Neuropathies Flashcards
Carpal tunnel Syndrome
S/Sx
Nerve affected?
Pain, burning, tingling and numbness to fingers in median nerve distribution
Typically increases with activity
Often report shaking the hand to help with symptoms
Weakness with more severe disease
Carpal tunnel
PE
Signs
Diminished sensation to 1st-3rd fingers and radial half of 4th finger
Poor grip strength; thenar atrophy (late)
+Tinel sign- reproduction of symptoms with nerve percussion
+Phalen sign- reproduction of symptoms with flexing wrist to 90degrees for 60 sec
carpal tunnel
Dx
Ultrasound may show flattening of nerve
Best test is EMG/NCV (electromyography/ nerve conduction velocity)- will give you a yes/no AND will give severity of disease (mild, moderate, severe)
carpal tunnel
Tx
Relieve pressure on the nerve
Splint in neutral position
Reduce repetitive activity
PT for modalities and tendon glide exercises
NSAIDs or oral steroids
Steroid injection
Surgical release (endoscopic or open)
Carpal tunnel
who is often affected? recovery? people with CT often have high rate of?
Often occurs in pregnancy
Odds of full recovery diminish with thenar atrophy
People with these diseases have high rate of CTS:
RA, myxedema, amyloidosis, sarcoidosis, leukemia, acromegaly, and hyperparathyroidism
Ulnar neuropathy
General
Compression of the ulnar nerve in one of two places
At elbow (cubital tunnel)
At wrist (Guyon’s canal)
Can be from resting arm on things
Can also be from growth in wrist
Ulnar neuropathy
S/Sx
Pain, tingling or numbness in the ulnar nerve distribution (1/2 4th finger and all of 5th finger)
Sometimes will have weakness and sometimes won’t (depends on location of compression)
Worse with elbow flexion (if compression is at elbow)
Ulnar neuropathy
Tx
Depends on location, but still need to reduce compression:
Bracing elbow or wrist, especially while sleeping
NSAIDs or oral steroids
Avoid putting pressure on the nerve
Surgical release with relocation of nerve at elbow (ulnar nerve transposition)
When at wrist/ hand, often related to mass/ tumor and requires surgery
Radial neuropathy
General
Damage to radial nerve with humerus fracture
Compression of radial nerve
Axilla, wrist
Radial neuropathy
S/Sx
Numbness to back of hand
Weakness with wrist extension and at triceps
All symptoms and physical exam findings depend on location of problem (obviously won’t have weakness of triceps if problem is distal)
Compression at axilla is often from crutches
Saturday night palsy is usually radial nerve (arm over chair or head on hand)
Radial neuropathy
PE and Dx
same as S/Sx
EMG/NCV
Radial neuropathy
Tx
Remove compression or stop the thing/ activity causing compression
ALWAYS check radial nerve status with humerus shaft fracture
tarsal tunnel syndrome
General
Compression of the posterior tibial nerve at the ankle/foot; sometimes due to nerve stretching
Often accompanied by over pronation of the foot (flat feet)- will get into this more in orthopedic lectures
Tarsal tunnel sydrome
PE
Abnormal sensation to areas mentioned in signs/symptoms
Sometimes very tender over posterior tibial tendons and nerve in the tarsal tunnel
Rarely will have weakness and only in the foot
tarsal tunnel
Dx and Tx
Same as all other compressive neuropathies but EMG/NCV is less accurate here than in upper extremity
Same as all other compressive neuropathies but EMG/NCV is less accurate here than in upper extremity
Meralgia Paresthetica
general
Compression of lateral femoral cutaneous nerve
Typically happens in pregnant, obese or diabetic patients
Meralgia Paresthetica
S/Sx
Numbness to lateral thigh that does not pass the knee joint
Often unilateral
Meralgia Paresthetica
PE and Dx
Same as signs and symptoms
No loss of motor function
No Dx necessary
Polyneuropathies & Mononeuritis Multiplex
Weakness, sensory disturbances (often including pain), or both in arms/ legs; diminished or absent DTRs; sometimes has family link; sometimes has a link to toxic exposure or systemic illness
Diabetic Neuropathy- Peripheral
