Peripheral neuropathy.ug
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This document discusses peripheral neuropathy and provides guidance on evaluating patients presenting with neuropathy symptoms. It describes how neuropathy affects the peripheral nervous system and is a common neurological disorder. Evaluation involves taking a thorough history, conducting a physical exam focusing on neurological signs, and utilizing electrodiagnostic studies and other tests to determine the etiology and nature of the neuropathy. The most common causes of neuropathy include diabetes mellitus, paraproteinemia, alcohol use, and chronic idiopathic axonal neuropathy. Treatment focuses on managing underlying causes, pain relief, and rehabilitation.
![ Clinical evaluation is often helpful in categorizing a
neuropathy as
◦ axonal,
◦ demyelinating,
◦ neuronal [dorsal root ganglion (DRG)]
Most axonal neuropathies follow length-dependent pattern
with sensory symptoms & signs predominating over
motor; distal reflexes are absent.](https://image.slidesharecdn.com/peripheralneuropathy-200202160013/85/Peripheral-neuropathy-ug-25-320.jpg)
Peripheral neuropathy.ug
- 1. Dr. Mukesh Kumar Shukla Senior Resident Department of Medicine Hind Institute Of Medical Sciences
- 9. Neuropathy indicates disorder or malfunction of the nerves. It refers to involvement of peripheral nervous system . It is a common neurological disorder.
- 10. 1. Cranial nerves (with the exception of the second) 2. Spinal nerve roots 3. Dorsal root ganglia 4. Peripheral nerve trunks and their terminal branches 5. Peripheral autonomic nervous system
- 11. The overall prevalence is 2.4%; It increases to 8% in individuals aged above 55 years. Diabetes mellitus is the most common cause worldwide. 1. Martyn CN, Hughes RA. Epidemiology of peripheral neuropathy. J Neurol Neurosurg Psychiatry.1997;62:310–8. 2. Medicine and Rehabilitation. Neurology 2009;72(2):185Y192.
- 12. 1. Is this a peripheral neuropathy? 2. What is its distribution? 3. Which fibers are affected? 4. What is the anatomic pattern? 5. What is the time course? 6. What is the likely etiology? 7. Is there evidence of hereditary neuropathy ?
- 13. The initial step is to confirm whether the signs and symptoms are related to peripheral nerve dysfunction.
- 14. Patients may present with positive and/or negative symptoms. The initial symptoms are often intermittent and examination can be normal. In most situations, sensory symptoms precede motor symptoms.
- 15. Positive sensory symptoms ◦ burning, ◦ lancinating pain, ◦ tingling, ◦ pins and needles ◦ walking on cotton wool, Negative sensory symptoms ◦ numbness, ◦ difficulty differentiating hot from cold ◦ worsening of balance in the dark
- 16. Negative motor symptoms ◦ Wasting ◦ Weakness (difficulty in turning keys in locks, unfasten button, opening bottles and jars, tripping on rugs or uneven ground.) • Positive motor symptoms Cramps Twitching • In the early stage, weakness is distal. • Early proximal weakness inflammatory neuropathy porphyric neuropathy.
- 17. Autonomic symptoms ◦ lightheadedness associated with orthostasis, ◦ impotence, ◦ sphincter disturbance, ◦ early satiety or bloating ◦ diarrhea, ◦ constipation, ◦ abnormality of sweating (hyperhydrosis/anhydrosis)
- 18. Patient should be asked regarding location at first involvement and asymmetry at the onset On the basis of distribution, neuropathies can be categorized into 1. Mononeuropathy, 2. Mononeuropathy multiplex 3. Polyneuropathy
- 19. It refers to single peripheral nerve involvement Usually occur due to trauma, compression or entrapment. The common entrapment neuropathies are ◦ carpal tunnel syndrome, ◦ ulnar nerve entrapment at the elbow ◦ peroneal nerve entrapment at the head of the fibula.
- 21. Refers to the involvement of multiple, separate noncontiguous peripheral nerves either simultaneously or sequentially. Sometimes, mononeuropathy may aggregate resembling polyneuropathy. Occurs most commonly due to ◦ leprosy and ◦ systemic vasculitis (polyarteritis nodosa, Churg- Strauss syndrome, rheumatoid arthritis, Sjogren's syndrome)
- 22. Most common variety of neuropathy. The nerve fibers are affected in a length- dependent pattern. A majority of these cases occur due to ◦metabolic, ◦toxic or ◦systemic disorders.
