Neuropathy

Submitted by – Dinesh choudhary

INTERNATIONAL SCHOOL OF MEDICINE

GROUP - 24

disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness.

Pain - burning, short jabs , tight or band like pressure, painful

hypersensitivity of non noxious stimuli

Paresthesia “pain and needle” sensationsSensory loss “ชา” “no sensation” “like block of

wood”Weakness - distal symmetrical weakness

- proximal symmetrical weakness – GBS - unilateral limb weakness- brachial plexus- lumbosacral plexus

Unstable balance - sensory loss - weakness in the legs

Neuropathy from History and physical exam

Mononeuropathy Mononeuropathy multiplex Polyneuropathy

axonal demyelinating

EntrapmentDMSubclinical polyneuropathy

VasculitisDM(rare)

HNPPMMNCIDP(rare)

Neuropathy from History and physical exam

Mononeuropathy Mononeuropathy multiplex Polyneuropathy

axonal demyelinating

DMToxicMetabolicNutritional deficiencyParaprotein emiaCAidiopathic

Hereditary

subacute chronicacute

GBS(axonal)Porphyria

acute subacute chronic

GBSDiphtheria

CIDPParaproteinemia

Hereditary

Neuronopathy

Axonopathy

Demyelination

Polyneuropathy

Poly(radiculopathy)

Neuronopathy

Peripheral neuropathy is caused by damage to your peripheral nerves. Peripheral nerves are nerves that are not located in the brain or spinal cord. They are found throughout your body and help you feel things. They also control the function of your organs. The damage is usually to nerves in the hands, feet, arms, and legs.

Mees’ line in arsenic poisoning

Arsenic

Thallium Lead

Peripheral neuropathy may be classified in a varieties of ways-

according to the 1.number of nerves affected Mononeuropathy Mononeuritis multiplex Polyneuropathy

2.the type of nerve cell affected motor

sensory autonomic

Mononeuropathy means a process affecting a

single nerve.

Mononeuritis multiplex (multiple mononeuropathy and/or multifocal neuropathy) affects several or multiple nerves.

Polyneuropathy describes diffuse, symmetrical disease, usually commencing peripherally.

The course may be- acute, chronic, static, progressive, relapsing or towards recovery.

Polyneuropathies are motor, sensory, sensorimotor and autonomic.

-Metabolic

-Toxic or drug

-Nutritional deficiency

Polyneuropathy caused by

•Mixture of UMN & LMN signs•No sensory deficit•Progressive course•No sphincter muscle or ocular

muscle involvement

Diabetic Neuropathy is a nerve disorder which is found in patients who have diabetes

Damage to nerves in Peripheral Nervous Systems

Classification of Diabetic neuropathies

Symmetric 1. Distal, primarily sensory

polyneuropathy a. Mainly large fibers affected b. Mixed (a)

c. Mainly small fibers affected (a)

2. Autonomic neuropathy 3. Chronically evolving proximal motor

neuropathy (a,b)Asymmetric 1. Acute or subacute proximal motor

neuropathy (a,b) 2. Cranial mononeuropathy (b)

3. Truncal neuropathy (a,b) 4. Entrapment neuropathy in the limbs

Different Types Diffuse Peripheral

Neuropathy Diffuse Autonomic

Neuropathy Localized Peripheral

Neuropathy

Exact cause is unknown Theories behind Neuropathy

High Glucose Concentration Chemical changes in nerves Damaged blood vessels

Genetic Disposition

Depends on part of body being affected. Diffuse Peripheral

Pain Numbness and tingling in the limbs Sensitivity to touch More susceptible to feet injury and infections Loss of Balance and Control Loss of sensation

Diffuse Autonomic Bladder infections Stomach disorders dizziness

Localized neuropathy Pain in front of thigh, lower back, chest stomach and

behind eyes Double vision Paralysis of one side of the face

Based upon symptoms Pain Assessment Screening Test for lost sensation Nerve Conduction Study Electromyography Ultrasound Nerve Biopsy (extreme cases)

Treat symptoms and not neuropathy Manage your glucose levels Drug Therapy can be used but is not suggested Pain Medication Early treatment more successful and reversing

damage. Later stages of neuropathy irreversible

the peripheral nerves have been damaged by too much alcohol use. The peripheral nerves transmit signals between the body, the spinal cord, and the brain.

Thiamine, folate, niacin, vitamins B6 and B12, and vitamin E are all needed for proper nerve function. Drinking too much can alter levels of these nutrients and affect the spread of alcoholic neuropathy. Fortunately, abstaining from alcohol can help restore your nutritional health.

