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Neurology > Peripheral Nerve Disorders > Flashcards

Peripheral Nerve Disorders Flashcards

1
Q

Polyneuropathy

A

sensory, motor or mixed deficit affecting more than one peripheral nerve simultaneously

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2
Q

Mononeuropathy

A

sensory, motor or mixed deficit affecting a specific nerve

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3
Q

Mononeuropathy Multiplex

A

sensory and/or motor deficits affecting single nerves in different, unrelated parts of the body

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4
Q

Radiculopathy

A

disease of the spinal nerve roots

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5
Q

Plexopathy

A

sensory and/or motor deficit involving

the lumbar or brachial plexus

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6
Q

Amyotrophy

A

pathological wasting of muscles due to a disease of the nerves supplying them

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7
Q

Charcot-Marie-Tooth (3)

A
  • HMSN I & II
  • Usually autosomal transmission
  • Short arm of chromosome 17 (or 1 or X)
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8
Q

Charcot-Marie-Tooth Presentation (5)

A
  • Foot deformities or gait disturbances in childhood
  • Distal weakness and wasting starts in the legs
  • Variable distal sensory loss
  • Depressed or absent tendon reflexes
  • Tremor is sometimes present
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9
Q

What are the phenotypes for Charcot Marie Tooth? (4)

A

– High arches (pes cavus)
– Calf muscle wasting
– Barrel chest
– Distinctive walk

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10
Q

Outcome of Charcot Marie Tooth (2)

A
  • EMG, NCS shows marked reduction in both sensory and motor conduction
  • Despite the neuropathy, these patients can live long, productive lives (orthotics help)
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11
Q

Dejerine-Sottas Dz (5)

A
  • HMSN III
  • Onset in infancy or childhood
  • Motor and sensory polyneuropathy
  • Peripheral nerves may be palpable
  • Segmental demyelination, Schwann cell hypertrophy and thin myelin sheaths
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12
Q

Inherited Neuropathies (5)

A 
– Charcot-Marie-Tooth
– Dejerine-Sottas
– Fredrich Ataxia
– Refsum disease
– Porphyria
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13
Q

Neuropathies a/w Systemic and Metabolic Disorders (4)

A

– Diabetic
– Uremic
– Alcohol and nutritional deficiency
– Paraproteinemias

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14
Q

Infectious and Inflammatory Neuropathies (6)

A
  • Leprosy,
  • AIDS,
  • Lyme disease,
  • Sarcoidosis,
  • Polyarteritis,
  • RA
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15
Q

Fredreich Ataxia (6)

A

– Chromosome 9
– Onset in childhood
– Gait is ataxic, Hands are clumsy, Other signs of cerebellar dysfunction
– Weakness in the legs, but primarily a sensory neuropathy (dorsal root ganglia, dorsal and lateral columns)
– Depressed DTRs
– Upgoing Babinski’s

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16
Q

Refsum Dz (6)

A
  • HMSV IV
  • Autosomal recessive disorder
  • Disturbance in phytanic acid metabolism
  • Pigmentary retinal degeneration
  • Progressive sensorimotor polyneuropathy, cerebellar signs, auditory dysfunction, cardiomyopathy, cutaneous manifestation
  • Dietary reduction in phytanic acid, plasmapheresis
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17
Q

Diabetic Peripheral Neuropathy Overview

A 
• Peripheral neuropathy
– Distal symmetric polyneuropathy 
– Isolated peripheral neuropathy
– Painful diabetic neuropathy
– Diabetic neuropathic cachexia
• Autonomic neuropathy
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18
Q

Distal Symmetric Polyneuropathy (5)

A
  • Most common type
  • Due to an axonal neuropathic process
  • Longer nerves are most vulnerable (foot)
  • Motor and sensory nerves
  • Achilles reflexes may be absent
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19
Q

Sensory Distal Symmetric Polyneuropathy(4)

A

– decreased sensation to vibration, pain and temperature
• Painful
• Progressive in severity and distribution
• Examination with monofilament picks up patients who are at risk for unperceived neuropathic injury

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20
Q

Motor Distal Symmetric Polyneuropathy (3)

A
  • denervation of the lumbricals in the feet -> clawing of the toes, anterior displacement of the submetatarsal fat pads -> increased plantar pressure
    • Neuropathic injury results from decreased pain sensation, increased plantar pressures and repetitive stress (walking)
    • Charcot foot
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21
Q

Distal Symmetric Polyneuropathy Tx (5)

A 
• Treatment of ulcers:
– Revascularization if possible ** 
– Unloading
– Treat infection
– Debride if necessary
• Recurrence should be minimized by wearing appropriate footwear, checking the feet daily
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22
Q

Isolated Peripheral Neuropathy

A
  • Sudden onset with later recovery of all or most of the function
  • Attributed to vascular ischemia or traumatic damage
  • Cranial and femoral nerves are commonly involved
  • Predominantly motor abnormalities
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23
Q

Isolated Peripheral Neuropathy Presentation (6)

A

– Diplopia: involvement of CN III, IV, OR VI
• Pupil is spared
• Full recovery in 6-12 weeks
• Severe pain in the anterior thigh (unilateral)
• Within days muscle wasting and weakness
• As weakness appears, pain improves

