Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis

BACKGROUND: Epidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems. METHODS: We performed an extensive systematic review to find published cohorts of use of epidural catheters during vascular, cardiac, and thoracic surgery, using electronic searching, hand searching, and reference lists of retrieved articles. RESULTS: Twelve studies included 14,105 patients, of whom 5,026 (36%) had vascular surgery, 4,971 (35%) cardiac surgery, and 4,108 (29%) thoracic surgery. There were no cases of epidural haematoma, giving maximum risks following epidural anaesthesia in cardiac, thoracic, and vascular surgery of 1 in 1,700, 1 in 1,400 and 1 in 1,700 respectively. In all these surgery types combined the maximum expected rate would be 1 in 4,700. In all these patients combined there were eight cases of transient neurological injury, a rate of 1 in 1,700 (95% confidence interval 1 in 3,300 to 1 in 850). There were no cases of persistent neurological injury (maximum expected rate 1 in 4,600). CONCLUSION: These estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding

Incidence of Concussion in Men's Super League, Championship, and Academy Rugby League Matches Between 2016 and 2022

Objectives: To quantify the incidence of concussion and compare between playing level in male rugby league. Design: Retrospective cohort Method: Between 2016 and 2022, medically diagnosed concussions in Super League, Championship, and Academy competitions were reported to the Rugby Football League via club medical staff. Anonymised data were analysed using generalized linear mixed-effects models by season, month, and between competitions. Results: Overall, 1,403 concussions were identified from 104,209 player-match hours. Concussion incidence for Super League, Championship, and Academy was 15.5, 10.5, and 14.3 per 1,000 player-match hours, respectively. Championship concussion incidence was significantly lower than the Super League (p<0.001) and Academy (p<0.001). No significant differences were identified between year for Super League (range: 13.3 to 18.8 per 1,000 player-match hours) and Championship (range: 8.4 to 12.1 per 1,000 player-match hours). In Academy (range: 9.6 to 20.5 per 1,000 player-match hours), concussion incidence was significantly greater in 2021 compared to earlier years (2016, p=0.01 and 2017, p=0.03). No significant differences were identified between months for any competition. Conclusions: The incidence of concussion is greater in Super League and Academy compared to the Championship. Academy concussion incidence has increased over time. Different factors between and within competitions, such as changes to medical standards and knowledge, could have influenced the identification and diagnosis of concussion