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Regional Anesthesia and Pain Medicine Aug 2021Dexmedetomidine is an effective local anesthetic adjunct for peripheral nerve blocks. The intravenous route for administering dexmedetomidine has been suggested to be...
BACKGROUND
Dexmedetomidine is an effective local anesthetic adjunct for peripheral nerve blocks. The intravenous route for administering dexmedetomidine has been suggested to be equally effective to the perineural route; but comparative evidence is conflicting.
OBJECTIVES
This evidence-based review evaluated trials comparing the effects of intravenous to perineural dexmedetomidine on peripheral nerve block characteristics in adult surgical patients. Our primary aim was to evaluate the durations of sensory and motor blockade. Duration of analgesia, onset times of sensory and motor blockade, analgesic consumption, rest pain, and dexmedetomidine-related adverse events were evaluated as secondary outcomes.
EVIDENCE REVIEW
We sought randomized trials comparing the effects of intravenous to perineural dexmedetomidine on peripheral nerve block characteristics. The Cochrane Risk of Bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation criteria was used to evaluate the quality of evidence for when an outcome was reported by at least three studies.
RESULTS
Ten studies compared intravenous and perineural dexmedetomidine in the setting of upper extremity blocks (seven), lower extremity blocks (two), and truncal block (one). The doses of dexmedetomidine supplementing long-acting local anesthetics varied between a predetermined dose (50 μg) and a weight-based dose (0.5 μg/kg-1.0 μg/kg). Clinical diversity precluded quantitative pooling; and evidence is presented as a systematic review. Compared with the intravenous route, moderate quality evidence found that perineural dexmedetomidine prolonged the duration of sensory blockade in four of six trials and motor blockade in five of seven trials. Perineural dexmedetomidine also hastened the onset of sensory and motor blockade in three of six trials. No differences were reported for the remaining outcomes; and intravenous dexmedetomidine was not superior for any outcome in any of the trials.
CONCLUSIONS
Moderate quality evidence appears to suggest that intravenous dexmedetomidine is an inferior peripheral nerve block adjunct compared with perineural dexmedetomidine. Perineural dexmedetomidine is associated with longer durations and faster onset of sensory and motor blockade.
Topics: Adult; Analgesia; Anesthesia, Conduction; Anesthetics, Local; Dexmedetomidine; Humans; Peripheral Nerves
PubMed: 33975918
DOI: 10.1136/rapm-2020-102353 -
The Journal of Urology Jan 2023We aimed to evaluate the clinical significance of perineural invasion in men on active surveillance for Grade Group 1 prostate cancer.
PURPOSE
We aimed to evaluate the clinical significance of perineural invasion in men on active surveillance for Grade Group 1 prostate cancer.
MATERIALS AND METHODS
We identified 1,969 men with Grade Group 1 prostate cancer and at least 1 follow-up biopsy. A time-dependent Cox model and a logistic regression model were used to assess the association between biopsy-detected perineural invasion and grade reclassification (defined as the detection of Grade Group ≥2 prostate cancer on a surveillance biopsy), and adverse pathology (defined as Grade Group ≥3 ± seminal vesicle invasion ± lymph node involvement) at radical prostatectomy, respectively.
RESULTS
The 198 men with perineural invasion detected during active surveillance had lower rates of grade reclassification-free survival than those without perineural invasion (001). On multivariable analysis perineural invasion was significantly associated with grade reclassification (HR 3.25, 95% CI 2.54-4.16, 001); an association that persisted in the multiparametric magnetic resonance imaging subset. At radical prostatectomy, men with biopsy-detected perineural invasion had more extraprostatic extension than men without perineural invasion (Relative Risk 1.71, 95% CI 1.15-2.56). However, on multivariable analysis biopsy-detected perineural invasion was not associated with adverse pathology (OR 0.68, 95% CI 0.27-1.68, 40) and these patients did not exhibit more biochemical recurrence at 5 years ( > .05).
