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Clin Med - Neuro > Neuropathies > Flashcards

Neuropathies Flashcards

1
Q

What disease populations are at high risk for developing neuropathies?

A

HIV

Diabetic

Hep C

autoimmune

cancer

leprosy

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2
Q

What is one important physical finding that distinguishes peripheral neuropathy from radiculopathy?

A

in PN, many or all of the dermatomes are affected as opposed to radiculopathy, which is usually isolated to a single dermatome

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3
Q

Neuropathy patients are typically weakest where and why?

A

In the most distal locations (feet first) because longest nerve tracts degenerate first

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4
Q

What is the typical pattern of a peripheral sensory neuropathy?

A

stocking/glove pattern, but don’t forget center thorax and abdomen

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5
Q

What two sensory modalities are part of the physical exam and test the spinothalamic tract?

A

pinprick (pain)

temperature

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6
Q

What two sensory modalities are part of the physical exam and test the corticospinal tract?

A

vibration

proprioception

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7
Q

Which type of fibers are typically impaired in spintothalamic tract testing (pinprick and temperature)?

A

small fibers

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8
Q

What type of fibers are typically impaired in the corticospinal tract (vibration and sensation)

A

large fibers

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9
Q

What additional tests should be given to all patients with PSN?

A
  • 2 hour oral glucose tolerance test/HgbA1C
  • hepatitis serologies
  • autoimmune diseases (ANA, RF, SS-A, SS-B)
  • B12 deficiency
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10
Q

What other tests might one consider in a patient with PSN?

A

HIV

B6

multiple myeloma

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11
Q

What is the test of choice for large fiber neuropathies?

A

Nerve conduction velocity

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12
Q

What is a genetic cause of PSN?

A

Charcot-Marie-Tooth

*heterogenous - need to know mutation

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13
Q

What is the first line treatment in PSN?

A

anti-convulsants

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14
Q

What is the most commonly prescribed anticonvulsant for PSN?

A

Gabapentin

*good safety profile, takes a few weeks to titrate

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15
Q

What can be used to treat breaktrhough pain in PSN?

A

Tramadol or other weak mu-opiod agonists

*not acceptable as a daily medication

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16
Q

Are opiates considered therapeutic for PSN?

A

Not usually -typically not effective for neuropathic pain and there’s substantial risk of addiction/dependence

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17
Q

What treatment is particularly good for focal neuropathies?

A

Lidocaine patches/topical creams

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18
Q

What is the role of exercise in the treatment of PSN?

A

exercise may be helpful for peripheral nerve regeneration (not just symptoms)*

non-weight bearing exercise is good for people with PSN because it won’t exacerbate symptoms

*need more research

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19
Q

What are the important components of patient education for PSN?

A
  • daily foot inspection
  • podiatry/assistance for nail cutting
  • fall prevention
  • risks of chemo and fluroquinolones
  • medication titration
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20
Q

Why would you chose an anticonvulsant over other therapies for PSN?

A

patient needs to be alert for work or driving

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21
Q

Why would you select antidepressants as a first choice for a patient with PSN?

A

patient is concurrently despressed?

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22
Q

What would be a good medication first choice for a patient with PSN and insomnia

A

tricyclic antidepressants at bedtime

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23
Q

What medications would you avoid in PSN in a patient with chronic constipation?

A

TCAs, Tramadol and Opiates

24
Q

What medications would you avoid in PSN for an older /orthostatic patient?

A

TCAs

25
Q

What are the common sites for compression neuropathies?

A

carpal tunnel

thoracic outlet

ulnar entrapment at the elbow (cubital tunnel)

tarsal tunnel

26
Q

What is the most common compression neuropathy?

A

carpal tunnel syndrome (CTS)

27
Q

What is the pathophysiology of CTS?

A

compromise of the median nerve at the wrist caused by increased perssure in the carpal tunnel (bounded by the carpal bones and transverse carpal ligament)

28
Q

What are the risk factors for CTS?

A
  • genetic pre-disposition
  • diabetes
  • pregnancy (esp. the swollen third trimester)
  • obesity
  • age
  • repetitive strain and work
29
Q

What are the symptoms of CTS?

A
  • dull, aching discomfort in the hand, forearm, upper arm
  • “pins and needles” or “electrical shocks”
  • weakness or clumsiness of the hand
  • provocation with sleep or repetitive motion
  • improvement with change in position or shaking of wrist
30
Q

Special testing to Dx CTS

A

+ Tinsel’s test - tapping on median nerve to see if it reproduces symtpoms

+Phelan’s test - place wrists in 90 degree flexion, facing each other for 1 minute to see if it reproduces symptoms

31
Q

How do you Dx CTS?

