Quadro-iliac plane block (QIPB) in lumbar stabilisation surgeries: A case series

Lumbar discectomies are widely performed surgical procedures aimed at alleviating pain and neurological symptoms caused by lumbar disc herniation. These surgeries, often involving multiple levels of the spine, are essential for patients suffering from significant spinal pathology. However, despite routine procedures, effective postoperative pain management remains a persistent challenge in ensuring optimal patient outcomes and satisfaction. In light of these difficulties, we would like to introduce and discuss a novel regional anaesthesia technique, the quadro-iliac plane block (QIPB), which has shown promising results in managing postoperative pain in patients undergoing lumbar spinal surgeries.[1] The block was performed before transitioning patients from the prone to the supine position, making it a practical option during lumbar stabilisation procedures such as multi-level discectomies. We performed this technique on five patients who underwent lumbar stabilisation surgeries (three-level discectomies) to evaluate its effectiveness in managing postoperative pain. All patients were operated under general anaesthesia with similar doses of anaesthetic drugs [intravenous 1–2 mg midazolam, 1 μg/kg fentanyl, 2–3 mg/kg propofol, 0.6–0.9 mg/kg rocuronium for induction and remifentanil infusion (0.05–0.2 μg/kg/min) and sevoflurane 2% with oxygen–air mixture for maintenance]. Each patient received a bilateral application of 100 mg of 0.25% bupivacaine as part of QIPB (20 ml per side) [Figure 1]. The perioperative analgesic regimen was standardised across all patients, consisting of 100 mg tramadol, 1 g paracetamol and 50 mg dexketoprofen administered intravenously 20 min before the block procedure. Following the surgery, 1 g paracetamol was routinely administered intravenously three times a day. The postoperative pain scores were assessed using the Visual Analogue Scale (VAS) at rest and during movement at 0, 1, 6, 12 and 24 h postoperatively. Fifty milligrams dexketoprofen was administered as rescue analgesia for patients with a VAS score of 4 or above. Patient demographic data are shown in Table 1. Our results demonstrated that QIPB provided substantial pain relief in the early postoperative period. The median VAS scores at rest were recorded as 2 [range: 2–3; interquartile range (IQR): 2–3], 2 (range: 1–2; IQR: 2–2), 2 (range: 1–2; IQR: 2–2), 1 (range: 1–2; IQR: 1–2) and 3 (range: 2–4; IQR: 3–3) at the 0-, 1-, 6-, 12- and 24-h marks, respectively. Similarly, the median VAS scores during movement were 3 (range: 2–3; IQR: 2–3), 2 (range: 1–3; IQR: 2–2), 2 (range: 1–2; IQR: 2–2), 2 (range: 1–2; IQR: 2–2) and 3 (range: 3–4; IQR: 3–4) at the corresponding time points. Notably, none of the patients required rescue analgesia within the first 12 h postoperatively. However, three patients did require 100 mg tramadol at the 16-h mark, indicating that while QIPB was effective in the early postoperative period, additional analgesic support was needed as the block’s effects began to wane. Notably, no adverse effects were reported. None of the patients experienced nausea, vomiting or motor blockade, all of which are common side effects associated with other regional anaesthesia techniques or systemic analgesics. The absence of these complications further highlights the potential advantages of QIPB as a regional anaesthesia technique for spinal surgeries.Figure 1: Sonoanatomy of quadro-iliac plane block: (a) quadratus lumborum muscle; (b) iliac crest; (c) needle; (d) spread of local anaestheticsTable 1: Patient dataTulgar et al.[2] described this novel fascial plane block, which targets the posterior aspect of the quadratus lumborum muscle at its attachment to the inner surface of the iliac crest. In this cadaveric study, they demonstrated that the local anaesthetic administered from this anatomical location could even spread to the epidural surface. This anatomical approach allows for effective coverage of the lower lumbar nerves, offering localised pain relief that is particularly beneficial for surgeries involving multiple lumbar levels.[1,3] This particular block has also demonstrated effectiveness for postoperative analgesia in proximal femur nidus surgeries.[4] In conclusion, QIPB shows promise in improving patient recovery, reducing the need for opioid analgesics and enhancing overall postoperative satisfaction. This technique could meaningfully impact postoperative pain management for spinal surgeries. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients consented to their images and other clinical information to be reported in the journal. The patients understand that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship There are no financial support and sponsorship for this paper. Conflicts of interest There are no conflicts of interest.