Neuropathies Flashcards
Neuropathy list
- Peripheral Neuropathy
- Compressive Neuropathy
- Bell’s Palsy
- Trigeminal Neuralgia
- Herpes Zoster/Post-herpetic neuralgia
- herpes zoster/post - HN
- Motor neuron dz/ AML
History
Pain
- location
- character
- pain elsewhere? (Back neck)
- pattern / time course of progression
- better/worse ?
- meds?
- ADL changes
- Bothered by touching, sheets
History
Causes
- DM, HIV, EtOH, Autoimmune, cancer, ?
- Healthy lifestyle
- Med use
- social hx (etoh)
- ‘Do elders in family always complain about feet?”
MC etiologies
- DM
- HIV/HepC
- Meds = Chemo,HIV,FQ
- vit deficiencies/excess (B)
- inherited neuropathies
- autoimmune dz
- cancer (weight loss?)
- idiopathic
- leprosy
Differential Dx
Painful feet
- Peripheral Neuro (both legs, whole leg)
- Radiculopathy (dermatomes - strip down leg)
- Claudication/Vascular dz - insuff blood
- Plantar fasciitis
- Gout
- Rheumatoid Arthritis
- Morton’s neuroma
Physical exam
- CN
- Motor exam
- reflexes
- sensory exam
- gait/romberg
- PSN
Strength testing
Weakness/symptoms worse distally than proximal
Pain limits strength test
Sensory testing
Stocking glove sensory loss
Also down mid chest (distal part of spinal offshoots)
Sensory testing
Modalities
- **Pinprick
- **Temperature
**Vibration
**Proprioception
DIFFERENT NERVE TRACTS, but these often go together
Small fibers
Unmyelinated fibers innervating skin
Large fibers
Macroscopic
Which impaired in small fiber neuropathy?
temperature
Pinprkc
Which impaired in large fiber neuropathy?
Vibration
Proprioception
Labs
- help with UNDERLYING CAUSE
- Glucose test/ A1C
- Hepatitis serologies
- Autoimmune
- Testing for B12
Labs
Extra tests
Serum protein electrophoresis (MM)
B6 levels
HIV testing
Electrical Studies
Measure speed of conduction / amplitude of transfer - LARGE FIBER, KNOWN PATHWAY
Problem with axon /myelin/both
Acute problem/ chronic
Genetic testing
- Charcot-Marie-Tooth syndrome
- only helpful if known mutation
- avoid unnecessary back surgery
- genetic non-discrimination concerns
PSN Tx
Anticonvulsants
1st line
Gabapentin
*NOT PAIN PILLS, PAIN PREVENTERS, need a week or two of regular dosing
PCN Tx
Anti-depressants
TCA - sleep difficulties
SNRI - depression
PSN Tx
Weak mu-opiod ag
Tramadol
S.E. - toxic metabolite = seizures
Give 10 for “bad days”
PSN Tx
Opiates
not effective for neuro pain
*NOT 1st line
PSN Tx
Lidocaine
for small focal areas
Wear gloves!
PSN Tx
Supplements
Alpha-lipoic acid
*Buy from german pharmacy (UNREGULATED in USA)
Tx
Exercise, Diet, Weight loss
- peripheral nerve regeneration
* Painful - try water, bicycle, rowing
PSN
Patient Education
- DAILY foot inspection
- Nail cutting at podiatry
- Fall prevention
- Med titration
- Family ed = it’s real!
- Risk of chemo/fluoroquinolones
Compression Neuropathies vs. radiculopathy
Radiculopathy is compression at nerve root, this is anywhere
Compression Neuropathies
Common sites
Carpal tunnel
Thoracic outlet
Ulnar entrapment at elbow
Tarsal tunnel
CTS risk factors
Genetic DM Pregnancy Age Repetitive strain
- Dull aching discomfort
- tingling
- weakness/clumsiness of hand
- sleep provokes
- repetitive actions provoke
- improve by changing posture
S/s
CTS
CTS
Tx
- night splints
- NSAID
- PT - muscular imbalance
- Rest/activity mods
- steroid injections
- Surgical decompression = do early
+Tinel’s test (medial nerve)
+Phelen’s Test
*Wasting/atrophy of hand muscles (late sign)
*abnormal nerve conduction tests
Signs
Carpal Tunnel CTS
Bell’s Palsy
Peripheral CN 7 abnormality
*entire nerve after foramen = affected
- facial weakness over DAYS - WEAKS
- Taste, lacrimation, hyperacusis change
- facial tingling pain near ear
s/s?
Bell’s Palsy
Bells Palsy
Tx
Early (72 hrs) - steroids +acyclovir
Symptomatic = eye patch, pain control
Late, just Symptomatic tx
Bell’s Palsy
Prognosis
Worse for older, complete palsy, severe pain
- Recurrent severe, lancinating pain - unilateral,
- come from slight stimulus - chewing, yawning, touch
S/s?