Alcoholic neuropathy can affect both movement and sensation. Symptoms range from slight discomfort to major disability. Although the condition is not life threatening, it can decrease your quality of life. Some areas of the body affected by alcoholic neuropathy include:

numbness tingling and burning prickly sensations muscle spasms and cramps muscle weakness and atrophy

Alcoholic neuropathy is the result of damage to these nerves. The damage may be the direct result of long periods where you drank too much alcohol. Nutritional problems linked to alcohol use, such as vitamin deficiency, can also cause nerve damage.

nerve biopsy nerve conduction tests upper GI and small bowel series neurological examination electromyography esophagogastroduodenoscopy (EGD) kidney, thyroid, and liver function tests complete blood count (CBC)

vitamin supplements to improve nerve health (folate, thiamine, niacin, and vitamins B6, B12, and E)

prescription pain relievers (tricyclic antidepressants and anticonvulsants)

medication for people with problems urinating physical therapy to help with muscle atrophy orthopedic appliances to stabilize extremities safety gear, such as stabilizing footwear, to

prevent injuries special stockings for your legs to prevent dizziness

Disorders of peripheral nerves are the most common neurological complications of systemic amyloidosis; an illness where a protein called amyloid is deposited in tissues and organs. Amyloidosis can affect peripheral sensory, motor or autonomic nerves and deposition of amyloid lead to degeneration and dysfunction in these nerves.

The typical symptoms of amyloid neuropathy are due to sensory and autonomic dysfunction. Patients may experience painful paresthesias (unusual sensations), numbness and balance difficulties due to sensory dysfunction and persistent nausea, vomiting, diarrhea, constipation, incontinence, sweating abnormalities or sexual dysfunction due to autonomic nerve involvement.

Diagnosis of amyloid neuropathies is based on history, clinical examination and supporting laboratory investigations. These include electromyography with nerve conduction studies, skin biopsies to evaluate cutaneous nerve innervation, and nerve and muscle biopsies for histopathological evaluation. In cases of familial amyloidosis, genetic testing in the blood may be useful.

Treatment of amyloid neuropathies is directed at both preventing further deposition of amyloid in peripheral nerves and treating painful symptoms. Depending on the type of amyloid protein, patients may benefit from liver or bone marrow transplant. Neuropathic pain due to amyloid neuropathy can be treated with anti-seizure medications, antidepressants, or analgesics including opiate drugs. In severe painful conditions patients may be referred to the Blaustein Chronic Pain Clinic for a multidisciplinary approach to pain management.

Most common type --- Acute inflammatory demyelinating

polyneuropathy (AIDP) Symptoms and Signs Muscles weakness – facial and orophyrengial cardiac arrhythmias, GI stasis, urinary retention,

and pupillary changes. An unusual variant (Fisher variant) may cause only ophthalmoparesis, ataxia, and areflexia.

Guillain Barre syndrome

Clinical evaluation Electrodiagnostic testing CSF analysis Neurophysiology

- Diagnostic Criteria for Guillain Barre Syndrome

REQUIRED 1 2. Progressive weakness of or more limbs due to neuropathy 2. Areflexia

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SUPPORTIVE

1. Relatively symmetric weakness 2. Mild sensory involvement 3. Facial nerve or other cranial nerve involvement 4. Absence of fever lllllllllll llllllll ll lllllll llllll5. ( , ) llllllllllllllllll llllllll ll lll llllllllll6.

Intensive supportive care IV immune globulin (IVIG) or plasma exchange Rihablisation Respiratory failure Pain

Scattered distribution of sensory loss in

Multiple Mononeuropat

hy

Can found in: Classic PAN Churg-Strauss disease Wegener’s granulomatosis Overlap syndrome Vasculitis associated with connective

tissue disease Sjóģren syndrome Lyme disease Leprosy Diabetes mellitus

Multiple mononeuropat

hy with vasculitis

Mycobacterium leprae – coolest tissue in the body

Tuberculoid (high-resistance) leprosy – single patch of hypoesthesia or anesthetic skin in any location

Lepromatous (low resistance) leprosy – numerous bacilli, wide spread skin thickening, cutaneous anesthesia, anhydrosis sparing axilla, groin and skin beneath the scalp hair

Nerve root disorders result in segmental radicular deficits (eg, pain or paresthesias in a dermatomal distribution, weakness of muscles innervated by the root). Diagnosis may require neuroimaging, electrodiagnostic testing, and systemic testing for underlying disorders. Treatment depends on the cause but includes symptomatic relief with NSAIDs, other analgesics, and corticosteroids.

