRS is mainly a clinical diagnosis, frequently missed. The critical aspect of the diagnosis is knowledge of the condition itself, which, when lacking, often results in the patient being referred to many different specialists and exposed to unnecessary and costly investigations. The management of the condition includes conservative techniques such as manipulation, localized anesthetic, and steroid or anesthetic nerve block. However, where conservative therapy fails, surgical treatment, with excision of the rib, may be performed. METHODS:: In this paper we describe the case of a patient with persistent and debilitating flank pain who, after many investigations, was diagnosed with SRS. RESULTS:: The usual conservative treatment failed, after which we treated the patient with injections of incobotulinumtoxin A into muscles inserting on the inferior side of the rib cage (quadratus lumborum muscle, muscle transversus abdomini, abdominal external oblique muscle, and recto abdomini) achieving a complete relief from pain. CONCLUSIONS:: To our knowledge botulinum toxin has never been proposed before for the treatment of SRS. We believe that it should be considered as a therapeutic option, especially where other medical treatments have failed or as an intermediate step before surgical intervention.

Concepts: Abdomen, Thorax, Rib, Human rib cage, Iliac crest, Abdominal external oblique muscle, Muscles of the torso, Quadratus lumborum muscle



A consensus has not been reached among strength and conditioning specialists regarding what physical fitness exercises are most effective to stimulate activity of the core muscles. Thus, the purpose of this paper was to systematically review the literature on the electromyographic (EMG) activity of three core muscles (lumbar multifidus, transverse abdominis, quadratus lumborum) during physical fitness exercises in healthy adults. CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, PubMed, SPORTdiscus, and Web of Science databases were searched for relevant articles using a search strategy designed by the investigators. Seventeen studies enrolling 252 participants met the review’s inclusion/exclusion criteria. Physical fitness exercises were partitioned into five major types: traditional core, core stability, ball/device, free weight, and non-core free weight. Strength of evidence was assessed and summarized for comparisons among exercise types. The major findings of this review with moderate levels of evidence indicate that lumbar multifidus EMG activity is greater during free weight exercises compared with ball/device exercises, and similar during core stability and ball/device exercises. Transverse abdominis EMG activity is similar during core stability and ball/device exercises. No studies were uncovered for quadratus lumborum EMG activity during physical fitness exercises. The available evidence suggests that strength and conditioning specialists should focus on implementing multi-joint free weight exercises, rather than core-specific exercises, in order to adequately train the core muscles in their athletes and clients.

Concepts: Muscle, Physical exercise, Exercise, Electromyography, Strength training, Exercise physiology, Bodybuilding, Quadratus lumborum muscle


Abdominal wall blocks rely on the spread of local anesthetic within musculofascial planes to anesthetize multiple small nerves or plexuses, rather than targeting specific nerve structures. Ultrasonography is primarily responsible for the widespread adoption of techniques including transversus abdominis plane and rectus sheath blocks, as well as the introduction of novel techniques such as quadratus lumborum and transversalis fascia blocks. These blocks are technically straightforward and relatively safe and reduce pain and opioid requirements in many clinical settings. The data supporting these outcomes, however, can be inconsistent because of heterogeneity of study design. The extent of sensory blockade is also somewhat variable, because it depends on the achieved spread of local anesthetic and the anatomical course of the nerves being targeted. The blocks mainly provide somatic analgesia and are best used as part of a multimodal analgesic regimen. This review summarizes the anatomical, sonographic, and technical aspects of the abdominal wall blocks in current use, examining the current evidence for the efficacy and safety of each.

Concepts: Anesthesia, Transversus abdominis muscle, Opioid, Pain, Morphine, Ketamine, Iliac crest, Quadratus lumborum muscle


Landmark and ultrasound-guided transversus abdominis plane blocks have demonstrated an opioid-sparing effect postoperatively after cesarean delivery. The more posterior quadratus lumborum (QL) might provide superior local anesthetic spread to the thoracolumbar fascia and paravertebral space. The aim of our study was to evaluate the efficacy of the QL block after cesarean delivery.