CONCLUSIONS
Perineural invasion during active surveillance was associated with grade reclassification. At radical prostatectomy biopsy-detected perineural invasion patients exhibited more extraprostatic extension but biopsy-detected perineural invasion was not independently associated with more adverse pathology. In addition, these patients did not have more biochemical recurrence during follow-up. Perineural invasion should not preclude Grade Group 1 patients from active surveillance but they may warrant more stringent monitoring.
Topics: Humans; Male; Clinical Relevance; Watchful Waiting; Prostatic Neoplasms
PubMed: 36073925
DOI: 10.1097/JU.0000000000002963 -
The Journal of Urology Oct 2023We assessed the prognostic significance of quantification of perineural invasion on prostate biopsy.
PURPOSE
We assessed the prognostic significance of quantification of perineural invasion on prostate biopsy.
MATERIALS AND METHODS
We quantified actual perineural invasion foci in the entire prostate biopsy specimens from 724 patients and compared corresponding radical prostatectomy findings and long-term oncologic outcomes.
RESULTS
No perineural invasion was detected in 524 (72.4%) prostate biopsies, whereas 1 (n=129; 17.8%), 2 (n=40; 5.5%), 3 (n=18; 2.5%), 4 (n=7; 1.0%), and 5-10 (n=6; 0.8%) perineural invasion foci were present in other cases. We confirmed a higher risk of recurrence after radical prostatectomy in patients with perineural invasion on prostate biopsy than in those with no perineural invasion ( < .001). Remarkably, recurrence-free survival was comparable between those with 0 vs 1 perineural invasion ( = .9) or 2 vs ≥3 perineural invasions ( = .3). Nonetheless, multifocal perineural invasion per prostate biopsy (vs single perineural invasion; < .001) and >1 perineural invasion per 10-mm tumor (vs ≤1 perineural invasion; = .008) were associated with worse outcomes. Interestingly, in a subgroup outcome analysis of single vs multifocal perineural invasions per prostate biopsy, there was a significant difference in patients showing perineural invasion involving only 1 of the sextant sites. In multivariable analysis, both multifocal perineural invasion/case (HR=5.48, < .001) and >1 perineural invasion/10-mm tumor (HR=3.96, < .001) showed significance for recurrence. Meanwhile, compared with CAPRA (Cancer of the Prostate Risk Assessment) score alone (0.687/0.685), Harrell's C index/AUC for predicting 5-year recurrence-free survival was gradually increased when 1 (0.722/0.740), 2 (0.747/0.773), or 3 (0.760/0.792) point(s) were additionally assigned to multifocal perineural invasion.
CONCLUSIONS
Multifocal perineural invasion and >1 perineural invasion per 10-mm tumor on each prostate biopsy were thus found to be associated with poorer prognosis, as independent predictors, in men with prostate cancer undergoing radical prostatectomy.
Topics: Male; Humans; Prostate; Neoplasm Invasiveness; Prostatic Neoplasms; Biopsy, Large-Core Needle; Prostatectomy; Biopsy; Risk Assessment
PubMed: 37433144
DOI: 10.1097/JU.0000000000003618 -
Diseases of the Colon and Rectum Nov 2022Lymphovascular and perineural invasion are well-known negative prognostic indicators in rectal cancer, but previous studies on their significance are not consistent.
BACKGROUND
Lymphovascular and perineural invasion are well-known negative prognostic indicators in rectal cancer, but previous studies on their significance are not consistent.
OBJECTIVE
This study assessed the prognostic value of lymphovascular and perineural invasion in rectal cancer patients who received preoperative chemoradiotherapy followed by curative resection.
DESIGN
This is a retrospective analysis.
SETTING
This study was performed at a tertiary cancer center.
PATIENTS
Rectal cancer patients who underwent curative resection after preoperative chemoradiotherapy between January 2000 and December 2010.
MAIN OUTCOME MEASURES
The primary outcomes were disease-free survival and overall survival. The survival rates were estimated using Kaplan-Meier analysis, and group comparisons were conducted using a log-rank test.
