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Neurology > Neuropathies > Flashcards

Neuropathies Flashcards

1
Q

Neuropathy list

A
  • Peripheral Neuropathy
  • Compressive Neuropathy
  • Bell’s Palsy
  • Trigeminal Neuralgia
  • Herpes Zoster/Post-herpetic neuralgia
  • herpes zoster/post - HN
  • Motor neuron dz/ AML
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2
Q

History

Pain

A
  • location
  • character
  • pain elsewhere? (Back neck)
  • pattern / time course of progression
  • better/worse ?
  • meds?
  • ADL changes
  • Bothered by touching, sheets
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3
Q

History

Causes

A
  • DM, HIV, EtOH, Autoimmune, cancer, ?
  • Healthy lifestyle
  • Med use
  • social hx (etoh)
  • ‘Do elders in family always complain about feet?”
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4
Q

MC etiologies

A
  • DM
  • HIV/HepC
  • Meds = Chemo,HIV,FQ
  • vit deficiencies/excess (B)
  • inherited neuropathies
  • autoimmune dz
  • cancer (weight loss?)
  • idiopathic
  • leprosy
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5
Q

Differential Dx

Painful feet

A
  • Peripheral Neuro (both legs, whole leg)
  • Radiculopathy (dermatomes - strip down leg)
  • Claudication/Vascular dz - insuff blood
  • Plantar fasciitis
  • Gout
  • Rheumatoid Arthritis
  • Morton’s neuroma
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6
Q

Physical exam

A
  • CN
  • Motor exam
  • reflexes
  • sensory exam
  • gait/romberg
  • PSN
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7
Q

Strength testing

A

Weakness/symptoms worse distally than proximal

Pain limits strength test

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8
Q

Sensory testing

A

Stocking glove sensory loss

Also down mid chest (distal part of spinal offshoots)

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9
Q

Sensory testing

Modalities

A
  • **Pinprick
  • **Temperature

**Vibration
**Proprioception
DIFFERENT NERVE TRACTS, but these often go together

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10
Q

Small fibers

A

Unmyelinated fibers innervating skin

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11
Q

Large fibers

A

Macroscopic

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12
Q

Which impaired in small fiber neuropathy?

A

temperature

Pinprkc

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13
Q

Which impaired in large fiber neuropathy?

A

Vibration

Proprioception

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14
Q

Labs

A
  • help with UNDERLYING CAUSE
  • Glucose test/ A1C
  • Hepatitis serologies
  • Autoimmune
  • Testing for B12
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15
Q

Labs

Extra tests

A

Serum protein electrophoresis (MM)

B6 levels

HIV testing

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16
Q

Electrical Studies

A

Measure speed of conduction / amplitude of transfer - LARGE FIBER, KNOWN PATHWAY

Problem with axon /myelin/both

Acute problem/ chronic

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17
Q

Genetic testing

A
  • Charcot-Marie-Tooth syndrome
  • only helpful if known mutation
  • avoid unnecessary back surgery
  • genetic non-discrimination concerns
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18
Q

PSN Tx

Anticonvulsants

A

1st line
Gabapentin

*NOT PAIN PILLS, PAIN PREVENTERS, need a week or two of regular dosing

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19
Q

PCN Tx

Anti-depressants

A

TCA - sleep difficulties

SNRI - depression

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20
Q

PSN Tx

Weak mu-opiod ag

A

Tramadol
S.E. - toxic metabolite = seizures
Give 10 for “bad days”

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21
Q

PSN Tx

Opiates

A

not effective for neuro pain

*NOT 1st line

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22
Q

PSN Tx

Lidocaine

A

for small focal areas

Wear gloves!