A

abnormal nerve conduction tests

special testing

wasting/atrophy of the hand muscles (late sign)

32
Q

Rx of CTS

A

carpal tunnel splints

NSAIDs

PT

steroid injections

surgical decompression of carpal tunnel

33
Q

What neurological disease is progressive and attacks both upper and lower motor neurons resulting in muscle weakness and atrophy?

A

Amyothrophic Lateral Sclerosis (ALS)

34
Q

What disease presents with signs and symptoms such as: weakness and muscles, weight loss, atrophy, stiffness, fasciculations, twitching and worsening fatigure?

A

ALS

NB: roughly 15% present with weakness in facial muscles, trouble speaking, swallowing, chewing or coughing as the first complaint. Worse prognosis

35
Q

What symptoms do you NOT see in ALS?

A

pain

sensory symptoms or senory level

loss of bowel or bladder control

difficulties with extra-ocular movements

rapidly progressing symptoms

36
Q

What are the important signs of ALS?

A

muscle weakness in facial/limb

atrophy

hyperreflexia

drooling

emotionally labile

37
Q

How do you diagnose ALS?

A

mostly exam and physical, but you can do nerve conduction studies

38
Q

How do you treat ALS?

A

Riluzole (Rilutek)

*shown to extend the time patient can breathe witout mechanical ventilation

symptomatic

psych/social work

39
Q

Prognosis for ALS?

A

Median survival is three years after dx

death due to respiratory failure

40
Q

What are the differences in an upper motor and lotor motor neuron lesion in the following categories:

  1. weakness
  2. atrophy
  3. fasciculations
  4. reflexes
  5. tone
A
41
Q

Any time you see shingles in the V1 (ophthalmic division of CN V) including on the tip of the nose, what disease MUST you consider?

A

Herpes Ophthalmicus

*medical emergency, refer immediately to the ophthalmologist

42
Q

What disorder has unilateral facial paralysis, including paralysis of the forehead muscles?

A

Bell’s Palsy - CNVII Palsy

43
Q

What is the pathophysiology of Bell’s Palsy?

A
  • it’s not well known, but a few hypotheses:
    • compression of the facial nerve
    • injury to the facial nerve
    • autoimmune attack
44
Q

What are the symptoms of Bell’s?

A
  • facial muscle weakness over days-weeks
  • change in taste, lacrimation
  • hyperacusis
  • facial tingling or pain near ear (subset)
45
Q

Bell’s Treatment?

A
  • if within the first 72 hours, acyclovir and steroids
  • eye patch
  • pain control
46
Q

What is the prognosis for Bell’s palsy?

A
  • worse with:
    • increasing
    • severe pain
    • complete palsy
47
Q

What is the epidemiology of Trigeminal Neuralgia?

A

Famales: males = 2:1

Age > 40 years

highest prevalence 70s

48
Q

What are the symptoms of trigeminal neuralgia?

A
  • recurrent episodes of severe pain on one side of the face in the CN V distribution
  • will occur in response to even light touch or yawning, swallowing
49
Q

What is the Rx for Trigeminal Neuralgia?

A
  • anti-convulsant medications (works for 70%)
  • glycerol injections
  • gamma knife radiosurgery
  • microvascular decompression surgery (most invasive)
50
Q

Shingles epidemiology

A
  • 10-20% of people
  • more likely when immunocompromised or stressed
51
Q

What are the symptoms of herpes zoster?

A
  • prodrome 2-4 days before, tingling, itching or pain in dermatomal distribution
  • rash ALWAYS consists of grouped vesicles on an erythematous base
  • ALWAYS in a dermatomal distribution
  • NEVER crossing the midline
52
Q

Rx of Herpes Zoster

A
  • anti-virals if in the first 72 hours of rash (acyclovir)
  • pain control - opiates, anti-convulsants, tramadol
53
Q

What is the clinical definition of post-herpetic neuralgia?

A
  • persistent pain in area previously affected by herpes zoster for more than 3 months
  • pain is severe - “electrical shock”
  • deep, severe itching
  • hypersensitive skin
54
Q

What are the risks for developing post-herpetic neuralgia?

A
  • advanced age (>50)
  • female
  • presence of prodromal symptoms
  • severe pain at presentation of rash (>5)
55
Q

what is the Rx for post-herpetic neuralgia?

A
  • anti-convulstants (gabapentin common)
  • anti-depressants (TCA and SNRI)
  • weak mu-opiod agonsists (tramadol/zydol)
  • opiates
  • lidocaine patches/topical creams

Clin Med - Neuro (17 decks)

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