- 23. In a polyneuropathy, manifestations can be classified as ◦ Small-fiber sensory, ◦ Large-fiber sensory, ◦ Motor ◦ Autonomic
- 25. Clinical evaluation is often helpful in categorizing a neuropathy as ◦ axonal, ◦ demyelinating, ◦ neuronal [dorsal root ganglion (DRG)] Most axonal neuropathies follow length-dependent pattern with sensory symptoms & signs predominating over motor; distal reflexes are absent.
- 26. Most demyelinating neuropathies affect motor & sensory fibers (large fiber > small fiber) equally & areflexia or hyporeflexia is more generalized. DRG lesions involve purely sensory fibers in a non-length-dependent fashion; sensory ataxia & generalized loss of reflexes are usually found.
- 28. The is important in categorizing neuropathy. ◦ Acute (<4 weeks), ◦ Sub-acute (4–8 weeks) ◦ Chronic (>8 weeks).
- 30. The standard history, physical examination and well planned battery of investigations serve as general framework to determine the etiology of neuropathy Despite of this, in 25 to 30% of the patients in tertiary referral centers evaluated by experts, the etiology cannot be established.
- 31. History should include questions regarding ◦ occupation (possibility of toxic exposures to solvents, glues, fertilizers) ◦ dietary habits (e.g. strict vegan diet) ◦ excessive alcohol intake, ◦ smoking (para-neoplastic disease). ◦ sexual history (HIV, hepatitis C) A childhood history of ‘‘clumsiness’’ or poor athletic performance suggests a hereditary cause
- 32. History should focus on illnesses associated with neuropathy, such as ◦ endocrinopathy (diabetes mellitus, hypothyroidism), ◦ renal insufficiency, ◦ hepatic dysfunction, ◦ connective tissue disorders, ◦ Cancer Surgical history should address ◦ bariatric surgery, ◦ multiple orthopedic procedures, ◦ surgeries for ‘‘entrapped nerves.’’
- 33. Skin and mucous membranes may demonstrate ◦ Maculo-anesthetic patches with thickened nerves (Leprosy) ◦ purpura, livedo reticularis (vasculitis ) ◦ oral ulcers ( HIV), ◦ salivary gland swelling, dry eyes or mouth (sarcoidosis, Sjogren syndrome), ◦ gum ‘‘lead lines’’ (lead exposure).
- 34. Nerve enlargement can be seen in ◦ Leprosy ◦ Heriditary motor and sensory neuropathy ◦ Refsum’s disease ◦ Amyloidosis Easy locations to palpate nerves are ◦ the greater auricular nerve ◦ the ulnar nerve ◦ the superficial radial nerve ◦ the common peroneal nerve
- 35. Skeletal deformities hammer toes, pes cavus, and kyphoscoliosis are suggestive of an inherited polyneuropathy. Feet should be specifically examined for signs of trauma as an insensate foot could be an early indicator of an impending Charcot foot deformity.
- 36. Anosmia (Refsum's disease, vitamin B12 deficiency) Optic atrophy (inherited neuropathies,vit B12 deficiency) External ophthalmoplegia (Miller Fisher syndrome, Botulism,Diabetes) Trigeminal sensory loss (Sjogren's syndrome) Facial weakness (GB syndrome)
- 37. Muscle power testing in context of nerve & root distribution is crucial. It should assess muscle bulk, tone, and strength. Because most neuropathies cause distal weakness, the intrinsic foot muscles may be affected first, resulting in clawed feet and hammer toes.
- 38. Approached with nerve anatomy & disease type in mind. Monofilament probes can grade severity of loss. Test modalities that sub-serve ◦ large fibers (vibration, joint position and Rhomberg’s test) ◦ small fiber (pinprick, pain and temperature)
- 39. Ankle hyporeflexia or areflexia is common in large fiber neuropathy, Ankle reflexes are typically preserved with small fiber neuropathy (SFN). . Distal reflex loss are characteristic of length-dependent axonopathies.
- 41. Routine blood investigations: ◦ Blood count ◦ ESR ◦ Blood sugar ◦ Liver and renal function tests ◦ Serum vitamin B12 ◦ Thyroid function test Blood investigations depending upon suspected etiology ◦ Vasculitis profile ◦ HIV ELISA ◦ Heavy metal screening
- 42. Electrodiagnostic studies ◦ EDx studies may be repeated to monitor disease progression. ◦ These tests are the standard for large fiber polyneuropathy diagnosis and are normal in purely SFN.
