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Dear Editor, Recently, Tulgar et al. defined another novel fascial plane block named the “quadro-iliac plane block” (QIPB).1 QIPB is performed between the inner surface of the iliac crest (IC) and the posterior aspect of the quadratus lumborum (QL) muscle—the quadro-iliac plane. Tulgar et al. applied 40 mL of methylene blue to the quadro-iliac plane on each side, and they reported that there was extensive dye spread over the posterior and anterior aspects of the QL muscle and along the transversalis fascia; the ilioinguinal, iliohypogastric, subcostal, and genitofemoral nerves; and the lumbar plexus.1 According to their results, QIPB could be an effective technique for acute or chronic pain management in the lumbosacral, abdominal, and hip regions. However, although there is a cadaveric spread examination of QIPB, there is no case report about its efficacy yet. Therefore, we performed QIPB on 7 patients who underwent laparoscopic renal transplantation donor surgery. In this letter, we share our experiences with QIPB. Written informed consent was obtained from the patients for this report. The demographic data of the patients are shown in Table 1. We performed unilateral QIPB on our patients, according to the side of the operation, at the end of the surgery before extubation. We used a low-frequency convex transducer (2–6 MHz) and a 22G, 80-mm block needle for the procedure. We performed QIPB while the patient was in the lateral decubitus position with the surgical site up. We placed the transducer in the parasagittal plane over the IC, where the QL muscle attaches to the IC. The erector spinae muscle over the QL muscle and the IC were visualized. The needle was directed toward the place where the QL muscle attaches to the IC, as previously described.1 After the tip of the needle touched the IC, 5 mL of isotonic was administered for the correction. Then, 40 mL of 0.25% bupivacaine was administered into the quadro-iliac plane. The spread of local anesthesia was visualized along the plane between the QL muscle and erector spinae muscle. We administered 400 mg of ibuprofen and 100 mg of tramadol intravenously to our patients 20 minutes before the end of the surgery. We administered 400 mg of ibuprofen intravenously every 8 hours postoperatively. We evaluated the pain levels with the numeric rating scale for the postoperative 24-hour period. The numeric rating scale scores and the need for additional analgesics are seen in Table 1. Demographic data of the patients, pain scores, and need for rescue analgesia. Demographic data of the patients, pain scores, and need for rescue analgesia. We performed QIPB on 7 (4 male, 3 female) patients. The ages of the patients were between 39 and 67 years. All of them underwent laparoscopic living-donor renal transplantation surgery. Only one of our patients needed rescue analgesic in the first postoperative hour (numeric rating scale score: 5), so we administered 40 mg meperidine intravenously. Our other patients had low pain scores (numeric rating scale scores: 3 or less than 3) and did not require rescue analgesics. According to our clinical experience, QIPB provided effective analgesia to renal transplant donor patients. Transplantation surgery develops through improvements in surgical techniques. Renal transplantation is the most effective treatment for end-stage renal disease. Most patients experience severe pain after transplantation surgery.2,3 Analgesia management is very important in these patients, as it accelerates mobilization and recovery in the postoperative period and increases patient comfort. Thoracic epidural analgesia is the gold standard after abdominal surgery; however, its use is limited in transplantation patients because of the high frequency of platelet dysfunction.3 The QL block may be used in this patient group.3 The QL block is a deep block, and it is necessary to be very careful not to damage the surrounding tissues.1 It can be difficult to apply. Unlike the QL block, QIPB is a more superficial block and is easier to visualize. CI is an anatomic landmark and plays the role of a bone barrier in front of the needle. QIPB combines anterior and posterior QL block in a single injection because it allows passage to both the front and back of the muscle. Because QIPB spreads to the ilioinguinal, iliohypogastric, subcostal, and genitofemoral nerves and lumbar plexus, it can provide extensive and effective analgesia in this area.1 Because there is distribution in both the anterior and posterior areas of the QL muscle, a strong analgesic effect can be achieved with a single injection of QIPB in the areas of the anterior and posterior QL blocks. Therefore, this block can be used in lower and upper abdomen and hip surgeries. QIPB can provide blockade in the T12–L1 dermatomes by spreading to the ilioinguinal, iliohypogastric, and subcostal nerves via the transversalis fascia, and it can provide effective analgesia after surgeries such as cesarean section and inguinal hernia involving this region. Because this block also spreads to the lumbar plexus, it can be used as an effective anesthetic method. However, it should not be forgotten that motor block can occur with increasing volumes. Given this spread, QIPB can also provide effective analgesia in spinal surgeries. The important advantages of QIPB in spinal surgery are that it is far from the surgical field and can be applied easily in the prone position. In this sense, QIPB might be a promising regional anesthesia technique in the future. Only one of our patients needed additional analgesia in the first hour postoperatively, but the amount needed was low, and there was no need for additional analgesia afterward. The reason for the relative failure of the QIPB in this patient might be inadequate distribution of the local anesthetic in the fascial planes, within the thoracolumbar fascia, and possible adhesions between the QL muscle and the erector spinae muscle. It could also depend on how the block is performed. In plane blocks, even the needle’s touching the bony anatomic landmark at various points could change the effect of the block.4 As a limitation of our case report, we did not evaluate the dermatome levels. More case reports and clinical studies are needed to fully understand the effectiveness and mechanism of this block. In our experience, QIPB provides effective abdominal analgesia. Author contributions: All of the authors (H.G., B.C., I.K., A.I., T.Y., and S.T.) made substantial contributions to the conception and design, or acquisition of data, or analysis and interpretation of data; they have been involved in drafting the manuscript or revising it critically for important intellectual content; and have given final approval of the version to be published. Consent for publication: Written informed consent was obtained from the participants. No funding. Conflicts of interest: The authors declare that they have no competing interests.
Güngör et al. (Sat,) studied this question.