Reply to Dr Fusco et al

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To the Editor:
We read with interest the comments of Fusco et al1 regarding our recent article,2 “Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial.” We respectfully disagree with the points highlighted in the letter, however.
There is no doubt that multimodal analgesia is important in providing adequate pain relief for cesarean deliveries, but the idea for this randomized controlled trial, comparing the 2 techniques, was to help providers choose the one that achieves better results.
Fusco et al suggest that the main point of objection to a quadratus lumborum block is that it is difficult to perform. We do not find this to be the case. We perform this block daily with the patient in the supine position, and we have never failed to achieve our target; nor have we registered any complications thus far. Can users of the transverse abdominis plane (TAP) block claim the same results? How many times have those performing TAP blocks observed the needle advancing too deeply into the intraabdominal cavity? An exercise of self-analysis should answer these questions. The contracting uterus postdelivery produces a very hard abdomen that may cause difficulty in maintaining a straight needle path without curving. This therefore requires skill to compensate for the curvature created to achieve the desired plane in the anterior abdominal wall. This pertains not only to “big” abdomens but also to thin patients, where the uterus is more prominent. This should also be considered as a factor that increases the difficulty of performing an anterior abdominal wall block.
In our study, the TAP block was proven inferior for pain management. We welcome the letter's authors, together with other groups worldwide interested in this subject, to conduct randomized controlled trials to confirm or refute our results.

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