Case report
Quadratus lumborum block. New approach for a chronic hip pain. Cases report
Bloqueo del cuadrado lumbar: nueva vía de abordaje para el dolor crónico de cadera. Serie de casos
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Serie de casos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "48" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Quadratus lumborum block. New approach for a chronic hip pain. Cases report" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1801 "Ancho" => 2166 "Tamanyo" => 305862 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abordaje anteroposterior e imagen ecográfica del bloqueo QL2 (AL: anestésico local; LT: músculo <span class="elsevierStyleItalic">latissimus dorsi;</span> MOE: músculo oblicuo externo; MOI: músculo oblicuo interno; QL: músculo cuadrado lumbar; T: músculo transverso del abdomen).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.T. Fernández Martín, S. López Álvarez, E. 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Cases report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "48" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.T. Fernández Martín, S. López Álvarez, E. Ortigosa Solorzano" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M.T." "apellidos" => "Fernández Martín" "email" => array:1 [ 0 => "maitefm70@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "López Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Ortigosa Solorzano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Medina del Campo, Medina del Campo, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Abente y Lago, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de Getafe, Getafe, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo del cuadrado lumbar: nueva vía de abordaje para el dolor crónico de cadera. Serie de casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1801 "Ancho" => 2166 "Tamanyo" => 304862 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Anteroposterior approach and ultrasound image of the QL2 block (Aguja: needle; AL: local anaesthetic; LT: <span class="elsevierStyleItalic">latissimus dorsi</span> muscle ; MOE: external oblique muscle; MOI: internal oblique muscle; QL: quadratus lumborum muscle; T: transverse abdomen muscle).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoarthritis of the hip is a common, difficult to manage condition, and pain it causes has a major impact on the patient’s mobility and quality of life. The main factors involved in its etiology are biomechanical stress on the articular cartilage and subchondral bone and changes in the synovial membrane. However, biochemical changes in the articular cartilage or pre-existing hip diseases can also contribute.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For this reason, multimodal strategies are part of the therapeutic approach in patients with chronic hip pain. Scientific societies recognise that patients with pain require periodic evaluations and treatment changes. The goal of treatment should be to reduce pain, improve function, and reduce suffering.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the complex innervation of the hip, the number of minimally invasive techniques for chronic pain management have increased in recent years. In this context, we present the results obtained in 4 patients with chronic pain due to coxarthrosis who received type 2 block quadratus lumborum block (QL2) for pain control.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case reports</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 60-year-old woman with a diagnosis of incipient left coxarthrosis was referred to the pain unit by her traumatologist due to the poor results obtained with previous treatments (oral anti-inflammatory agents and minor opioids). The patient reported an 8-month history of nociceptive pain that prevented her from performing her daily activities and caused sleep disturbances. She rated the pain as 8 on the verbal numeric scale (VNS). In this clinical context, after informing the patient and obtained the corresponding signed consent, we focused our analgesic treatment on minimally invasive techniques involving the hip joint. We first performed obturator and femoral nerve block; but results were short-lived. Due to the good results obtained with QL block for postoperative analgesia in hip surgery, we decided to use this procedure to treat the patient’s chronic pain. The appropriate aseptic techinques were used, and the patient was placed supine with the ipsilateral pelvis elevated (the patient can also be placed lateral if the planes are not clearly visualised). We used a high frequency linear transducer (5–12<span class="elsevierStyleHsp" style=""></span>Mhz), which was placed transversely in the axillary midline, a few centimetres above the iliac crest. From this position, we scanned from anterior to posterior, locating the different muscle planes (external and internal oblique muscle and transverse abdominis muscle), continuing until the quadratus lumborum muscle was visualised. An 80<span class="elsevierStyleHsp" style=""></span>mm Ultraplex® 360 needle (B. Braun®, Germany) was introduced in plane from anterior to posterior until the tip reached the posterior surface of the quadratus lumborum muscle, where 15<span class="elsevierStyleHsp" style=""></span>ml 0.25% levobupivacaine plus 8<span class="elsevierStyleHsp" style=""></span>mg dexamethasone were deposited. Correct location was confirmed by observing the spread of the local anaesthetic between the quadratus lumborum muscle and the <span class="elsevierStyleItalic">latissimus dorsi</span> and paravertebral muscles (erector spinae) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">After the nerve block, the patient’s pain remained at VNS 1 for 15 days, after which the intensity increased (VNS 5), so it was decided to repeat the QL2 block. In the 30-day follow-up interview she reported no pain at rest (VNS 0), with good sleep and VNS 2 on effort (long walks), so she was discharged and referred to her orthopaedic surgeon, who confirmed the effectiveness of the blockade for more than 6 months.