Clincial Peripheral Neuropathy

Question 1

Nomenclature for neuropathies

Answer 1

1) central neuropathy
- myelopathy = spinal cord associated
- encephalopathy = Brain associated

2) peripheral neuropathy
- mononeuropathy = solitary nerve associated
- polyneuropathy = multiple solitary nerve associated (directly tied together)
- mononeuropathy multiplex = multiple non solitary nerves associated (not directly tied together)

Question 2

Which type of peripheral neuropathy is more treatable, axonal or demyelination?

Answer 2

Demyelination

Question 3

Details of patterns of different types of neuropathies

Answer 3

Mononeuropathies

• symptoms reflect a single dermatome
• typically are caused by a compressive or traumatic incident
• almost nerve a systemic process

Poly-peripheral neuropathy

• symptoms are symmetric and bilateral usually
• usually a systemic issue and challenging to diagnosis

Mononeuritis multiplex

• often vasculitis and systemic
• incredibly painful that is acute with multiple different nerves affected

Question 4

3 most importaint characteristics of polyperipheral neuropathies

Answer 4

1) distal
- loss will occur in the extremities first (usually feet then hands) and then move to trunk overtime

2) Length dependent
- always affects longest nerves first (lower limbs) since the most distal portion of the nerve is the first to die/damage due to metabolic issues

3) symmetric symptoms
- affects both sides of the feet, then both hands, etc. (never just one)

Question 5

Lower motor vs upper moron neuron patterns

Answer 5

Lower motor neurons

• nerves off spinal cord
• reduced or absent reflexes
• atrophy-muscle loss
• fasciculations are present

Upper motor neurons

• nerves in the spinal cord or brain
• hyperreflexia
• spasticity muscle tone

Question 6

How to test posterior column pathways

Answer 6

Proprioception

• ask patient if they have difficulties moving/ standing in the dark, on uneven surfaces or with eyes closed
• can test in these three conditions as well (rhomberg)

Vibration
- get a 120 Hz running fork and test one different parts of the body

Question 7

Functional neurological symptoms

Answer 7

Occur in patient that appears to have a neuropathy, but a EMG/NCS is negative for a specific pattern

Is a functional issue, but not a structural issue

Treatment is usually anxiety or depression (functional neurologic therapies)

Question 8

Acute poly peripheral neuropathy

Answer 8

#1 on the differential list from the start should be AIDP (Guillain Barre syndrome)

Can be post viral or idiopathic

Symptoms: (onset is within days)

• numbness/weakness starting at extremities/face and moving proximal
• pain accompanies the numbness/weakness
• • can affect diaphragm and/or autonomic system which causes respiratory failure or difficulty breathing
• • areflexia is present

Treated with IVIG/plasmapheresis

• takes months-a year to fix and often does not go back to 100%
• *if it is a chronic IDP (will show relapsing and remitting episodes as well as increased CSF proteins without white blood cell increases)

Question 9

VITAMINS acronym for polyperipheral neuropathy

Answer 9

Helps to suggest the most common broad causes of polyperipheral neuropathy

Vitamin deficiencies 
Inflammatory processes 
Toxic or trauma events 
Autoimmune reactions/diseases
Metabolic dysfunctions 
Infectious disease 
Neoplastic syndromes 
Structural abnormalities (usually genetic) 

Symptoms: onset is weeks-years (chronic)

• symmetrical distal and length dependent
• • must have a good history to help narrow down

Question 10

Vitamin related neuropathy

Answer 10

highly suspect in gastric bypass/malnourished/alcoholics/vegans

Types of vitamin deficient that cause neuropathies:

• B1 (common in alcoholics (must give thiamin IV STAT)
• B6
• copper (elevation)
• vitamin E
• B16 (common in malnourished patients)
• vitamin D (usually autoimmune or neoplastic)

Question 11

Inflammatory neuropathies

Answer 11

Vasculitis

Wagner’s granulomatosis

Sarcoidosis

Polyarteritis Nodosa

always treated with immunosuppressive drugs (usually rituximab or cyclophosphamide)

Question 12

Toxic neuropathies

Answer 12

most common is alcohol overdose

Chemo therapies

Anti-retrovirals

The following drugs: (especially in ODs or prolonged use)

• phenytoin
• amiodarone
• metronidazole

Mercury/lead/arsenic/organophosphates

Question 13

Autoimmune neuropathies

Answer 13

Hypothyroidism

Sjögren

RA

SLE

Question 14

Infectious neuropathies

Answer 14

Leprosy (mycobacterium)

Lyme disease

Syphilis

Hepatitis B/C

HIV

Question 15

Metabolic neuropathies

Answer 15

diabetes is the #1 cause of all poly neuropathies

Uremic (kidney failure or polycystic kidneys)

Amyloidosis

Severe sepsis w/ poor perfusion