RESULTS
Of the 1156 included patients, 109 (9.4%) presented with lymphovascular invasion and 137 (11.9%) presented with perineural invasion. Lymphovascular and perineural invasion were associated with T and N downstaging after preoperative chemoradiotherapy ( p < 0.001). In the ypN0 patients, the 5-year disease-free survival rates were 70.8% and 78.5% ( p = 0.150) for the lymphovascular invasion and absent groups, respectively. In the perineural invasion group, the 5-year disease-free survival rate was 59.0% compared to 80.2% in the absent group ( p = 0.001). Among the ypN+ patients, the 5-year disease-free survival rates were 36.9% and 44.4% for the lymphovascular invasion and absent groups, respectively ( p = 0.211). The perineural invasion group had a poorer 5-year disease-free survival rate compared to the absent group (29.7% vs 46.7%; p = 0.011). By multivariable analyses, perineural invasion correlated with a poor disease-free survival (HR 1.412, 95% CI 1.082-1.843; p = 0.011) and also in ypN0 subgroup analysis (HR 1.717, 95% CI 1.093-2.697; p = 0.019).
LIMITATIONS
This study was a retrospective study conducted at a single center.
CONCLUSIONS
Perineural invasion is a reliable independent predictor of recurrence in rectal cancer patients treated with preoperative chemoradiotherapy. Patients with perineural invasion should be considered for closer surveillance even with ypN0 status. See Video Abstract at http://links.lww.com/DCR/B833 .IMPLICACIÓN CLÍNICA DE LA INVASIÓN PERINEURAL Y LINFOVASCULAR EN PACIENTES CON CÁNCER DE RECTO SOMETIDOS A CIRUGÍA DESPUÉS DE QUIMIORRADIOTERAPIA PREOPERATORIA.
ANTECEDENTES
La invasión linfovascular y perineural en cancer de recto, son indicadores pronósticos negativos bien conocidos, pero estudios previos sobre su significancia, no son consistentes.
OBJETIVO
El estudio evaluó el valor pronóstico de la invasión linfovascular y perineural en pacientes con cáncer de recto sometidos a quimiorradioterapia preoperatoria seguida de resección curativa.
DISEO
Es un análisis retrospectivo.
ENTORNO CLINICO
El estudio se realizó en un centro oncológico terciario.
PACIENTES
Pacientes con cáncer de recto sometidos a resección curativa después de quimiorradioterapia preoperatoria entre enero de 2000 y diciembre de 2010.
PRINCIPALES MEDIDAS DE VALORACION
Los resultados primarios fueron la supervivencia libre de enfermedad y la supervivencia general. Las tasas de supervivencia se estimaron mediante el análisis de Kaplan-Meier y las comparaciones de grupos se realizaron mediante una prueba de rango logarítmico.
RESULTADOS
De los 1156 pacientes incluidos, 109 (9,4%) presentaron invasión linfovascular y 137 (11,9%) invasión perineural. La invasión linfovascular y perineural se asoció con reducción del estadio de T y N después de la quimiorradioterapia preoperatoria ( p < 0,001). En los pacientes ypN0, las tasas de supervivencia libre de enfermedad a 5 años fueron del 70,8% y el 78,5% ( p = 0,150) para los grupos con y sin invasión linfovascular, respectivamente. En el grupo de invasión perineural, la tasa de supervivencia libre de enfermedad a 5 años fue del 59,0%, en comparación con el 80,2% en el grupo ausente ( p = 0,001). Entre los pacientes ypN +, las tasas de supervivencia sin enfermedad a 5 años fueron del 36,9% y 44,4% para los grupos con y sin invasión linfovascular, respectivamente ( p = 0,211). El grupo de invasión perineural mostró una tasa de supervivencia libre de enfermedad a 5 años menor, en comparación con el grupo ausente (29,7% versus 46,7%, p = 0,011). Mediante análisis multivariable, la invasión perineural se correlacionó con una pobre tasa de supervivencia de enfermedad (índice de riesgo 1,412; intervalo de confianza del 95%: 1,082-1,843; p = 0,011) y también en el análisis de subgrupos ypN0 (índice de riesgo 1,717; intervalo de confianza del 95%: 1,093-2,697; p = 0,019).