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23
Q

PSN Tx

Supplements

A

Alpha-lipoic acid

*Buy from german pharmacy (UNREGULATED in USA)

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24
Q

Tx

Exercise, Diet, Weight loss

A
  • peripheral nerve regeneration

* Painful - try water, bicycle, rowing

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25
Q

PSN

Patient Education

A
  • DAILY foot inspection
  • Nail cutting at podiatry
  • Fall prevention
  • Med titration
  • Family ed = it’s real!
  • Risk of chemo/fluoroquinolones
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26
Q

Compression Neuropathies vs. radiculopathy

A

Radiculopathy is compression at nerve root, this is anywhere

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27
Q

Compression Neuropathies

Common sites

A

Carpal tunnel
Thoracic outlet
Ulnar entrapment at elbow
Tarsal tunnel

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28
Q

CTS risk factors

A 
Genetic
DM
Pregnancy
Age
Repetitive strain
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29
Q
  • Dull aching discomfort
  • tingling
  • weakness/clumsiness of hand
  • sleep provokes
  • repetitive actions provoke
  • improve by changing posture

S/s

A

CTS

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30
Q

CTS

Tx

A
  • night splints
  • NSAID
  • PT - muscular imbalance
  • Rest/activity mods
  • steroid injections
  • Surgical decompression = do early
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31
Q

+Tinel’s test (medial nerve)
+Phelen’s Test
*Wasting/atrophy of hand muscles (late sign)
*abnormal nerve conduction tests

Signs

A

Carpal Tunnel CTS

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32
Q

Bell’s Palsy

A

Peripheral CN 7 abnormality

*entire nerve after foramen = affected

33
Q
  • facial weakness over DAYS - WEAKS
  • Taste, lacrimation, hyperacusis change
  • facial tingling pain near ear

s/s?

A

Bell’s Palsy

34
Q

Bells Palsy

Tx

A

Early (72 hrs) - steroids +acyclovir

Symptomatic = eye patch, pain control

Late, just Symptomatic tx

35
Q

Bell’s Palsy

Prognosis

A

Worse for older, complete palsy, severe pain

36
Q
  • Recurrent severe, lancinating pain - unilateral,
  • come from slight stimulus - chewing, yawning, touch

S/s?

A

Trigeminal Neuralgia (CN 5)

*Trigem distribution

37
Q

Trigeminal Neuralgia

Tx

A
  • before tx - high suicide rate
  • Anti-convulsant meds
  • Glycerol injections

if refractory, remove nerve insult to allow regeneration

  • Gamma knife radiosurgery
  • microvascular decompression (most invasive, sometimes no effect)
38
Q

Shingles (herpes zoster)

Who

A
  • those primary varicella zoster

* immunocompromised

39
Q

Where does VZV live?

A

Sensory dorsal root ganglia

40
Q

Grouped vesicles on an erythematous base

A

Herpes

41
Q

Zoster distribution on body

A

Can’t cross midline

Always on dermatome

42
Q
  • Shingles in V1 distribuition

* Vesicles on tip of nose

A

Herpes Ophthalmicus

URGENT REFER OPTHALMALOGIST TODAY

43
Q

Herpes Zoster

Tx

A

W/In 72 hours - Antivirals

  • Acyclovir
  • Valacyclovir
  • Famciclovir

Pain Control

  • Opiates
  • Anti-convulsants
44
Q

Persistence of electric shock pain and severe itching >3 months after rash

A

Post-herpetic neuralgia

45
Q

Post-Herpetic Neuralgia development risks

A
  • Old (>50s)
  • Female >
  • w/ prodrome
  • PAIN w/ rash
46
Q

Post-Herpetic Neuralgia

Tx

A

*Anti-convulsants
GABAPENTIN

*ADD 
TCA / SNRI
*Weak mu-Opioid
(TRAMADOL / ZYDOL)
*Opiates, Lidocaine patch (GOOD = LOCAL) cream
47
Q

ALS

Name

A

Amyotrophic Lateral Sclerosis

48
Q

ALS

Causes

A
  • Excess glutamate in brain

* Muscle weakness + atrophy

49
Q

UMN vs. LMN Lesion

Weakness

A

BOTH

50
Q

UMN vs. LMN Lesion

Atrophy

A

LMN Lesion = YES

51
Q

UMN vs. LMN Lesion

Fasciculations

A

LMN Lesion = YES

52
Q

UMN vs. LMN Lesion

Reflexes

A

LMN Lesion = DOWN

UMN Lesion = UP

53
Q

UMN vs. LMN Lesion

Tone

A

LMN Lesion = DOWN

UMN Lesion = UP

54
Q
  • progressive arm/weak weakness, asymmetrick
  • fasciculations/twitching
  • Stiffness
  • Weight loss/ muscle atrophy
  • Drool
  • NO PAIN, NO SENSORY, NO BOWEL CONTROL, OCULAR CONTROL

