Erector Spinae and Quadratus Lumborum - Anatomy, DOMS, and Treatment

ERECTOR SPINAE

Anatomy

• The sacrum
• Spinous processes of the lumbar and lower thoracic vertebrae
• Iliac crest

DOMS of Erector Spinae

• Deep, aching stiffness along the thoracic and/or lumbar spine, typically beginning 12-24 hours after unaccustomed activity and peaking at 24-72 hours
• Common triggers: deadlifts, heavy squats, rowing, prolonged forward bending, carrying loads
• Reduced range of motion in spinal extension and lateral flexion
• Tenderness to palpation of the longitudinal muscle columns alongside the spine
• Pain is bilateral when the cause is axial loading; unilateral in asymmetric tasks

Treatment of Erector Spinae DOMS / Myofascial Pain

• Rest and activity modification
• NSAIDs (e.g. ibuprofen, naproxen) - reduce prostaglandin-mediated pain
• Muscle relaxants (e.g. cyclobenzaprine)
• Spray and stretch - vapocoolant spray followed by passive stretching of the muscle
• Massage therapy
• Ischemic compression of trigger points
• Heat application (improves blood flow and reduces stiffness)

1. Position the patient recumbent (relaxes muscle, prevents syncope)
2. Identify and mark the trigger point; clean skin with antiseptic
3. Use a 22-gauge, 1.5-inch needle for superficial muscles; 21-gauge, 2-2.5-inch for deeper
4. Grasp skin between thumb and index finger; insert needle 1-1.5 cm from the trigger point at a 30-degree angle
5. Aspirate first (to exclude blood vessel entry), then inject a small amount
6. Withdraw to skin, redirect, and reinject using a fast-in, fast-out technique to elicit a local twitch response - this is critical for effectiveness
7. Paresthesia or severe cramping = withdraw immediately (nerve contact)
8. After injection, put the muscle through a full active stretch

• Local anesthetic (lidocaine 1%) is preferred - reduces post-injection soreness
• Sterile saline or dry needling are equally effective (nature of injectate does not change outcome)
• Steroids are NOT recommended for trigger points - no inflammatory basis for trigger point pain
• Botulinum toxin has been used

• Patient seated or lateral decubitus
• Linear/curvilinear ultrasound probe in parasagittal orientation
• Identify trapezius, rhomboid, and erector spinae muscles superficial to transverse processes
• Insert long block needle caudad-to-cephalad or cephalad-to-caudad, in-plane, until it contacts the transverse process
• Inject a large volume (30-50 mL) of local anesthetic - spread should be seen over several spinal levels
• Local anesthetic diffuses into the paravertebral space covering multiple dermatomes

• Morgan and Mikhail's Clinical Anesthesiology, 7e, p. 1952
• Miller's Anesthesia, 10e

QUADRATUS LUMBORUM (QL)

Anatomy

• Gray's Anatomy for Students, p. 431

DOMS of Quadratus Lumborum

• Presents as unilateral or bilateral low back pain and stiffness, often extending to the iliac crest, lower abdomen, or groin
• Triggered by: heavy lifting in lateral flexion, carrying loads on one side, prolonged sitting with lumbar asymmetry, or sudden trunk side-bending
• Trigger points are extremely common in the QL and are found along the 12th rib, around the iliac crest, and along the lateral border of the muscle
• Referred pain can go to the anterior abdominal wall; QL trigger points can also accentuate postoperative pain or painful lower-quadrant abdominal scars
• Trigger points may be associated with distress on deep inspiration and 12th rib pain (because the QL stabilizes rib XII during breathing)
• The QL and gluteus medius should be suspected in all patients presenting with low back pain
• Roberts & Hedges' Clinical Procedures in Emergency Medicine

Treatment of Quadratus Lumborum DOMS / Myofascial Pain

• Miller's Anesthesia, 10e, p. 11096-11098
• Morgan & Mikhail's Clinical Anesthesiology, 7e, p. 1962

Summary Table