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Summary: Non‐steroidal anti‐inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre‐clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri‐operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90–180 days in previously opioid‐naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid‐naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri‐operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri‐operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736‐patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri‐operative NSAID prescription within 30 days was 1.32 (1.30–1.35), p < 0.001; and 1.12 (1.10–1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre‐existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population‐based cohort study suggests that peri‐operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision‐making for post‐surgical pain management, risk–benefit discussions with patients and future research. [ABSTRACT FROM AUTHOR]

Summary: Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta‐analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid‐related adverse effects and functional recovery. Network meta‐analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft‐donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single‐injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid‐related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single‐injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction. [ABSTRACT FROM AUTHOR]

Summary: The quadratus lumborum block (QLB) is reported to reduce pain and improve function following total hip arthroplasty; however, randomised controlled trials evaluating the benefits of adding this block to general or spinal anaesthesia in this population are conflicting. We performed a systematic review seeking randomised controlled trials investigating QLB benefits for total hip arthroplasty, stratifying comparisons regarding the addition of QLB to either general or spinal anaesthesia. The primary outcome was 24‐h area under the curve (AUC) pain score. Pain scores were interpreted in the context of a population‐specific minimal clinically important difference of 1.86 cm on a 10‐cm visual analogue scale, or an AUC pain score of 5.58 cm.h. Secondary outcomes included analgesic consumption, functional recovery and opioid‐related side‐effects. In all, 18 trials (1318 patients) were included. Adding QLB to general or spinal anaesthesia improved 24‐h AUC rest pain scores by a mean difference (95%CI) of −3.56 cm.h (−6.70 to −0.42; p = 0.034) and − 4.19 cm.h (−7.20 to −1.18; p = 0.014), respectively. These improvements failed to reach the pre‐determined minimal clinically important difference, as did the reduction in analgesic consumption. Quadratus lumborum block improved functional recovery for general, but not spinal, anaesthesia. Opioid‐related side‐effects were reduced with QLB regardless of anaesthetic modality. Low‐to‐moderate quality evidence suggests that the extent to which adding QLB to either general or spinal anaesthesia reduces postoperative pain and opioid consumption after total hip arthroplasty is statistically significant but may be clinically unimportant for most patients. However, adding QLB to general anaesthesia might enhance functional recovery. Taken together, our findings do not support the routine use of QLB as part of multimodal analgesic regimens for total hip arthroplasty. [ABSTRACT FROM AUTHOR]

Keywords: regional management; risk disclosure; upper extremity EN regional management risk disclosure upper extremity 1572 1576 5 11/08/21 20211201 NES 211201 Nerve injury is among the most feared complications of regional anaesthesia for both patients and providers alike. Based on the available literature, we therefore maintain that patient self-reported rates of postoperative neurological symptoms following peripheral nerve blockade within the context of prospective clinical regional anaesthesia research trials can be unreliable, invalid or both. Variations within clinical anaesthesia research trials may introduce bias and undermine the reliability, validity and generalisability of resultant patient-reported rates of postoperative neurological symptoms. Patient-reported rates of postoperative neurological symptoms following regional anaesthesia in clinical research trials. [Extracted from the article]

Summary: Deep serratus anterior plane block has been widely adopted as an analgesic adjunct for patients undergoing breast surgery, but robust supporting evidence of efficacy is lacking. We randomly allocated 40 patients undergoing simple or partial mastectomy with sentinel node biopsy to receive either a pre‐operative deep serratus anterior plane block (serratus group) or a placebo injection (sham group), in addition to systemic analgesia. The primary outcome measure was the quality of recovery score at discharge, as assessed by the quality of recovery‐15 questionnaire at various time‐points. Secondary analgesic outcomes included: pain severity; postoperative opioid consumption; opioid‐related side‐effects; patient satisfaction up to 7 days postoperatively; and persistent postoperative pain up to 3 months after surgery. All patients who were recruited completed the study. There were no differences in the quality of recovery‐15 scores between patients in the serratus and control groups, with mean (SD) scores of 96 (14) and 102 (20) for the control and serratus groups, respectively. We were also unable to detect differences in any of the secondary analgesic outcomes examined. The addition of a deep serratus anterior plane block to systemic analgesia does not enhance quality of recovery in patients undergoing ambulatory breast cancer surgery. [ABSTRACT FROM AUTHOR]

