Lecture 5

The quadratus lumborum muscle under investigation – what really hurts?

  • Dr. Simon Vulfsons, MD

    Pain Medicine Physician
    Musculoskeletal Medicine

Institute for Pain Medicine
Rambam Health Care Center
11 Ephron Street, Haifa 31096, Israel


Acknowledgments: Dr. Ronern Cozacov, Dr. Amir Minerbi

Lower back pain is a very common ailment in the population and is a cause of numerous calls for medical assistance and the loss of  working days. There are many etiologies for the origin of lower back pain such as myofascial pain syndrome, facet joint , sacroiliac joint , intervertebral discs , spinal canal stenosis, failed back surgery syndrome and so forth.The Quadratus Lumborum (QL) muscle is located at the rear of the abdominal wall.  This muscle is a common cause of lower back pain especially when associated with Myofascial Pain Syndrome (MPS). This syndrome is characterized by the presence of trigger points.Trigger points are hyperirritable painful spots involving a limited number of muscle fibers. these sensitive points are found either in the fascial tissue enveloping a muscle, in the muscle itself, or in both the fascia and the muscle.One of the treatment methods currently available for patients suffering from lower  back pain due to MPS of the QL, is dry needling. The QL muscle is wrapped with fascia tissue rich in blood vessels and nerves that transmit extensive sensory information. It is widely known that the sensory innervation of a muscle's fascia is much richer than the innervation of a muscle itself, and this is reflected in patient treatment of MPS. "Dry Needling" includes the insertion of a thin needle (usually an acupuncture needle) guided by anatomical landmarks. Experienced clinicians are accustomed to "sense" the fascia where patients report sensitivity. After the needle is inserted through the fascia tissue into the muscle there may be a decrease in sensitivity especially after a muscle twitch response.The primary aim of this study was to describe the exact location of tenderness in the QL, either around the muscle fascia, in the fascia tissue, or within the muscle. We could track the self reported pain level for each location by using ultrasound guidance. We  visualized the needle and followed its track from the subcutaneous tissue, to the fascia, through the fascia and into the muscle. Doing so, we enquired for the pain level at each location and, in addition, registered if there was a twitch reaction of the muscle. In this brief discussion we will report the findings of this study.

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Director of the Institute for Pain Medicine, Rambam Medical Center, Haifa, Israel

Chairman and Founding member of the Israel Society for Musculoskeletal Medicine

2014-2018 President of the International Federation for Manual/ Musculoskeletal Medicine

2009 Founder of the Rambam School for Pain Medicine

Establisher of trustee courses taught in conjunction with the Technion School for continuing Medical Education