Quadratus lumborum block (QLB) is clinically used for postoperative analgesia of abdominal or hip surgery, which can reduce the dose of general anesthetic, inhibit postoperative pain, and promote postoperative rehabilitation. However, accumulated studies have shown several drawbacks of QLB, such as only a small portion of local anesthetic spread into the thoracic paravertebral space, relatively longer onset time, and easily-influenced block effect by the integrity of lumbar fascia, etc. Therefore, on the basis of traditional anterior QLB, our group proposed the techniques of a supra-arcuate ligament block, which include a paramedian short-axis scanning approach, paramedian long-axis scanning approach, infra-lateral arcuate ligament QLB with the apposition zone between diaphragm and quadratus lumborum as drug diffusion target and supra-arcuate ligament block under direct laparoscopic visualization. Recent studies have demonstrated that the supra-arcuate ligament blocks have the advantages of clear anatomy, are easy to perform, and have rapid onset, which avoid some drawbacks of the conventional QLB techniques. This article reviews the anatomical basis, sonoanatomy, technical points, and clinical considerations of supra-arcuate ligament blocks.

Several studies have shown the effectiveness of trans-muscular quadratus lumborum block (TQLB) in analgesia after cesarean delivery. However, the influence of anterior QLB at the lateral supra-arcuate ligament (QLB-LSAL) in this surgery is unclear. This study aimed to compare the analgesic efficacy of bilateral TQLBs with bilateral QLBs-LSAL following cesarean delivery. Ninety-four parturients scheduled for cesarean delivery under spinal anesthesia were enrolled and randomly allocated to undergo either bilateral TQLBs or bilateral QLBs-LSAL with 0.375% of ropivacaine (20 mL each side) following cesarean delivery. Intravenous sufentanil was administered for patient-controlled analgesia (PCA). The primary outcome was postoperative sufentanil consumption during the initial 24 h post-surgery. Secondary endpoints included pain scores, time to the first PCA request, postoperative rescue analgesia, satisfaction scores, and nausea/vomiting events. Sufentanil consumption was significantly reduced in the QLB-LSAL group in the first 24 h compared with the TQLB group after surgery (29.4 ± 5.7 μg vs. 39.4 ± 9.6 μg, p < 0.001). In comparison with TQLB, the time to the first PCA request in the QLB-LSAL group was significantly longer (10.9 ± 4.1 h vs. 6.7 ± 1.8 h, p < 0.001). No differences were observed between two groups regarding pain scores, rescue analgesia after surgery, satisfaction scores, or nausea/vomiting incidence. The significant reduction in opioid consumption in the first 24 h and prolongation in time to first opioid demand in parturients receiving QLB-LSAL compared with TQLB suggest that the QLB-LSAL is a superior choice for multimodal analgesia after cesarean delivery.

Diaphragm Dysfunction (DD) is a respiratory disorder with multiple causes. Although both unilateral and bilateral DD could ultimately lead to respiratory failure, the former is more common. Increasing research has recently delved into perioperative diaphragm protection. It has been established that DD promotes atelectasis development by affecting lung and chest wall mechanics. Diaphragm function must be specifically assessed for clinicians to optimally select an anesthetic approach, prepare for adequate monitoring, and implement the perioperative plan. Recent technological advancements, including dynamic MRI, ultrasound, and esophageal manometry, have critically aided disease diagnosis and management. In this context, it is noteworthy that therapeutic approaches for DD vary depending on its etiology and include various interventions, either noninvasive or invasive, aimed at promoting diaphragm recruitment. This review aims to unravel alternative anesthetic and operative strategies that minimize postoperative dysfunction by elucidating the identification of patients at a higher risk of DD and procedures that could cause postoperative DD, facilitating the recognition and avoidance of anesthetic and surgical interventions likely to impair diaphragmatic function.

Purpose: The subcostal quadratus lumborum (QL) block was used in postoperative analgesia for abdominal surgery. However, it is difficult to precisely put the needle tip into the target fascia compartment. In the current study, we proposed a modified approach to facilitate the subcostal QL block. Patients and Methods: Twenty-four patients scheduled for laparoscopic renal surgery were enrolled. The modified QL block was placed preoperatively. The transducer was placed just laterally to the tip of L1 transverse process to perform the parasagittal scan. The needle was inserted in-plane and advanced toward the target compartment between the QL muscle and the anterior thoracolumbar fascia and just below the lateral arcuate ligament. The 20 mL of 0.5% ropivacaine was injected slowly if the saline spread cranially via the posterior pathway of lateral arcuate ligament was observed on the sonogram. Then, the paramedian transverse scanning at the level of T12-L1 was performed to observe the injectate diffusion. The dermatomal coverage of sensory block was tested at 5 min and 10 min after LA injections. The complications associated with the block were recorded. Results: Twenty-three (95.8%) patients received the successful block. All patients achieved the sensory block dermatomes of T9–T12 and T6–L1, at 5 and 10 minutes after injection, respectively. The mean numbers of block dermatomes were 5.6± 1.8 at 5 min and 6.5± 2.2 at 10 min after injection. Two out of twenty-three (8.7%) patients achieved coverage as cephalad as T5 at 10 min after injections. The lunar-shaped spread of LA along the diaphragm into the T12 paravertebral space was observed in every patient. No complications occurred. Conclusion: The modified subcostal QL block has the advantages of clear sonoanatomy, rapid onset time, and consistent dermatomal coverage and provides a new choice for postoperative analgesia of abdominal surgery. Trial Registration: Chinese Clinical Trial Registry: ChiCTR2000029210.

Synapses serve as the interface for the transmission of information between neurons in the central nervous system. The structural and functional characteristics of synapses are highly dynamic, exhibiting extensive plasticity that is shaped by neural activity and regulated primarily by trans-synaptic cell-adhesion molecules (CAMs). Prototypical trans-synaptic CAMs, such as neurexins (Nrxs) and neuroligins (Nlgs), directly regulate the assembly of presynaptic and postsynaptic molecules, including synaptic vesicles, active zone proteins, and receptors. Therefore, the trans-synaptic adhesion mechanisms mediated by Nrx–Nlg interaction can contribute to a range of synaptopathies in the context of pathological pain and other neurological disorders. The present review provides an overview of the current understanding of the roles of Nrx–Nlg interaction in the regulation of trans-synaptic connections, with a specific focus on Nrx and Nlg structures, the dynamic shaping of synaptic function, and the dysregulation of Nrx–Nlg in pathological pain. Additionally, we discuss a range of proteins capable of modulating Nrx–Nlg interactions at the synaptic cleft, with the objective of providing a foundation to guide the future development of novel therapeutic agents for managing pathological pain.