- 43. Bedside autonomic tests: ◦ Blood pressure response to standing (Normal fall: <20/10 mmHg), ◦ HR variation with respiration (normal: ≥15 beats/m, I:E ratio 1.2),
- 44. Cerebrospinal fluid (CSF) ◦ useful in CIDP, AIDP and chronic immune-mediated axonal neuropathies where CSF protein are elevated Genetic testing – For hereditary causes
- 45. Rarely performed now a days Primary indication is amyloid neuropathy and vasculitis Should only be performed when NCS is abnormal Sural nerve is the most commonly biopsied nerve as it is pure sensory nerve
- 46. Sometimes used to diagnose small fibre neuropathy Used to measure density of small unmyelinated fibre Density of these fibres are reduced in whom nerve biopsy and NCS are abnormal
- 47. Other tests ◦ chest x-ray or CT-thorax for sarcoidosis; ◦ PET scan or CT of chest, abdomen, and pelvis for malignancy; ◦ Skeletal survey and bone marrow biopsy for lymphoproliferative diseases ◦ Salivary gland biopsy for Sjogren syndrome; ◦ Endoscopy and duodenal biopsy for celiac disease ◦ MRI may document nerve root enhancement in CIDP, show nerve root clumping in arachnoiditis, or reveal nerve enlargement in tumors.
- 49. Diabetes1 2 Paraproteinaemia2 3 Alcohol misuse1 Renal failure1 Vitamin B-12 deficiency1 HIV infection1 Chronic idiopathic 4 axonal neuropathy Prevalence 11-41% (depending on duration, type,and control) 9-10% 7% 4% 3.6% 16% (depending on the population studied, usually much lower) 10-40% of different hospital series BMJ 2010:341:c6100
- 50. SJOGREN’S SYNDROME VIT B12 NEUROPATHY CISPLATIN PYRIDOXINE NEUROTOXICITY FRIEDEREICH’S ATAXIA
- 51. Heriditary sensory neuropathy Lepromatous leprosy Diabetes mellitus Amyloidosis(early familial&primary) Tangier disease Fabry’s disease-pain predomonates Dysautonomia-riley-day syndrome HIV & antiretroviral therapy neuropathy
- 52. Global sensory loss Carcinomatous sensory neuropathy Hereditary sensory neuropathy Diabetic sensory neuropathy Vacor intoxication Xanthomatous neuropathy of primary biliary cirrhosis
- 53. Immune neuropathies Heriditary motor sensory neuropathies Acute intermittent porphyria Diphtheritic neuropathy Lead neuropathy Brachial neuritis Diabetic lumbosacralplexus neuropathy
- 55. RECURRENT POLYNEUROPATHY Relapsing CIDP Porphyria Refsum’s disease HNPP GBS Beriberi Toxic neuropathy
- 56. ◦ Guillain-Barré syndrome ◦ Chronic inflammatory demyelinating polyradiculoneuropathy ◦ Diabetes mellitus ◦ Porphyria ◦ Osteosclerotic myeloma ◦ Waldenstrom's macroglobulinemia ◦ Monoclonal gammopathy of undetermined significance ◦ Acute arsenic polyneuropathy ◦ Lymphoma ◦ Diphtheria ◦ HIV/AIDS ◦ Lyme disease ◦ Hypothyroidism ◦ Vincristine (Oncovin, Vincosar PFS) toxicity
- 57. Treatment of the underlying disorder ◦ Glycemic control for diabetic neuropathy, ◦ Vitamin replacement for B12 deficiency, ◦ Immunosuppression for vasculitis, ◦ Surgery for entrapment neuropathy, ◦ Enzyme replacement for genetic diseases Pain management Supportive care to protect and rehabilitate damaged tissue.
- 58. First line-Lidoderm 5% patch,TCA,Gabapentin Pregabalin,Duloxetine Second line- Carbamazepine,Phenytoin,Venlafaxine,Trama dol Third line-Mexiletene Others-EMLA Cream,Capsaicin
- 60. case of neuropathy | Motor Sensory Autonomic Mixed | Focal Multifocal Generalized | Proximal or Distal Symmetric or asymmetr | UMN features present or not | Acute Subacute Chronic | Narrow down etiology and go for Edx studies