LIMITACIONES
Estudio retrospectivo realizado en un solo centro.
CONCLUSIONES
La invasión perineural es un predictor independiente y confiable de recurrencia en pacientes con cáncer de recto tratados con quimiorradioterapia preoperatoria. Los pacientes con invasión perineural deben considerarse para una vigilancia más estrecha incluso con estadio ypN0. Consulte Video Resumen en http://links.lww.com/DCR/B833 . (Traducción-Dr. Fidel Ruiz Healy ).
Topics: Chemoradiotherapy; Disease-Free Survival; Humans; Neoplasm Staging; Rectal Neoplasms; Retrospective Studies
PubMed: 34856592
DOI: 10.1097/DCR.0000000000002219 -
Pain Management Jan 2023Painful diabetic polyneuropathy is one of the most common disabling problems worldwide. We aimed to determine if a perineural injection of hypertonic saline compared... (Randomized Controlled Trial)
Randomized Controlled Trial
Efficacy of perineural hypertonic saline injection versus acupoints of foot in the management of diabetic neuropathy: a multicenter, double-blinded randomized controlled trial.
Painful diabetic polyneuropathy is one of the most common disabling problems worldwide. We aimed to determine if a perineural injection of hypertonic saline compared with foot acupoints decreased the neuropathic pain score in patients with diabetes. Patients were assigned to receive either perineural or acupoints injection of hypertonic saline 5% in their feet for three weekly sessions. Douleur Neuropathique 4 (DN4) questionnaire for neuropathic pain was assessed. Both groups observed a significant reduction of the DN4 score throughout 8 weeks of follow-up. Both perineural and acupoints hypertonic saline injections of the foot could improve neuropathic pain in patients with diabetes.
Topics: Humans; Diabetic Neuropathies; Acupuncture Points; Foot; Neuralgia; Diabetes Mellitus
PubMed: 36384321
DOI: 10.2217/pmt-2022-0042 -
Journal of Gastrointestinal Surgery :... Aug 2013The significance of perineural invasion in extrahepatic cholangiocarcinoma has not been fully elucidated. This study aims to determine the prognostic impact of and...
BACKGROUND
The significance of perineural invasion in extrahepatic cholangiocarcinoma has not been fully elucidated. This study aims to determine the prognostic impact of and optimal treatment strategy for perineural invasion in patients with extrahepatic cholangiocarcinoma.
METHODS
Medical records of 133 patients with extrahepatic cholangiocarcinoma who underwent curative resection were reviewed retrospectively. Ninety-eight patients had perineural invasion and 35 patients did not. Univariate and multivariate survival analyses were performed to clarify the prognostic impact of and optimal treatment strategy for perineural invasion.
RESULTS
Only tumor differentiation (P=0.024) was independently associated with perineural invasion in the multivariate logistic regression model. Multivariate survival analysis revealed that perineural invasion (P=0.002), resection margin status(P=0.016), and International Union Against Cancer (UICC) pT factor (P=0.015) were independent prognostic factors of overall survival. Overall 5-year survival rates for patients with and without perineural invasion were 28 and 74 %, respectively. Among 98 patients with perineural invasion, the use of adjuvant chemotherapy (P=0.003), lymph node status (P=0.015), resection margin status (P=0.008), and UICC pT factor (P=0.016) were independently associated with overall survival by multivariate analysis. Overall 5-year survival rates for patients with perineural invasion who did and did not receive adjuvant chemotherapy were 33 and 21 %, respectively (P=0.023).
CONCLUSIONS
Perineural invasion is a potent prognostic factor in extrahepatic cholangiocarcinoma. Adjuvant chemotherapy may improve the overall survival of patients with perineural invasion.