Summary: Both perineural and intravenous dexamethasone and dexmedetomidine are used as local anaesthetic adjuncts to enhance peripheral nerve block characteristics. However, the effects of dexamethasone and dexmedetomidine based on their administration routes have not been directly compared, and the relative extent to which each adjunct prolongs sensory blockade remains unclear. This network meta‐analysis sought to compare and rank the effects of perineural and intravenous dexamethasone and dexmedetomidine as supraclavicular block adjuncts. We sought randomised trials investigating the effects of adding perineural and intravenous dexamethasone or dexmedetomidine to long‐acting local anaesthetics on supraclavicular block characteristics, including time to block onset and durations of sensory, motor and analgesic blockade. Data were compared and ranked according to relative effectiveness for each outcome. Our primary outcome was sensory block duration, with a 2‐h difference considered clinically important. We performed a frequentist analysis, using the GRADE framework to appraise evidence. One‐hundred trials (5728 patients) were included. Expressed as mean (95%CI), the control group (local anaesthetic alone) had a duration of sensory block of 401 (366–435) min, motor block duration of 369 (330–408) min and analgesic duration of 435 (386‐483) min. Compared with control, sensory block was prolonged most by intravenous dexamethasone [mean difference (95%CI) 477 (160–795) min], followed by perineural dexamethasone [411 (343–480) min] and perineural dexmedetomidine [284 (235–333) min]. Motor block was prolonged most by perineural dexamethasone [mean difference (95%CI) 294 (236–352) min], followed by intravenous dexamethasone [289 (129–448)min] and perineural dexmedetomidine [258 (212–304)min]. Analgesic duration was prolonged most by perineural dexamethasone [mean difference (95%CI) 518 (448–589) min], followed by intravenous dexamethasone [478 (277–679) min] and perineural dexmedetomidine [318 (266–371) min]. Intravenous dexmedetomidine did not prolong sensory, motor or analgesic block durations. No major network inconsistencies were found. The quality of evidence for intravenous dexamethasone, perineural dexamethasone and perineural dexmedetomidine for prolongation of supraclavicular sensory block duration was 'low', 'very low' and 'low', respectively. Regardless of route, dexamethasone as an adjunct prolonged the durations of sensory and analgesic blockade to a greater extent than dexmedetomidine. Differences in block characteristics between perineural and intravenous dexamethasone were not clinically important. Intravenous dexmedetomidine did not affect block characteristics. [ABSTRACT FROM AUTHOR]

Summary: Phrenic‐sparing analgesic techniques for shoulder surgery are desirable. Intra‐articular infiltration analgesia is one promising phrenic‐sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta‐analysis evaluated the benefits and risks of intra‐articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra‐articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24‐h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time‐to‐first analgesic request; patient satisfaction; opioid‐related side‐effects; block‐related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra‐articular infiltration reduced 24‐h postoperative analgesic consumption by a weighted mean difference (95%CI) of −30.9 ([−38.9 to −22.9]; p < 0.001). Intra‐articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4 h (−2.2 cm [(−4.4 to −0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid‐ or block‐related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra‐articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery. [ABSTRACT FROM AUTHOR]