Concepts: Clinical trial, Randomized controlled trial, Effectiveness, Anesthesia, Transversus abdominis muscle, Pharmaceutical industry, Clinical research, Quadratus lumborum muscle


OBJECTIVE:: The objective of the study was to determine the magnitude and side of quadratus lumborum (QL) asymmetries in elite, adult, cricket fast bowlers and the relationship with lumbar spine injury. STUDY DESIGN:: Cohort study. SETTING:: Cricket fast bowers had magnetic resonance (MR) scans at the start of a cricket season and their injury characteristics over the next cricket season were compared with the amount of QL asymmetry. PARTICIPANTS:: Twenty-three elite, asymptomatic, adult, cricket fast bowlers. ASSESSMENT OF RISK FACTORS:: The cross-sectional area (CSA) of QL was measured using MR imaging. The association between side-to-side differences in CSA (asymmetry) was evaluated as a possible risk factor for development of lumbar spine injury. MAIN OUTCOME MEASURES:: The main outcome measurements were QL CSA and asymmetry in relation to lumbar spine injury in cricket fast bowlers. RESULTS:: There were a greater proportion of dominant (bowling arm) side asymmetries (65%). Asymmetry magnitudes that favored the dominant side were not significantly larger than those on the nondominant side. Four participants who had bone oedema on MR imaging preseason went on to develop symptomatic lumbar stress fractures. Participants with no lumbar spine injury had significantly larger QL asymmetries than those who sustained lumbar spine injury. CONCLUSIONS:: Cricket fast bowlers demonstrated asymmetrical QL development, which may be related to the trunk positions adopted in the fast bowling technique. Uninjured bowlers had larger asymmetries than those who developed lumbar spine injury, which is contrary to some previous research.

Concepts: Cohort study, Epidemiology, Bowler, Fast bowling, Quadratus lumborum muscle, Australia national cricket team


Several types of quadratus lumborum block (QLB) are used for postoperative analgesia and are believed to be effective against both somatic and visceral pain via a local anesthetic (LA) effect in the paravertebral space (PVS). However, it remains unclear whether all QLB techniques result in LA spread into the PVS. We hypothesized that LA administered via intramuscular QLB would spread into the paravertebral space and investigated the spread and sensory block area of LA in intramuscular QLB.

Concepts: Pain, Ketamine, Quadratus lumborum muscle


The quadratus lumborum (QL) block has been widely used for acute postoperative pain management after numerous surgical procedures including urological, abdominal, gynaecological and orthopaedic surgical procedures. The local anaesthetic spread in this area can provide unilateral sensory block in T6-L2 dermatomes. We performed bilateral quadratus lumborum block for the management of acute pain after the uterine artery embolization (UAE).

Concepts: Surgery, Anesthesia, Pain, Uterine artery embolization, Quadratus lumborum muscle


The anterior iliac crest (AIC) is one of the most common sites for harvesting autologous bone, but the associated postoperative pain can result in significant morbidity. Recently, the transmuscular quadratus lumborum block (TQL) has been described to anesthetize the thoraco-lumbar nerves. This study utilizes a combination of cadaveric models and clinical case studies to evaluate the dermatomal coverage and analgesic utility of TQL for AIC bone graft donor site analgesia.

Concepts: Opioid, Pain, Pelvis, Heroin, Analgesic, Iliac crest, Kanye West, Quadratus lumborum muscle


Ultrasound (US)-guided transversalis fascia plane block (TFPB) was first described by Hebbard as a technique for blockade of T12-L1 nerves. Although this technique appears similar to the quadratus lumborum 1 block, the point of injection is more caudal and anterior, specifically targeting ilioinguinal and iliohypogastric nerves. There are only few published data on US-guided TFPB demonstrating effective postoperative analgesia in iliac crest bone graft harvesting. We report the use of US-guided TFPB in a patient undergoing inguinal herniorrhaphy. Our experience suggests that this technique could represent a viable alternative to general anesthesia and standard regional techniques for inguinal hernia repair.

Concepts: Surgery, Inguinal hernia, Hernia, Hernias, Herniorrhaphy, Iliac crest, Transversalis fascia, Quadratus lumborum muscle