Trigeminal Neuralgia (CN 5)
*Trigem distribution
Trigeminal Neuralgia
Tx
- 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)
Shingles (herpes zoster)
Who
- those primary varicella zoster
* immunocompromised
Where does VZV live?
Sensory dorsal root ganglia
Grouped vesicles on an erythematous base
Herpes
Zoster distribution on body
Can’t cross midline
Always on dermatome
- Shingles in V1 distribuition
* Vesicles on tip of nose
Herpes Ophthalmicus
URGENT REFER OPTHALMALOGIST TODAY
Herpes Zoster
Tx
W/In 72 hours - Antivirals
- Acyclovir
- Valacyclovir
- Famciclovir
Pain Control
- Opiates
- Anti-convulsants
Persistence of electric shock pain and severe itching >3 months after rash
Post-herpetic neuralgia
Post-Herpetic Neuralgia development risks
- Old (>50s)
- Female >
- w/ prodrome
- PAIN w/ rash
Post-Herpetic Neuralgia
Tx
*Anti-convulsants
GABAPENTIN
*ADD TCA / SNRI *Weak mu-Opioid (TRAMADOL / ZYDOL) *Opiates, Lidocaine patch (GOOD = LOCAL) cream
ALS
Name
Amyotrophic Lateral Sclerosis
ALS
Causes
- Excess glutamate in brain
* Muscle weakness + atrophy
UMN vs. LMN Lesion
Weakness
BOTH
UMN vs. LMN Lesion
Atrophy
LMN Lesion = YES
UMN vs. LMN Lesion
Fasciculations
LMN Lesion = YES
UMN vs. LMN Lesion
Reflexes
LMN Lesion = DOWN
UMN Lesion = UP
UMN vs. LMN Lesion
Tone
LMN Lesion = DOWN
UMN Lesion = UP
- progressive arm/weak weakness, asymmetrick
- fasciculations/twitching
- Stiffness
- Weight loss/ muscle atrophy
- Drool
- NO PAIN, NO SENSORY, NO BOWEL CONTROL, OCULAR CONTROL
S/S
ALS
ALS
Tx
***RIluzole
- Ventilatory Support - (a serious decision)
- Symptomatic Speech Therapy
- Psyc
ALS
Assessment
PE:
Weakness, Hyperflexia, fasiculations
ALS
Prognosis
- 3 years after Dx (median)
- come in w/ facial s/s = 1 yr left
- Respiratory failure
- Pins + Needles
- Numbness
- Hypersensitiive/burning
- Bunched sock feeling
General Presentation?
Peripheral Neuropathy
Peripheral Neuropathy (PSN)
General Tx
- Anti-convulsants
- Antidepressants (TCA/SNRI)
- Weak u-opioid ags (tramadol)
- Opiates
- Lidocaine patches/creams
- Healthy lifestyle
Peripheral Neuropathy (PSN) Tx
Anti-convulsants
1st LINE
Gabapentin
Peripheral Neuropathy (PSN) Tx
Anti-Depressants
*TCA/SNRI
- TCA = sleep
- SNRI = depression
Peripheral Neuropathy (PSN) Tx
u-opioid ags
Tramadol
- breakthrough pain
- NOT daily med
Peripheral Neuropathy (PSN) Tx
LIdocaine patch/cream
focal neuropathies
NO 24 hr
Peripheral Neuropathy (PSN) Tx
Supplements
Alpha-lipoic acid
Peripheral Neuropathy (PSN) Tx
Pt needs to be alert and driving?
Anti-convulsants
Gabapentin
Peripheral Neuropathy (PSN) Tx
Pt w/ concurrent depression?
anti-depressants
Peripheral Neuropathy (PSN) Tx
Pt w/ very focal pain?
Lidocaine patches/topical cream
Peripheral Neuropathy (PSN) Tx
Pt w/ insomnia?
TCAs - bedtime
Peripheral Neuropathy (PSN) Tx
Pt w/ chronic constipation?
NO TCAs, Tramadol, Opiates
Peripheral Neuropathy (PSN) Tx
Pt w/ orthostasis/older pt?
NO TCAs
Compression Neuropathy vs. Radiculopathy
Radiculopathy = compression neuropathy at nerve root
Compression Neuropathies
MC sites
- Carpal Tunnel
- Thoracic Outlet
- Ulnar Entrapment at the Elbow (Cubital Tunnel)
- Tarsal Tunnel
What is MC compression Neuropathy?
Carpal Tunnel
Median N.
Carpal Tunnel
Risk Factors
- Genetic
- DM
- pregnancy
- fat
- Age
- Repetitive strain
Facial muscle weakness:
Can raise both sides of forehead
CNS problem
Facial muscle weakness:
One side of forehead completely paralyzed
Peripheral problem
Bell’s Palsy (CN 7)
Trigeminal Neuralgia vs Bell’s Palsy
*Trigeminal Neuralgia = Facial PAIN
Bell’s Palsy = Facial WEAKNESS
Trigeminal Neuralgia
Cause?
UNCLEAR
- compression
- demyelination
- inflammation
- trauma
