2a7bPeripheral Neuropathy

8/6/2019 2a7bPeripheral Neuropathy

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Peripheral NeuropathyPeripheral Neuropathy

Dr. Sunil J. PanjwaniDr. Sunil J. Panjwani M.D.M.D. Associate Professor in Medicine, Associate Professor in Medicine,

Medical College, Bhavnagar.Medical College, Bhavnagar.


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T ypes of nerve fibersT ypes of nerve fibers

Diameter Diameter ConductionConduction FunctionFunctionmicronsmicrons Velocity m/sVelocity m/s

A alpha 1 A alpha 1- -2020 7070--110110 Motor, ProprioceptionMotor, Proprioceptionbeta 5beta 5- -1010 3030--6060 TouchTouchgama 3gama 3- -66 2020--3030 Fusimotor, spindlesFusimotor, spindlesdelta 2delta 2- -55 2020--3030 Sharp painSharp pain

BB


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Peripheral NervePeripheral Nerve

MyelinMyelin : Current cannot flow: Current cannot flow Axon Axon : Not nerves left: Not nerves left


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T he Peripheral Nervous SystemT he Peripheral Nervous System

Motor: weakness,Motor: weakness,atrophyatrophySensory lossSensory loss

Large FibersLarge Fibers(position)(position)Small fiber (pain)Small fiber (pain)

Reflex lossReflex loss Autonomic Autonomicsymptomssymptoms

(redness,(redness,dizziness, ED)dizziness, ED)


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M echanisms of damageM echanisms of damageDemyelinationDemyelination Myelin sheath disruptedGBS Post Diphtheric HSMN

Ax onal degenerationAx onal degeneration Axon damage

Toxic neuropathies

W allerian degenerationW allerian degeneration Nerve section BothC ompressionC ompression Focal demyelinationEntrapment-Carpel tunnel syndrome

InfarctionInfarction ArteritisPolyarteritis nodosa Churg-Strauss synd. DMInfiltrationInfiltration Infiltration

Leprosy Sarcoidosis


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D efinitionsD efinitionsNeuropathyNeuropathy

Pathological process affecting aPathological process affecting a peripheral nerve/speripheral nerve/s

MononeuropathyMononeuropathy A single nerve affected A single nerve affected

Mononeuritis multiplexMononeuritis multiplexMultiple mononeuropathy or Multifocal neuropathyMultiple mononeuropathy or Multifocal neuropathy

PolyneuropathyPolyneuropathy

Diffuse symmetrical disease usually beginning peripherallyDiffuse symmetrical disease usually beginning peripherally Acute/Chronic Static/Prog. Acute/Chronic Static/Prog. Relapsing/RecoveringRelapsing/RecoveringMotor Motor SensorySensory Sensrimotor(Mixed)Sensrimotor(Mixed) Autonomic AutonomicDemyelinatingDemyelinating Axonal Axonal

RadiculopathyRadiculopathy Nerve root diseaseNerve root disease


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C lassificationC lassificationEX AM IN AT ION F IN DING SEX AM IN AT ION F IN DING S

Purely Motor or Sensory or Sensorimotor?Purely Motor or Sensory or Sensorimotor?Proximal or distal? Symmetric or asymmetric?Proximal or distal? Symmetric or asymmetric?

Multifocal, generalized, regional?Multifocal, generalized, regional?Upper limbs, lower limbs, neck, trunk?Upper limbs, lower limbs, neck, trunk?

T IMINGT IMING

Acute or chronic? Acute or chronic?ASS OCI AT E D F IN DING SASS OCI AT E D F IN DING S

Painful or painless?Painful or painless?Hereditary or sporadic?Hereditary or sporadic?

ELEC TR O DIAGNO S ISELEC TR O DIAGNO S IS Axonal or demyelinating? Axonal or demyelinating?

L AB O RAT O RYL AB O RAT O RYParaprotein present? Type?Paraprotein present? Type?

Antibody against nerve? Antibody against nerve?CSF protein level?CSF protein level?