S/S

A

ALS

55
Q

ALS

Tx

A

***RIluzole

  • Ventilatory Support - (a serious decision)
  • Symptomatic Speech Therapy
  • Psyc
56
Q

ALS

Assessment

A

PE:

Weakness, Hyperflexia, fasiculations

57
Q

ALS

Prognosis

A
  • 3 years after Dx (median)
  • come in w/ facial s/s = 1 yr left
  • Respiratory failure
58
Q
  • Pins + Needles
  • Numbness
  • Hypersensitiive/burning
  • Bunched sock feeling

General Presentation?

A

Peripheral Neuropathy

59
Q

Peripheral Neuropathy (PSN)

General Tx

A
  • Anti-convulsants
  • Antidepressants (TCA/SNRI)
  • Weak u-opioid ags (tramadol)
  • Opiates
  • Lidocaine patches/creams
  • Healthy lifestyle
60
Q 
Peripheral Neuropathy (PSN)
Tx

Anti-convulsants

A

1st LINE

Gabapentin

61
Q 
Peripheral Neuropathy (PSN)
Tx

Anti-Depressants

A

*TCA/SNRI

  • TCA = sleep
  • SNRI = depression
62
Q 
Peripheral Neuropathy (PSN)
Tx

u-opioid ags

A

Tramadol

  • breakthrough pain
  • NOT daily med
63
Q 
Peripheral Neuropathy (PSN)
Tx

LIdocaine patch/cream

A

focal neuropathies

NO 24 hr

64
Q 
Peripheral Neuropathy (PSN)
Tx

Supplements

A

Alpha-lipoic acid

65
Q 
Peripheral Neuropathy (PSN)
Tx

Pt needs to be alert and driving?

A

Anti-convulsants

Gabapentin

66
Q 
Peripheral Neuropathy (PSN)
Tx

Pt w/ concurrent depression?

A

anti-depressants

67
Q 
Peripheral Neuropathy (PSN)
Tx

Pt w/ very focal pain?

A

Lidocaine patches/topical cream

68
Q 
Peripheral Neuropathy (PSN)
Tx

Pt w/ insomnia?

A

TCAs - bedtime

69
Q 
Peripheral Neuropathy (PSN)
Tx

Pt w/ chronic constipation?

A

NO TCAs, Tramadol, Opiates

70
Q 
Peripheral Neuropathy (PSN)
Tx

Pt w/ orthostasis/older pt?

A

NO TCAs

71
Q

Compression Neuropathy vs. Radiculopathy

A

Radiculopathy = compression neuropathy at nerve root

72
Q

Compression Neuropathies

MC sites

A
  • Carpal Tunnel
  • Thoracic Outlet
  • Ulnar Entrapment at the Elbow (Cubital Tunnel)
  • Tarsal Tunnel
73
Q

What is MC compression Neuropathy?

A

Carpal Tunnel

Median N.

74
Q

Carpal Tunnel

Risk Factors

A
  • Genetic
  • DM
  • pregnancy
  • fat
  • Age
  • Repetitive strain
75
Q

Facial muscle weakness:

Can raise both sides of forehead

A

CNS problem

76
Q

Facial muscle weakness:

One side of forehead completely paralyzed

A

Peripheral problem

Bell’s Palsy (CN 7)

77
Q

Trigeminal Neuralgia vs Bell’s Palsy

A

*Trigeminal Neuralgia = Facial PAIN

Bell’s Palsy = Facial WEAKNESS

78
Q

Trigeminal Neuralgia

Cause?

A

UNCLEAR

  • compression
  • demyelination
  • inflammation
  • trauma

Neurology (20 decks)

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