Can Ultrasound Predict Nerve Injury Following Posterior Tibial Nerve Block in Patients With Peripheral Neuropathy?

NCT01002053 | Completed

• 1 other identifier: UHN 09-0803-AE
• Study Type: observational
• Target: 40
• Locations: 1 country
• Sites: 1

Brief Summary

The use of regional anesthesia for nerve block in diabetic patients with peripheral neuropathy is currently made on a case-by-case basis, also remains underlying uncertainty regarding the preferred technique and the likelihood of block-related nerve injury. For this many diabetic patients with otherwise healthy nerves may receive general anesthesia instead of regional anesthesia, thus giving up the benefits associated with the latter technique, including a decrease in health complications and superior analgesia following the operation. Ultrasound is used to identify the target nerve and guide needle insertion for nerve blocks, may be a useful tool to detect the presence and severity of neuropathy prior to block placement, a recent study demonstrated a statistically significant increase in the sonographic cross-sectional area of the posterior tibial nerve (PTN) in all diabetic patients who had abnormal motor transmission on nerve conduction studies. For regional anesthesiologists, the ultimate goal of detecting peripheral neuropathy and in particular, diabetic neuropathy by US is to avoid nerve injury. To do so, the association between US-detected diabetic neuropathy and block-related nerve damage must be first established, hence the purpose of this study. We aim to examine whether the cross-sectional area of PTN as assessed by preoperative US can predict nerve injury as assessed by worsening nerve conduction studies following PTN block inpatients scheduled to receive an ankle block. A further subgroup analysis will be performed in diabetic patients. We hypothesize that the cross sectional area of the PTN will correlate with motor conduction velocity on nerve conduction studies (NCS) following PTN block in patients with peripheral neuropathy. All eligible patients will undergo NCS to confirm or exclude distal neuropathy. Patients without neuropathy will be excluded from further participation in this study. Also excluded will be diabetic patients with neuropathy caused by genetic, metabolic and inflammatory diseases as well as toxic agents and drug induced. A systematic US examination of the PTN will be performed for all patients. After Block administration at surgery day the block successes will be assessed and for the purposes of the present study, patients in whom the block was not successful will be excluded from further intervention and data analyses. Eight weeks after surgery, all study patients will return to hospital for repeat NCS and US.

Conditions

Diabetic Neuropathy

Keywords

diabetes; neuropathy; ankle block; regional anesthesia; ultrasound; nerve localization; Nerve localization in patients undergoing foot surgery and having ankle block

Outcome Measures

Primary Outcomes (1)

• Interval worsening of the severity of neuropathy

  8 weeks

Secondary Outcomes (1)

• New functional neuropathy defined as any new sensory or motor deficit compared to preoperatively.

  8 weeks

Study Arms (1)

Diabetics with peripheral neuropathy

Patients with diabetes and peripheral neuropathy.

Procedure: Nerve conduction study and Ultrasound of the PTN

Interventions

Nerve conduction study and Ultrasound of the PTN PROCEDURE

Nerve Conduction studies and ultrasound of PTN will be performed to the patient before the operation and 8 weeks postoperatively.

Diabetics with peripheral neuropathy

Eligibility Criteria

• Age: 18 Years - 80 Years
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Diabetic and non-diabetic patients undergoing foot surgery involving regional anesthesia/nerve blockade.

You may qualify if:

• Patients undergoing PTN block for foot surgery
• Type I diabetic patients (diagnosed more than 5 years), and II diabetic patients with demonstrated peripheral neuropathy
• ASA I-III

You may not qualify if:

• Non-diabetic neuropathy caused by genetic, metabolic and inflammatory diseases as well as toxic agents and drug induced (e.g. chemotherapy agents)
• Psychiatric history
• Allergy to local anesthetics

Sponsors & Collaborators

• University Health Network, Toronto: lead

Study Sites (1)

Toronto Western Hospital, University Health Network

Toronto, Ontario, M5T 2S8, Canada

Location

Related Publications (24)

• Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973 Aug 18;2(7825):359-62. doi: 10.1016/s0140-6736(73)93196-6. No abstract available.