general
Due to late-stage diabetes mellitus (types I and II)
Damage to axons, worse with long nerves (why legs/ feet are worse)
Causes motor and sensory problems
Eventually develop vascular problems
Diabetic neuropathy - peripheral
Early S/Sx
Early- sensory: diminished sensation to pain, vibration and temperature
Stocking glove pattern (starts distally and progresses proximally)
diabetic neuropathy - peripheral
PE
Perform Semmes-Weinstein filament test- if cannot feel 5.07 size, they are at significant risk for injury
May have toe clawing
Calluses and ulcerations on plantar skin over MT heads
Diabetic neuropathy - peripheral
Dx
X-rays will eventually show joint subluxation (shifting), subtle fractures and then bone destruction
Obviously need to monitor blood glucose levels
Might consider EMG/NCV early to determine tarsal tunnel syndrome vs diabetic neuropathy
Diabetic Neuropathy- Peripheral
Charcot arthropathy
Prolonged neuropathy in addition to trauma can lead to collapse of arch and destabilization of midfoot joints
Patient ends up with rocker bottom foot deformity
Leads to ulcers on bottom of foot
diabetic neuropathy - peripheral
Tx
Improve glucose control
Shoe adjustments (diabetic shoes reduce injuries that cause calluses and ulcers)
Ulcers must be treated by wound care specialists
Prevention!! See podiatrist regularly for exams and paring of calluses
Medications:
Low dose nortriptyline and amitriptyline (tricyclic antidepressants) treat the pain and cause drowsiness which helps with sleep
Gabapentin and pregabalin help with pain but have abuse potential
SSRIs give some relief but not as much as tricyclics
Sometimes topicals give some relief (capsaicin and lidocaine creams)
Diabetic Neuropathy- Autonomic
general
Just like peripheral, damage to autonomic nerves by long term high blood glucose
Can change BP, pulse, GI activity, bladder fxn, ED
Diabetic neuropathy - autonomic
S/Sx
GI- N&V, feeling of fullness, reflux, constipation or diarrhea, gastroparesis (more in type I)
GU- incomplete emptying of bladder, erectile dysfunction
Circulatory- orthostatic hypotension
Diabetic neuropathy - autonomic
Tx
Treatments: treat each issue individually as you normally would treat it, nothing special specifically for cases related to neuropathy
Charcot-Marie Tooth Disease
general
NOT THE SAME AS CHARCOT FOOT
Inherited, motor and sensory
Type 1- mutations in myelin protein genes
Type 2- axonal loss, also genetic
Charcot-Marie Tooth Disease
S/Sx
Foot deformities, abnormal gait as a child or early adult
Progresses slowly and eventually leads to muscle wasting that starts in the legs
Distal sensory loss
Sometimes will have slight tremor
CHarcot-Marie Tooth disease
PE
Same as signs and symptoms
Will have diminished or absent DTRs
Claw foot and high arch
Claw fingers
Charcot-Marie Tooth Disease
Dx and Tx
EMG/NCV
No cure
NSAIDs and acetaminophen for pain
Surgeries for deformities
Friederich Ataxia
general
Autosomal recessive trinucleotide repeat disease
Obvious cerebellar dysfunction (gait and hand coordination)
Weakness in legs
Sensory disturbance and diminished DTRs
Guillain-Barre Syndrome
general
Acute, idiopathic polyneuropathy
Often follows infection, vaccine, or surgery
Probably immune-based but no real known cause
Guillain-barre Syndrome
S/Sx
Weakness is more of a problem than sensory issues, but they do NOT have loss of sensation or neuropathic pain
Tends to be symmetric
Begins in proximal legs, spreads to arms and sometimes the face
Guilain-barre syndrome
PE
See signs and symptoms
Can develop autonomic nerve problems like cardiac irregularities, hypo or hypertension, pulmonary dysfunction, impaired sphincter control
Guillain-barre syndrome
LP and EMG
Lumbar puncture: CSF has high protein count with normal cell ct
EMG/NCV- very odd changes, neurologist will interpret
Guillain-barre syndrome
Tx
Not much for mild cases
Plasmapheresis- need to do this early and especially with severe cases
Need to be in ICU if trouble breathing
Clot prevention
