SummaryShoulder surgery is well recognised as having the potential to cause severe postoperative pain. The aim of this review is to assess critically the evidence relating to the effectiveness of regional anaesthesia techniques commonly used for postoperative analgesia following shoulder surgery. Subacromial ⁄ intra-articular local anaesthetic infiltration appears to perform only marginally better than placebo, and because the technique has been associated with catastrophic chondrolysis, it can no longer be recommended. All single injection nerve blocks are limited by a short effective duration. Suprascapular nerve block reduces postoperative pain and opioid consumption following arthroscopic surgery, but provides inferior analgesia compared with single injection interscalene block. Continuous interscalene block incorporating a basal local anaesthetic infusion and patient controlled boluses is the most effective analgesic technique following both major and minor shoulder surgery. However, interscalene nerve block is an invasive procedure with potentially serious complications and should therefore only be performed by practitioners with appropriate experience.

SummaryLittle data exists regarding the frequency of neurological complications following ultrasound guided peripheral nerve blockade. Therefore, we studied single injection and continuous ultrasound guided interscalene, supraclavicular, infraclavicular, femoral and sciatic nerve blocks in patients undergoing orthopaedic extremity surgery. All patients were contacted during postoperative weeks 2-4 and questioned for numbness or altered sensation anywhere in the involved extremity, and pain or weakness unrelated to surgery. The presumed aetiology of symptoms was based on the collective agreement of principal investigator, primary surgeon and a neurologist. Multivariate analysis was performed for characteristics potentially important in the causation of neurological complications. Of 1010 consecutive blocks, successful follow up between weeks 2 and 4 occurred in 98.6%. New, all-cause, neurological symptoms were present in 56 ⁄ 690 blocks (8.2%) at day 10, 37 ⁄ 1010 (3.7%) at 1 month and 6 ⁄ 1010 (0.6%) at 6 months. Most symptoms were due to causes unrelated to the block. Of 452 patients directly questioned at the time of the block, new neurological symptoms were more common in patients who experienced procedure-induced paraesthesia (odds ratio = 1.7, p = 0.029). The postoperative neurological symptom rate in this series is very similar to those previously reported following traditional techniques.

Following pediatric inguinal surgery, ilioinguinal block provides more effective analgesia than the TAP block.

SummaryThis prospective, randomised, observer blinded study compared the onset time of brachial plexus block using 2% lidocaine 25-30 ml with adrenaline 5 lg.ml )1 into the 'corner pocket' inferolateral ⁄ lateral to the subclavian artery (supraclavicular, n = 30) or to a triple point injection around the axillary artery (infraclavicular, n = 30). Mean (SD) onset time for complete pinprick sensory blockade assessed by a blinded observer in all four distal nerves was similar in both groups: supraclavicular = 22 (9.4) min, infraclavicular = 21 (7.1) min, p = 0.59. Complete sensory blockade in all four nerve territories at 30 min was achieved in 57% in group supraclavicular and 70% in group infraclavicular (p = 0.28). Painless surgery without the requirement for block supplementation was higher in group infraclavicular (28 ⁄ 30, 93%) compared with group supraclavicular (19 ⁄ 30, 67%; p = 0.01). Of the 11 failures in group supraclavicular, nine were due to incomplete ulnar nerve territory anaesthesia. These results do not support the concept of rapid onset successful supraclavicular block via a simple ultrasound-guided local anaesthetic injection inferolateral to the subclavian artery. The widespread availability of portable ultrasound equipment has re-ignited interest in brachial plexus blockade around the level of the clavicle. These blocks are increasingly being used for distal upper extremity surgery as an alternative to general anaesthesia. Compared with the axillary approach, brachial plexus block at the level of the clavicle can anaesthetise all four distal upper extremity nerve territories without the requirement for a separate block of the musculocutaneous nerve. The supraclavicular approach has the additional anatomical advantage of blockade at a level where the brachial plexus elements are tightly grouped, which facilitates a single point injection and is thought to result in a very rapid onset block [1]; the aptly named 'spinal of the arm'. However, prior to the widespread availability of portable ultrasound machines, the popularity of both approaches was limited by reports of pneumothorax [2]. It is believed that the risk of pneumothorax can be reduced through real-time ultrasound imaging of both needle tip and pleura.Recently, a new technique for ultrasound guided supraclavicular block has been described, the so-called 'eight ball corner pocket' technique [3], and promising results have been reported by several workers [4,5]. This technique involves local anaesthetic injection without concomitant nerve stimulation in the pocket bordered inferiorly by the first rib and medially by the subclavian artery. It has been suggested that injection of local anaesthetic at this point results in a reliable, rapid onset block within minutes [3]. On the other hand, other workers have reported excellent results with the lateral sagittal infraclavicular approach [6], specifically when local anaesthetic is placed deep to the septum posterolateral to the axillary artery [7,8].Block onset time has clinical importance in m...