  PMID: 4124532 BACKGROUND

• Blumenthal S, Borgeat A, Maurer K, Beck-Schimmer B, Kliesch U, Marquardt M, Urech J. Preexisting subclinical neuropathy as a risk factor for nerve injury after continuous ropivacaine administration through a femoral nerve catheter. Anesthesiology. 2006 Nov;105(5):1053-6. doi: 10.1097/00000542-200611000-00028. No abstract available.

  PMID: 17065901 BACKGROUND

• Zochodne DW. Diabetic polyneuropathy: an update. Curr Opin Neurol. 2008 Oct;21(5):527-33. doi: 10.1097/WCO.0b013e32830b84cb.

  PMID: 18769245 BACKGROUND

• Dyck PJ, Karnes JL, O'Brien PC, Litchy WJ, Low PA, Melton LJ 3rd. The Rochester Diabetic Neuropathy Study: reassessment of tests and criteria for diagnosis and staged severity. Neurology. 1992 Jun;42(6):1164-70. doi: 10.1212/wnl.42.6.1164.

  PMID: 1603343 BACKGROUND

• Kalichman MW, Calcutt NA. Local anesthetic-induced conduction block and nerve fiber injury in streptozotocin-diabetic rats. Anesthesiology. 1992 Nov;77(5):941-7. doi: 10.1097/00000542-199211000-00017.

  PMID: 1443749 BACKGROUND

• Hebl JR, Kopp SL, Schroeder DR, Horlocker TT. Neurologic complications after neuraxial anesthesia or analgesia in patients with preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy. Anesth Analg. 2006 Nov;103(5):1294-9. doi: 10.1213/01.ane.0000243384.75713.df.

  PMID: 17056972 BACKGROUND

• Kroin JS, Buvanendran A, Williams DK, Wagenaar B, Moric M, Tuman KJ, Kerns JM. Local anesthetic sciatic nerve block and nerve fiber damage in diabetic rats. Reg Anesth Pain Med. 2010 Jul-Aug;35(4):343-50. doi: 10.1097/aap.0b013e3181e82df0.

  PMID: 20607875 BACKGROUND

• Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg. 1998 Mar;86(3):598-612. doi: 10.1097/00000539-199803000-00032.

  PMID: 9495424 BACKGROUND

• Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth. 2000 Apr;84(4):450-5. doi: 10.1093/oxfordjournals.bja.a013468.

  PMID: 10823094 BACKGROUND

• Hadzic A, Arliss J, Kerimoglu B, Karaca PE, Yufa M, Claudio RE, Vloka JD, Rosenquist R, Santos AC, Thys DM. A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology. 2004 Jul;101(1):127-32. doi: 10.1097/00000542-200407000-00020.

  PMID: 15220781 BACKGROUND

• Chan VW, Peng PW, Kaszas Z, Middleton WJ, Muni R, Anastakis DG, Graham BA. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis. Anesth Analg. 2001 Nov;93(5):1181-4. doi: 10.1097/00000539-200111000-00025.

  PMID: 11682392 BACKGROUND

• Alshami AM, Cairns CW, Wylie BK, Souvlis T, Coppieters MW. Reliability and size of the measurement error when determining the cross-sectional area of the tibial nerve at the tarsal tunnel with ultrasonography. Ultrasound Med Biol. 2009 Jul;35(7):1098-102. doi: 10.1016/j.ultrasmedbio.2009.01.011. Epub 2009 May 7.

  PMID: 19427097 BACKGROUND

• Cartwright MS, Passmore LV, Yoon JS, Brown ME, Caress JB, Walker FO. Cross-sectional area reference values for nerve ultrasonography. Muscle Nerve. 2008 May;37(5):566-71. doi: 10.1002/mus.21009.

  PMID: 18351581 BACKGROUND

• Lee D, Dauphinee DM. Morphological and functional changes in the diabetic peripheral nerve: using diagnostic ultrasound and neurosensory testing to select candidates for nerve decompression. J Am Podiatr Med Assoc. 2005 Sep-Oct;95(5):433-7. doi: 10.7547/0950433.