Radiculopathy

Cervical

CausesCompressive : herniated disc, spondylosis, tumor

Infiltrative : tumor seeding, infection

Inflammatory : immune-mediated

Brachial plexus Lumbosacral plexus

Trauma Tumor infiltration Infection by viral Immune-mediated Delayed effects of radiotherapy

Traction birth injury

(Erb’s palsy)

Acute pain in back of shoulderPostmastectomy

and radiation

Brachial plexopathy

Upper C5,6 or Erb-Duchenne type Lower C8, T1 or Dejerine-Klumpke type Total

Klumpke’s palsy (injury

of lower brachial plexus

C7,C8,T1) and often Horner’s

syndrome

Erb’s palsy (injury

of upper brachial plexus C5,C6)

Multiple spinal roots and peripheral nerves ท่ีขา

Roots : T12-S4 Nerves : iliohypogastric, ilioinguinal,

genitofemoral, lateral femoral cutaneous, femoral, obturator, superior gluteal, inferior gluteal, sciatic, posterior femoral cutaneous, pudendal nerves

Lumbar plexopathy

Sacral plexopathy

Clinical manifestation

Tumors : CA cervix, prostate, bladder, colorectal, kidney, breast, testis, ovary, sarcoma, lymphoma

Compressed by aortic aneurysm Radiation plexopathy Plexitis : follow herpes zostor Diabetic amyotrophy Trauma (rare) As a manifest of mononeuropathy multiplex

Median nerve

Carpal tunnel syndrome

Anterior interosseous syndrome

Pronator syndrome

Ligament of Struthers

Carpal tunnel syndrome

Nocturnal pain or paresthesiaThenar atrophy

AtrophySensory loss

Ulnar nerve

Lesion at condylar groove

Lesion at wrist and handGuyon’s canal

At elbow : Condylar groove or in cubital tunnel

Wasting hypothenar eminence and web space of (1st dorsal interossei)

Claw hand

Radial nerve

Saturday night palsy

Posterior interosseous syndrome

Cheiralgia parestheticaCheiralgia paresthetica

Axillary lesion : weak triceps and radial innervated m.

Mid-upper arm lesion : ‘Saturday night palsy’ (spiral groove or intermuscular septum) : wrist drop, normal triceps, variable motor and sensory deficit

Posterior interosseous : weak extensor of thumb and other fingers, no sensory loss

Superficial radial n. : terminal cutaneous br.

Radial nerve

Wrist drop

Lateral femoral cutaneous nerve of thigh (L2 and L3)

• Meralgia paresthetica• Pure sensory

Femoral nerve

Femoral nerve (L2,3,4)

• Mix sensorimotor• Quadriceps femoris or knee extensor• Weakness of hip flexor in intraabdominal lesion• Sensory deficit over anteromedial aspect of thigh and perhaps leg• Absent or diminished knee jerk

Obturator nerves

• L2,3,4• Hip adductors• vulnerable during obstetric and gynecological

procedures

Sciatic

Sciatic nerve•L4-S3

Composed of 2 main nerves of leg : common peroneal and tibial nerve

Paralysis of all muscles below knee plus hamstrings and for high lesion, external rotators of thigh

Sensory loss below knee except anteromedial aspect of leg and foot

Common peroneal nerve

• Foot-drop

• Paralysis of anterior and lateral compartment of leg

• Sensory loss over dorsum of foot and toes and anterolateral aspect of leg

Tibial nerve

Medial division of sciatic nerve Lesions at ankle

Tarsal tunnel syndrome Pain and paresthesia in sole Paralysis of intrinsic muscles of foot Tenderness of Tinel’s sign at flexor retinaculum

Sural nerve compression syndrome Pure sensory Numbness on lateral aspect of foot

Chorda tympani

Clinical features :

postauricular pain (few days) lower motor neuron facial weakness impaired taste hyperacusis

Bell’s palsy : idiopathic, HSV 1 Ramsay Hunt syndrome : external ear pain with

presence of herpes zoster vesicles in auditory canal and pinna, VZV

Trauma : blunt impact to temporal bone Middle ear infection : otitis media (infrequent in ATB

era), mastoid pain persist after acute infection resolved Neoplasm : rarely compressed by CPA tumor but due to

surgery for tumor removal

Management Reassurance – not a stroke

Short course of prednisolone 60 mg/day Prognosis : complete recovery 75% satisfactory 15% poor function 10%