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 58-year-old woman, ASA I with signs of incipient coxarthrosis as the primary diagnosis, referred from orthopaedics for intolerance of oral treatments (NSAIDs and opioids). In the interview, the patient reported mechanical/degenerative pain that reached VNS 7 at rest, with partially improvement after walking (VNS 4), and sleep disturbances (VNS 8).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was scheduled for QL2 block as described in case 1. After the first procedure, the patient’s pain was controlled for 3 weeks, after which it reappeared, although with lower intensity (VNS 5), so we performed a second block. Pain after the second intervention was VNS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>2, allowing the patient to perform her daily activities and enjoying undisturbed sleep for more than 6 months.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0040" class="elsevierStylePara elsevierViewall">A 55<span class="elsevierStyleHsp" style=""></span>year old man, ASA III. Anti-inflammatories were contraindicated due to the patient’s comorbidity, so QL2 block was considered as a palliative pain technique. As in the previous cases, the patient was scheduled for the technique after signing the informed consent form and, where appropriate, suspending anticoagulant treatment according to protocol. Because of his weight (BMI 28), the muscle planes were more easily visualised in the lateral position. With the target hip elevated, the needle was inserted in plane from anterior to posterior, and the local anaesthetic was deposited on the posterior side of the quadratus lumborum muscle (15<span class="elsevierStyleHsp" style=""></span>ml). In subsequent follow-ups the patient has remained free from pain at rest or occasionally has tolerable pain on movement (VNS 2), so he was referred to his orthopaedic surgeon for follow-up.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Case 4</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 59<span class="elsevierStyleHsp" style=""></span>year old man, ASA II, was referred to our unit for chronic pain due to incipient coxarthrosis. Following the protocol used in the foregoing patients, a QL2 block was performed as a minimally invasive analgesic technique. After good initial response to treatment (VNS decreased from 7 to 1), the pain reappeared at 4 weeks, requiring a second analgesic block. At the time of writing (6 weeks later) his pain remains under control, with occasional pain on movement (VNS 2).</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">In hip osteoarthritis, damage to the articular cartilage alters the congruence and coaptation of the joint. The pain it produces is usually located in the groin area, extending to the thigh and trochanter, and has a major impact on the patient’s mobility and quality of life. The therapeutic goal is to restore functionality by providing pain relief with analgesic and anti-inflammatory drugs. However, the appearance of complications and reduced effectiveness as the disease progresses require other solutions (intra-articular drugs or nerve blocks), and ultimately hip replacement.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hip innervation is complicated, and arises from the lumbar and sacral plexuses (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The obturator and femoral nerves (branches of the lumbar plexus) supply sensory innervation to the anterior surface of the capsule, and the sciatic and gluteal nerves (branches of the sacral plexus) provide sensory innervation to the posterior and anterolateral face of the capsule.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These rami pass anteriorly through the psoas muscle and thoracolumbar fascia (TLF).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Our knowledge of anatomy and neurophysiology and our experience in ultrasound-guided regional anaesthesia enabled us to perform femoral and obturator nerve block<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> in the first of our patients. However, this gave only temporary relief, because the local anaesthetic did not provide lasting pharmacological neurolysis. Because radiofrequency is not available in our hospital, and given the good results obtained with quadratus lumborum block in hip surgery, we decided to use the QL2 block to treat chronic hip pain.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The quadratus lumborum technique is an interfascial block of the posterior wall of the abdomen, and was first described for postoperative pain management in abdominal surgery due to its effect on the nerves roots of T7-L1.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Type 1 quadratus lumborum block has been shown to provide effective postoperative analgesia in femur fracture<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and hip surgery.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Some studies have described the QL2 as an effective analgesia option in chronic pain after hernia repair surgery,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> or, as Hochberg described, in pancreatic cancer.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the 4 cases described in this report, the QL2 block was performed as an analgesic technique in patients with chronic coxalgia, under the hypothesis that the local anaesthetic would spread to the roots of the lumbosacral plexus, which supplies sensory innervation to the hip.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The landmark for quadratus lumborum block, and the key to its analgesic effect, is the TLF. The fascia is a tubular connective tissue formed of aponeurotic and fascial laminae that covers the posterior muscles, connecting the anterolateral wall to the paravertebral lumbar region. The analgesic mechanism of the quadratus lumborum block is not entirely clear, but the three-layered model is the most widely accepted. According to this model, the posterior lamina of the TLF wraps around the erector spinae and quadratus lumborum muscles, and the anterior lamina is located on the anterior aspect of the quadratus lumborum and psoas muscles. This anterior lamina joins cranially with the endothoracic fascia and the arcuate ligament and caudally with the iliac fascia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> These relationships could potentially provide the pathway for spread of the local anaesthetic.