  PMID: 16166459 BACKGROUND

• Vijayan J, Therimadasamy AK, Teoh HL, Chan YC, Wilder-Smith EP. Sonography as an aid to neurophysiological studies in diagnosing tarsal tunnel syndrome. Am J Phys Med Rehabil. 2009 Jun;88(6):500-1. doi: 10.1097/PHM.0b013e3181a5b94b.

  PMID: 19454856 BACKGROUND

• Watanabe T, Ito H, Morita A, Uno Y, Nishimura T, Kawase H, Kato Y, Matsuoka T, Takeda J, Seishima M. Sonographic evaluation of the median nerve in diabetic patients: comparison with nerve conduction studies. J Ultrasound Med. 2009 Jun;28(6):727-34. doi: 10.7863/jum.2009.28.6.727.

  PMID: 19470812 BACKGROUND

• Watanabe T, Ito H, Sekine A, Katano Y, Nishimura T, Kato Y, Takeda J, Seishima M, Matsuoka T. Sonographic evaluation of the peripheral nerve in diabetic patients: the relationship between nerve conduction studies, echo intensity, and cross-sectional area. J Ultrasound Med. 2010 May;29(5):697-708. doi: 10.7863/jum.2010.29.5.697.

  PMID: 20427781 BACKGROUND

• Harati Y. Diabetic neuropathies: unanswered questions. Neurol Clin. 2007 Feb;25(1):303-17. doi: 10.1016/j.ncl.2007.01.002.

  PMID: 17324729 BACKGROUND

• Misur I, Zarkovic K, Barada A, Batelja L, Milicevic Z, Turk Z. Advanced glycation endproducts in peripheral nerve in type 2 diabetes with neuropathy. Acta Diabetol. 2004 Dec;41(4):158-66. doi: 10.1007/s00592-004-0160-0.

  PMID: 15660198 BACKGROUND

• Partanen J, Niskanen L, Lehtinen J, Mervaala E, Siitonen O, Uusitupa M. Natural history of peripheral neuropathy in patients with non-insulin-dependent diabetes mellitus. N Engl J Med. 1995 Jul 13;333(2):89-94. doi: 10.1056/NEJM199507133330203.

  PMID: 7777034 BACKGROUND

• Perkins BA, Bril V. Diabetic neuropathy: a review emphasizing diagnostic methods. Clin Neurophysiol. 2003 Jul;114(7):1167-75. doi: 10.1016/s1388-2457(03)00025-7.

  PMID: 12842711 BACKGROUND

• Vinik AI, Bril V, Litchy WJ, Price KL, Bastyr EJ 3rd; MBBQ Study Group. Sural sensory action potential identifies diabetic peripheral neuropathy responders to therapy. Muscle Nerve. 2005 Nov;32(5):619-25. doi: 10.1002/mus.20423.

  PMID: 16116628 BACKGROUND

• Olaleye D, Perkins BA, Bril V. Evaluation of three screening tests and a risk assessment model for diagnosing peripheral neuropathy in the diabetes clinic. Diabetes Res Clin Pract. 2001 Nov;54(2):115-28. doi: 10.1016/s0168-8227(01)00278-9.

  PMID: 11640995 BACKGROUND

• Yesildag A, Kutluhan S, Sengul N, Koyuncuoglu HR, Oyar O, Guler K, Gulsoy UK. The role of ultrasonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome. Clin Radiol. 2004 Oct;59(10):910-5. doi: 10.1016/j.crad.2004.03.020.

  PMID: 15451351 BACKGROUND

MeSH Terms

Conditions

Diabetic Neuropathies; Diabetes Mellitus

Condition Hierarchy (Ancestors)

Peripheral Nervous System Diseases; Neuromuscular Diseases; Nervous System Diseases; Diabetes Complications; Endocrine System Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases

Study Officials

• Sheila Riazi, MD, MSc, FRCPC

  University Health Network - University of Toronto

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: observational
• Observational Model: OTHER
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: October 26, 2009
• First Posted: October 27, 2009
• Study Start: February 1, 2012
• Primary Completion: December 1, 2013
• Study Completion: February 1, 2014
• Last Updated: November 24, 2017

Record last verified: 2011-11

Locations

CA (1)