Topics: Adult; Aged; Aged, 80 and over; Antineoplastic Combined Chemotherapy Protocols; Bile Duct Neoplasms; Bile Ducts, Extrahepatic; Chemotherapy, Adjuvant; Cholangiocarcinoma; Deoxycytidine; Drug Combinations; Female; Hepatectomy; Humans; Kaplan-Meier Estimate; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Grading; Neoplasm Invasiveness; Neoplasm Staging; Neoplasm, Residual; Oxonic Acid; Peripheral Nerves; Proportional Hazards Models; Retrospective Studies; Survival Rate; Tegafur; Treatment Outcome; Gemcitabine
PubMed: 23797881
DOI: 10.1007/s11605-013-2251-0 -
Archives of Physical Medicine and... Nov 2022To compare perineural dextrose injection efficacy in the treatment of ulnar neuropathy at the elbow with a control group. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To compare perineural dextrose injection efficacy in the treatment of ulnar neuropathy at the elbow with a control group.
DESIGN
Prospective double-blind randomized control study.
SETTING
Training and research hospital.
PARTICIPANTS
The study was completed with 40 patients with ulnar neuropathy at the elbow.
INTERVENTION
Normal saline (0.9% sodium chloride) was injected in patients in the control group (n=20; mean age=38.1±10.7 years; median duration of symptoms=4.5 months), and 5% dextrose was injected in patients in the dextrose group (n=20; mean age=43.6±13.5 years; median duration of symptoms=5 months), perineurally under ultrasound guidance twice at 2-week intervals. Ultrasound-guided perineural injection of 1 cc each was administered into the ulnar nerve, 2 cm and 4 cm distal to the medial epicondyle, at the level of the medial epicondyle, and 2 cm and 4 cm proximal to the medial epicondyle. The amount of total fluid injected was 5 cc.
MAIN OUTCOME MEASURE(S)
At baseline and weeks 2, 4, and 12, the patients were evaluated with the Visual Analog Scale for pain and the Disabilities of the Arm Shoulder and Hand questionnaire for disability. Electrophysiological evaluation was performed with ulnar nerve conduction studies, and the ulnar nerve cross-sectional area was measured on ultrasonography.
RESULTS
The improvements in pain, disability, ulnar motor nerve velocity, and ulnar nerve cross-sectional area in the dextrose group were superior to those in the control group, especially at weeks 4 and 12 (P<.001, using independent samples t tests).
CONCLUSION
Perineural 5% dextrose may be an effective alternative therapy for those with ulnar neuropathy at the elbow for up to the 12th week.
Topics: Humans; Adult; Middle Aged; Elbow; Double-Blind Method; Prospective Studies; Ulnar Neuropathies; Ulnar Nerve; Ultrasonography; Pain; Glucose
PubMed: 35690093
DOI: 10.1016/j.apmr.2022.04.013 -
The Australasian Journal of Dermatology Aug 2020Basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (SCCs) are the most commonly encountered cancers in fair-skinned populations worldwide. Perineural...
BACKGROUND/OBJECTIVES
Basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (SCCs) are the most commonly encountered cancers in fair-skinned populations worldwide. Perineural invasion is associated with worse outcomes for patients with BCC or SCC. Estimates of perineural invasion prevalence range widely, likely reflecting non-representative patient samples. We sought to determine the prevalence of perineural invasion in BCC and SCC in the general population, as well as among cancers arising in solid organ transplant recipients.
METHODS
We retrospectively analysed histopathology reports of BCC and SCC from patients enrolled in the QSkin Study (a population-based cohort of 43 794 Queensland residents recruited 2010-2011) and the Skin Tumours in Allograft Recipients (STAR) study (a cohort of 509 high-risk kidney or liver transplant recipients at the Princess Alexandra Hospital, Brisbane, recruited 2012-2014.) We estimated the prevalence of perineural invasion (and 95% confidence interval) in BCC and SCC, respectively, and identified clinical factors associated with perineural invasion.
