Quadroiliac plane block for postoperative pain management in a pediatric patient undergoing tethered cord release surgery: a case report.

Background: Opioid-free analgesia is critical in pediatric patients with complex comorbidities to avoid adverse effects, such as respiratory depression. Patients with tethered cord syndrome (TCS), often presenting with conditions like spina bifida, renal impairment, and musculoskeletal deformities, pose unique perioperative challenges that demand alternative pain management strategies.

Case: We present the case of an 11-year-old male with spina bifida and chronic kidney disease (CKD) undergoing tethered cord release surgery. Due to her renal impairment and the need to minimize opioid use, a Quadro-Iliac Plane Block (QIPB) was chosen for postoperative analgesia. General anesthesia was induced with midazolam, fentanyl, propofol, and rocuronium, and maintained with sevoflurane in oxygen-air mixture. Bilateral QIPB was performed with a total of 0.3 ml/kg of 0.25% bupivacaine (divided to both sides) under ultrasound guidance before extubation. Pain was assessed using the FLACC scale at 1, 6, 12, and 24 h postoperatively. The patient's initial FLACC score was 0 at both rest and movement, remaining consistently low at 0 until the 24-hour mark, where it was recorded as 1. Throughout the postoperative period, the patient did not require any opioids, achieving effective analgesia without additional analgesic interventions. Notably, no motor block or common side effects like nausea, vomiting, or hematoma were observed, contributing to a smooth and comfortable recovery as reported by both the patient and her family.

Discussion: The Quadro-Iliac Plane Block (QIPB), first described by Tulgar et al., has shown potential for epidural spread, making it suitable for lumbar surgeries. Although no randomized controlled trials exist, QIPB has demonstrated efficacy in various clinical contexts, including single-level lumbar discectomy, renal transplantation, and proximal femoral nidus surgeries. This case represents the first documented use of QIPB in a pediatric patient, highlighting its potential as an opioid-sparing analgesic technique with minimal complications.

Conclusion: QIPB provided effective postoperative pain control in an 8-year-old with TCS and CKD, supporting its application in pediatric patients who benefit from opioid-free analgesia. This case underscores the potential of QIPB as a component of multimodal analgesia strategies, especially in high-risk pediatric cases. Further studies are needed to confirm its safety and efficacy in larger pediatric populations.