H IS TOLOG YH IS TOLOG YInflammatory CellsInflammatory Cells


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O bjectivesO bjectives

To learn a logical/sequential approachTo learn a logical/sequential approach

To know the types and etiologiesTo know the types and etiologies

To understand the treatmentTo understand the treatment


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B ackgroundB ackground

Common problemCommon problemLogical/sequential approach necessaryLogical/sequential approach necessary

Variable presentation and disparate causesVariable presentation and disparate causesEvaluation and managementEvaluation and management


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E pidemiologyE pidemiology

PrevalencePrevalence~ 2.4%~ 2.4%~ 8% in people older than 55 years~ 8% in people older than 55 years

DM is most common causeDM is most common cause


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E pidemiologyE pidemiology

O ther common systemic causesO ther common systemic causesMetabolic disordersMetabolic disordersInfectious agentsInfectious agentsVasculitisVasculitisToxinsToxins

DrugsDrugs Autoimmunity AutoimmunityInheritedInherited


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D iagnosisD iagnosis

Most important details to determineMost important details to determineDistributionDistributionDurationDurationCourseCourse


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L aboratory Screening for L aboratory Screening for T reatable Neuropathy? T reatable Neuropathy?

B12B12 N ot truly lengthN ot truly length- -dependentdependent

DiabetesDiabetes This type of neuropathyThis type of neuropathy

generally a late findinggenerally a late findingAN A, chronic diseaseAN A, chronic disease

screenscreenScreen for connective tissueScreen for connective tissuediseases (late finding)diseases (late finding)

TS HTS H If positive , have you provenIf positive , have you provenanything?anything?

E S RE S R If onset is recentIf onset is recent

H IVH IV R isk FactorsR isk Factors

R eview medicationsR eview medications B ig questionB ig question


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D iagnosisD iagnosis

Establish distributionEstablish distributionMononeuropathyMononeuropathyMononeuropathy multiplexMononeuropathy multiplexPolyneuropathyPolyneuropathy

Determine primary pathologyDetermine primary pathologyDemyelinatingDemyelinating

Axonal Axonal


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M ononeuropathyM ononeuropathy

Focal lesion involving a single nerveFocal lesion involving a single nerveElectro diagnostic studies indispensibleElectro diagnostic studies indispensible

Localize site of injuryLocalize site of injuryDetermine severity of lesionDetermine severity of lesion


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M ononeuropathyM ononeuropathy

CausesCausesEntrapmentEntrapment

Carpal tunnel syndrome is most commonCarpal tunnel syndrome is most commonFoot dropFoot drop

Focal compressionFocal compression

TraumaTrauma


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M ononeuropathy M ultiplexM ononeuropathy M ultiplex

Separate/noncontiguous involvementSeparate/noncontiguous involvementSimultaneouslySimultaneouslySeriallySerially

PatternPatternRandomRandom

MultifocalMultifocalFrequently evolves quicklyFrequently evolves quickly


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M ononeuropathy M ultiplexM ononeuropathy M ultiplex

Urgent assessment for vasculitisUrgent assessment for vasculitisPolyarteritis nodosaPolyarteritis nodosaChurgChurg--Strauss diseaseStrauss diseaseConnective tissue diseasesConnective tissue diseases

Rheumatoid arthritisRheumatoid arthritis

Sjogrens syndromeSjogrens syndrome


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Most commonly distal symmetricalMost commonly distal symmetricalFiber effect is lengthFiber effect is length- -dependentdependentToes and soles affected firstToes and soles affected first

Associations AssociationsSystemic diseasesSystemic diseases

Metabolic disordersMetabolic disordersExogenous toxinsExogenous toxins


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Diabetes is prototypeDiabetes is prototypeChronic, sensory and motor Chronic, sensory and motor Commonest in developed worldCommonest in developed world

Alcoholism is the second most common Alcoholism is the second most common


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Early symptomsEarly symptomsSensory abnormalitiesSensory abnormalities

NumbnessNumbnessBurningBurningParesthesiasParesthesiasDysesthesiasDysesthesias

Distally predominantDistally predominantSymmetricalSymmetrical


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Evolution is centripetalEvolution is centripetalSymptoms spread up legsSymptoms spread up legs

Sensory lossSensory lossDysesthesiasDysesthesias

Ankles jerks are depressed Ankles jerks are depressed

Patients have trouble walking on their heelsPatients have trouble walking on their heelsFoot plantar flexion remains strongFoot plantar flexion remains strong


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Symptoms noticed in fingertipsSymptoms noticed in fingertipsNumbnessNumbnessDysesthesiasDysesthesias