RESULTS
In QSkin, we observed 35 instances of perineural invasion in 9850 histopathologically confirmed BCCs (0.36%) and 9 instances of perineural invasion in 3982 confirmed SCC (0.23%) lesions. In the STAR cohort, we identified 4 lesions with perineural invasion in 692 BCCs (0.58%) and 16 reports of perineural invasion in 875 SCC lesions (1.9%).
CONCLUSIONS
These data suggest that the overall prevalence of perineural invasion in keratinocyte cancer is low, although perineural invasion prevalence may be slightly higher among organ transplant recipients when compared to the general population.
Topics: Aged; Allografts; Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Female; Humans; Kidney Transplantation; Liver Transplantation; Male; Middle Aged; Neoplasm Invasiveness; Peripheral Nerves; Prevalence; Queensland; Retrospective Studies; Skin Neoplasms
PubMed: 32017030
DOI: 10.1111/ajd.13247 -
World Neurosurgery Jun 2018Perineural spread leading to brachial plexopathy has recently been described in cases of melanoma. The occurrence and mechanism for nonmelanoma skin cancer spread to the...
BACKGROUND
Perineural spread leading to brachial plexopathy has recently been described in cases of melanoma. The occurrence and mechanism for nonmelanoma skin cancer spread to the brachial plexus is poorly understood.
METHODS
A retrospective chart review of the Mayo Clinic database was conducted to identify patients with nonmelanoma skin cancer and brachial plexopathy between 2000 and 2017. Inclusion criteria were a history of nonmelanoma skin cancer, a clinical diagnosis of brachial plexopathy, imaging features of perineural spread, and a positive result of examination of a biopsy specimen showing tumor in a skin nerve.
RESULTS
Thirty-seven patients with a history of nonmelanoma skin cancer and brachial plexopathy were identified. Inclusion criteria were fulfilled in 2 cases of cutaneous squamous cell carcinoma. One case of recurrent basal cell carcinoma with perineural spread confirmed in the brachial plexus by pathologic examination was excluded because confirmatory evidence of perineural spread from the skin to the brachial plexus was not available.
CONCLUSIONS
Perineural spread of nonmelanoma skin cancer leading to brachial plexopathy is rare. Our 2 cases and the cases found in the literature demonstrate different entry points to the neural highway resulting in neurologic deficits. The cervical plexus serves as a hub for further spread in certain cases of perineural spread of skin cancer.
Topics: Adult; Brachial Plexus; Brachial Plexus Neuropathies; Carcinoma, Squamous Cell; Female; Humans; Male; Melanoma; Middle Aged; Peripheral Nervous System Neoplasms; Skin Neoplasms
PubMed: 29572176
DOI: 10.1016/j.wneu.2018.03.092 -
Operative Orthopadie Und Traumatologie Feb 2020The so-called ankle block represents a local anesthesia form which enables easy performance of all surgical procedures of the foot and ankle. (Review)
Review
OBJECTIVE
The so-called ankle block represents a local anesthesia form which enables easy performance of all surgical procedures of the foot and ankle.
INDICATIONS
Interventions distal to the medial and lateral malleoli.
CONTRAINDICATIONS
Acute and chronic infections in the area of injection; allergy to the local anesthesia.
SURGICAL TECHNIQUE
All five sensory foot nerves are blocked. The two deep lying nerves, the tibial nerve and the deep fibular nerve, can be directly anesthetized perineurally using anatomical landmarks. The other three nerves are subcutaneously infiltrated near their branches.
RESULTS
The success rate ranges from 88 to 94%; smaller areas may also be further blocked intraoperatively. The ankle block is a cost-effective procedure which can also be performed without problems in multimorbid patients due to its minor side effects.
Topics: Ankle; Foot; Humans; Nerve Block; Tibial Nerve; Treatment Outcome
PubMed: 31940050
DOI: 10.1007/s00064-019-00634-x