Background and Goal of Study:

Acute compartment syndrome (ACS) typically occurs secondary to tissue injury, either traumatic or iatrogenic in origin. ACS is associated with significant morbidity and mortality, especially in cases of delayed diagnosis. Pain out of proportion to injury is deemed the most important diagnostic sign of evolving compartment syndrome.[1] As a result, there is significant trepidation in the use of regional anaesthesia (RA) in patients deemed at risk of ACS in both surgeons and anaesthetists alike.[2] We conducted a systematic review of the evidence to assess whether RA contributes to delayed diagnosis of ACS. 

Materials and Methods:

This review was conducted following PRISMA guidelines. The healthcare database advanced search (HDAS) tool provided by the National Institute for Health and Care Excellence (NICE) was used to collect the literature. The search terms used were (“compartment syndrome” AND (“spinal anaesthesia” OR “spinal anesthesia” OR “regional anaesthesia” OR “regional anesthesia”)). There were no historic or language restrictions placed upon the search criteria. Cases involving paediatric patients or intravenous regional anaesthesia were excluded. Each article was assessed according to GRADE criteria.

Results and Discussion:

Our search generated 133 publications. After removal of articles according to the above criteria we were left with 28 papers. There have been no other systematic reviews conducted on this subject. We found no greater than low quality evidence in support of the hypothesis that RA contributes to the delayed diagnosis of ACS. Of particular relevance in our review are recent publications from military trauma specialists which are strongly in favour of the use of RA despite their patients being at high risk of ACS.[3] We acknowledge that publication bias is likely to be a significant factor on this subject. There are no prospective studies and the retrospective work is of relatively poor quality. There is clearly need for further research in this area.

Conclusion:

Given the benefits of regional anaesthesia, withholding it in patients deemed at risk of acute compartment syndrome is not supported by the published evidence.

References:

1.	Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. Journal of Bone and Joint Surgery. 2003;85:625-632 
2.	Thonse R, Ashford RU, Williams IR, et al. Differences in attitudes to analgesia in post-operative limb surgery put patients at risk of compartment syndrome. Injury. 2004;35:290-295 
3.	Stojadinovic A, Auton A, Peoples G, et al. Responding to challenges in modern combat casualty care: innovative use of advanced regional anaesthesia. Pain Medicine. 2006;7(4):330-338


01 / Regional anaesthesia and the diagnosis of compartment syndrome: a systematic review