Advanced picture is easily recognizable Advanced picture is easily recognizableStockingStocking- -glove sensory lossglove sensory loss

Distal muscle wasting and weaknessDistal muscle wasting and weakness Absent tendon reflexes Absent tendon reflexes


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Sub classificationSub classificationHistorical features are indispensibleHistorical features are indispensible

O ther medical conditionsO ther medical conditionsSymptoms of systemic diseaseSymptoms of systemic diseaseRecent viral or other infectious diseasesRecent viral or other infectious diseasesRecent vaccinationsRecent vaccinationsInstitution of new medicationsInstitution of new medications


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Exposure to toxinsExposure to toxins Alcohol AlcoholHeavy metalsHeavy metalsO rganic solventsO rganic solvents

Family historyFamily history

Duration and clinical course areDuration and clinical course arehelpfulhelpful

Acute = days to weeks Acute = days to weeksChronic = months to yearsChronic = months to years


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L aboratory InvestigationsL aboratory Investigations

CBCCBCSUGARSUGAR

TFTsTFTs

ESRESR

CRPCRP

UREAUREA

B12B12Methylmalonic acidMethylmalonic acidHomocysteineHomocysteine

FolateFolate


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T reatmentT reatment

GeneralGeneralSubtype specificSubtype specific

Diabetes mellitusDiabetes mellitusRenal insufficiencyRenal insufficiencyHypothyroidismHypothyroidism

Vitamin B12 deficiencyVitamin B12 deficiencySystemic vasculitisSystemic vasculitis


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GeneralGeneralPainPain

Antiepileptic drugs Antiepileptic drugs Antidepressants AntidepressantsTramadolTramadol


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Preventative and palliativePreventative and palliativeWeight reductionWeight reduction

Assiduous foot care Assiduous foot careGood shoesGood shoes

Ankle Ankle--foot orthoses as neededfoot orthoses as needed

Several organizations provideSeveral organizations providesupportsupport


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O bjectives RevisitedO bjectives Revisited

SubtypesSubtypesMononeuropathyMononeuropathy

EntrapmentEntrapmentFocal compressionFocal compressionTraumaTrauma

MononeuropathyMononeuropathymultiplexmultiplex

DMDMVasculitisVasculitis


DMDMToxinToxin


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O bjectives RevisitedO bjectives Revisited

TreatmentTreatmentGeneralGeneral

Pain controlPain controlPreventative/Preventative/PalliativePalliative

SpecificSpecificDMDMRenalRenalinsufficiencyinsufficiency

VasculitisVasculitisB12 deficiencyB12 deficiencyHypothyroidismHypothyroidism


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C hronic L ength D ependentC hronic L ength D ependentNeuropathyNeuropathy

Begins in toes or feetBegins in toes or feetStocking distributionStocking distribution

Progresses rostrallyProgresses rostrallyTops and bottoms of Tops and bottoms of feetfeet

Weakness begins inWeakness begins inankles whenankles whensensation reachessensation reachescalvescalves

Sometimes diagnosable, Never treatable?Sometimes diagnosable, Never treatable?


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Phenotype C ID PPhenotype C ID P

Small DifferentialSmall Differential


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PhenotypePhenotype- -MAD S AM MAD S AM

NeuropathyNeuropathyK ey DDx:K ey DDx:Brachial plexopathiesBrachial plexopathiesVasculitisVasculitis

mononeuropathymononeuropathymultiplexmultiplexCompressionCompressionneuropathiesneuropathies

HNPP (genetic testing)HNPP (genetic testing)


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M ultifocal M otor M ultifocal M otor Neuropathy ( MM N)Neuropathy ( MM N)

Almost always in Almost always inhands and wristshands and wristsPattern of weakness isPattern of weakness is

in the distribution of in the distribution of individual peripheralindividual peripheralnervesnerves

i.e. severe involvement ini.e. severe involvement inulnar distribution sparingulnar distribution sparing

medianmedianLack of atrophy inLack of atrophy inweak musclesweak musclesNo pathologicalNo pathological

reflexesreflexes


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U ncertaintyU ncertainty

Many cases are not easily definableMany cases are not easily definablebecause of multiplicity of patternsbecause of multiplicity of patterns

Cases that are not clearly untreatable areCases that are not clearly untreatable arepossibly treatablepossibly treatable

2a7bPeripheral Neuropathy

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