Effective analgesic alternatives to interscalene brachial plexus block are sought for shoulder surgery. Peri-articular infiltration analgesia is a novel, less invasive technique, but evidence surrounding its use is unclear. This systematic review and meta-analysis aims to evaluate the utility of peri-articular infiltration analgesia in shoulder surgery. We searched literature for trials comparing peri-articular infiltration analgesia with control or with interscalene brachial plexus block. Control groups received no intervention, placebo or systemic opioids. The primary outcome was cumulative oral morphine equivalent consumption during the first 24 h postoperatively. Secondary outcomes included: rest pain scores up to 48 h; risk of side-effects; and durations of post-anaesthetic care unit and hospital stay. Data were pooled with random-effects modelling. Seven trials (383 patients) were included. Compared with control, peri-articular infiltration analgesia reduced 24-h oral morphine consumption by a mean difference (95%CI) of -38.0 mg (-65.5 to -10.5; p = 0.007). It also improved pain scores up to 6 h, 36 h and 48 h, with the greatest improvement observed at 0 h (-2.4 (-2.7 to -1.6); p < 0.001). Peri-articular infiltration analgesia decreased postoperative nausea and vomiting by an odds ratio (95%CI) of 0.3 (0.1-0.7; p = 0.006). In contrast, peri-articular infiltration analgesia was not different from interscalene brachial plexus block for analgesic consumption, pain scores or side-effects. This review provides moderate evidence supporting peri-articular infiltration for postoperative analgesia following shoulder surgery. The absence of difference between peri-articular infiltration analgesia and interscalene brachial plexus block for analgesic outcomes suggests that these interventions are comparable, but further trials are needed to support this conclusion and identify the optimal peri-articular infiltration technique. [ABSTRACT FROM AUTHOR]

Intravenous magnesium has been reported to improve postoperative pain; however, the evidence is inconsistent. The objective of this quantitative systematic review is to evaluate whether or not the peri-operative administration of intravenous magnesium can reduce postoperative pain. Twenty-five trials comparing magnesium with placebo were identified. Independent of the mode of administration (bolus or continuous infusion), peri-operative magnesium reduced cumulative intravenous morphine consumption by 24.4% (mean difference: 7.6 mg, 95% CI −9.5 to −5.8 mg; p < 0.00001) at 24 h postoperatively. Numeric pain scores at rest and on movement at 24 h postoperatively were reduced by 4.2 (95% CI −6.3 to −2.1; p < 0.0001) and 9.2 (95% CI −16.1 to −2.3; p = 0.009) out of 100, respectively. We conclude that peri-operative intravenous magnesium reduces opioid consumption, and to a lesser extent, pain scores, in the first 24 h postoperatively, without any reported serious adverse effects. [ABSTRACT FROM AUTHOR]

The coexistence of progressive multifocal leukoencephalopathy (PML) and primary central nervous system lymphoma (PCNSL) is a rare event, usually associated with a fatal outcome. We report the case of a human immunodeficiency virus (HIV)-infected individual presenting with both PML and PCNSL who made a remarkable recovery after highly active anti retroviral theraphy (HAART) and radiation therapy, and discuss diagnostic and therapeutic aspects of both conditions. [ABSTRACT FROM AUTHOR]

Quality of recovery scores in deep serratus anterior plane block vs. sham block in ambulatory breast cancer surgery: a randomised controlled trial. We thank Stokes et al. [1] for their interest in our study evaluating the effects of the addition of the deep serratus anterior plane block to systemic analgesia on postoperative quality of recovery and analgesic outcomes in patients undergoing ambulatory breast cancer surgery [2]. [Extracted from the article]

A letter to the editor about ultrasound-guided posterior tibial nerve block is presented.

Eighteen published trials have examined the use of neuraxial magnesium as a peri-operative adjunctive analgesic since 2002, with encouraging results. However, concurrent animal studies have reported clinical and histological evidence of neurological complications with similar weight-adjusted doses. The objectives of this quantitative systematic review were to assess both the analgesic efficacy and the safety of neuraxial magnesium. Eighteen trials comparing magnesium with placebo were identified. The time to first analgesic request increased by 11.1% after intrathecal magnesium administration (mean difference: 39.6 min; 95% CI 16.3-63.0 min; p = 0.0009), and by 72.2% after epidural administration (mean difference: 109.5 min; 95% CI 19.6-199.3 min; p = 0.02) with doses of between 50 and 100 mg. Four trials monitored for neurological complications: of the 140 patients included, only a 4-day persistent headache was recorded. Despite promising peri-operative analgesic effect, the risk of neurological complications resulting from neuraxial magnesium has not yet been adequately defined. [ABSTRACT FROM AUTHOR]