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our patients, we performed the QL2 block in the supine position with the ipsilateral pelvis elevated, or in 1 case in the lateral position in order to obtain a clearer view of the musculature. We began by placing a linear transducer in the axillary midline, slightly above the iliac crest, and then slid it posteriorly to locate the quadratus lumborum muscle. The needle was inserted in plane, from anterior to posterior, until the tip reached the posterior surface of the quadratus lumborum, between the muscle and the middle lamina of the TLF, which separates it from the latissimus dorsi and the paraspinal muscles (erector spinae muscles). We use dexamethasone as an adjuvant, following the recommendations of the latest meta-analyses,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> which claim that perineural administration prolongs the analgesic effect.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The success of the analgesia administered in our coxarthrosis patients could be due to 2 mechanisms. In the first of these, according to cadaver studies,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> the local anaesthetic spreads to the roots and branches of the lumbar plexus. The roots of L–L3 roots would be covered when the block is administered and the level of L3–4. The second of the mechanisms could be explained by the histopathological characteristics of the TLF. The superficial lamina of the TFL contains a large network of sympathetic neurons in addition to mechano-nociceptors that are sensitive to the action of local anaesthetics. These nociceptors play a fundamental role in the control of chronic pain.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">It is important to bear in mind that the TLF contains blood vessels that emerge from the paravertebral space; therefore, when performing QL2 block in anticoagulated patients, the treatment should be suspended in order to avoid the risk of haematoma.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion, the QL2 block, which has proven efficacy in the control of acute postoperative pain, could also be used to treat chronic pain. Although studies with larger sample sizes are needed, the results obtained in our patients are promising.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have not received funding for this study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1294721" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1195619" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1294722" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1195618" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case reports" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Case 3" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Case 4" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-04-16" "fechaAceptado" => "2019-10-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1195619" "palabras" => array:5 [ 0 => "Hip" 1 => "Chronic pain" 2 => "Quadratus lumborum block" 3 => "Ultrasonography" 4 => "Endothoracic fascia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1195618" "palabras" => array:5 [ 0 => "Cadera" 1 => "Dolor crónico" 2 => "Bloqueo cuadrado lumbar" 3 => "Ecografía" 4 => "Fascia toracolumbar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hip arthrosis is a frequent and difficult to manage disease. The generated pain supposes a great impact in the quality life of the patient. The goal of the treatment should be to reduce pain and to improve function. Based on the complex innervation of the hip, the minimally invasive thecniques have been increasing. In this context, we present the results obtained in four patients with a hip chronic pain due to arthrosis, to whom we performed a quadratus lumborum block type 2 (QL2) with levobupivacaine plus dexametasone as therapeutic option. The results have shown a significant decrease of the intensity of pain (NRS) for more than 6 months.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La artrosis de cadera es una patología frecuente y de difícil manejo. El dolor que genera supone un gran impacto en la calidad de vida del paciente. El objetivo del tratamiento debe ser reducir el dolor y mejorar la función. Atendiendo a la compleja inervación de la cadera las técnicas mínimamente invasivas han ido en aumento. En este contexto presentamos los resultados obtenidos en cuatro pacientes con dolor crónico por coxatrosis a los que realizamos un bloqueo del cuadrado lumbar tipo 2 (QL2) con levobupivacaína más dexametasona como opción terapéutica. Los resultados han mostrado un descenso significativo de la intensidad del dolor evaluado en la escala verbal numérica (EVN) durante un periodo superior a 6 meses.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Martín MT, López Álvarez S, Ortigosa Solorzano E. Bloqueo del cuadrado lumbar: nueva vía de abordaje para el dolor crónico de cadera. Serie de casos. Rev Esp Anestesiol Reanim. 2020;67:44–48.s</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1458 "Ancho" => 2500 "Tamanyo" => 347358 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Innervation of the hip.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Plexo lumbar: lumbar plexus; PS: psoas muscle; QL: quadratus lumborum muscle.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Source: Image courtesy of Complete Anatomy.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1801 "Ancho" => 2166 "Tamanyo" => 304862 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Anteroposterior approach and ultrasound image of the QL2 block (Aguja: needle; AL: local anaesthetic; LT: <span class="elsevierStyleItalic">latissimus dorsi</span> muscle ; MOE: external oblique muscle; MOI: internal oblique muscle; QL: quadratus lumborum muscle; T: transverse abdomen muscle).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A clinically relevant review of hip biomechanics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.F. 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