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24
Q

Isolated Peripheral Neuropathy Tx (2)

A
  • Analgesia, better control of diabetes

* Symptoms improve over 6-18 months

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25
Q

Painful Diabetic Neuropathy (2)

A
  • Hypersensitivity to light touch

* Severe burning pain (nocturnal)

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26
Q

Painful Diabetic Neuropathy Tx (6)

A 
– Amitriptyline
– Tricyclic antidepressants (TCA)
– Gabapentin
• Improvement in 48-72 hours is usual
• Improves sleep
• Discontinue medication if no improvement in 5 days
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27
Q

Diabetic Neuropathic Cachexia (4)

A
  • a/w profound weight loss
    – Painful dysesthesias affecting the proximal lower limbs, the hands or the lower trunk
    – Treatment is insulin and analgesia
    – Prognosis is good with recovery of weight and cessation of pain within one year
28
Q

Autonomic Neuropathy Overview (6)

A
  • Postural hypotension
  • Decreased cardiovascular response to valsalva
  • Gastroparesis
  • Diarrhea/constipation (IBS)
  • Inability to empty the bladder
  • Impotence
29
Q

Postural Hypotension (3)

A

– Thigh high compression stocking
– Sleeping semi-recumbant
– Fludricortisone or midodrine

30
Q

Gastroparesis (2)

A

– Can present as pain, bloating, and vomiting following meals
– Can present as fluctuations in blood sugar following meals

31
Q

Gastroparesis Tx (4)

A

– Metaclopramide can be used for treatment **
– Erythromycin binds to motilin receptors in the stomach
– Botox injections at the pylorus
– Implanted gastric electric stimulators

32
Q

Diarrhea (7)

A 
– Broad-spectrum antibiotics
– a/w impaired sphincter control and fecal incontinence
– Loperamide
– Diphenoxylate with atropine
– Paregiroc
– Codeine
– Clonidine
33
Q

Constipation (4)

A
  • Usually responds well to stimulant laxatives
    • Start with fiber supplementation
    • Add an osmotic cathartic
    • Then go to stimulants
34
Q

Neurogenic Bladder (3)

A

– Distended bladder
– Overflow incontinence
- Flaccid

35
Q

Neurogenic Bladder Tx (3)

A

– Parasympathomimetics – bethanechol – Catheter decompression
– Surgical severing of the internal vessicle sphincter

36
Q

Impotence (5)

A 
– Medical
• Viagra, Cialis, Levitra
• Intracorporeal injection of papaverine, phentolamine, alprostadil
• Urethral pellets of alprostadil 
– Mechanical
• External vacuum therapy 
– Surgical
• Penile prosthesis
37
Q

Guillian-Barre Syndrome (4)

A
  • Acute or subacute progressive polyradiculoneuropathy
  • Weakness is more severe than sensory loss
  • Acute dysautonomia may be life-threatening
  • Pathology shows primary demyelination or less commonly axonal degeneration
38
Q

Guillian-Barre Presentation (4)

A

– Symmetric weakness starts proximally
– Starts in legs, then arms, then muscles of respiration or deglutition
– Sensory disturbances include paresthesias or dysesthesias, neuropathic or radicular pain
– Autonomic disturbances are common **

39
Q

Guillian-Barre Differential Diagnosis (4)

A
  • Rule out porphyric, diphtheric or toxic neuropathies with labs
  • Acute timing excludes other peripheral neuropathies
  • Exclude Polio, tick paralysis, botulism
  • Focal cord lesion is suggested by asymmetric motor deficit, pyramidal signs, a sharp sensory level or early sphincter involvement
40
Q

Guillian-Barre Tx (6)

A 
– Steroids don’t help and might hurt 
– Plasmapheresis
– IVIG
– Supportive care
• Ventilator support
• Support of blood pressure
41
Q

Guillian-Barre Prognosis

A

– 20% of patients have persisting disability

– The rest make a full recovery after several months

42
Q

Myasthenia Gravis (5)

A
  • Fluctuating weakness of commonly used voluntary muscles
  • Activity increases weakness in affected muscles
  • Onset is insidious**
  • Autoantibodies bind to Ach receptors
  • Powerful muscles fatigue rapidly
43
Q

Myasthenia Gravis Presentation (7)

A

– Ptosis, diplopia, difficulty chewing or swallowing, respiratory problems, limb weakness
– May be focal or generalized
– Symptoms fluctuate during the day
– Exam confirms weakness and fatigability of affected muscles, improves with rest
– Sensation is normal and DTRs intact
– Myasthenic crisis: severe respiratory weakness

44
Q

Myasthenia Gravis Diagnosis (2)

A

– Electrophysiologic tests shows decrementing response to repetitive 2-3Hz stimulation
– Serologic testing for acetylcholine receptor antibiodies is 80-90% sensitive

45
Q

Myasthenia Gravis Tx (6)

A

– Avoid aminoglycosides
– Neostigmine/pyridostigmine (anticholinesterase) can be used but do not alter progression
– Thymectomy can help (patients <60, unless disease is focal)
– Corticosteroids are used if above measures fail – start in hospital
– Azathioprine
– Plasmapheresis or IVIG

46
Q

Mononeuropathies (9)

A
  • Carpal tunnel syndrome
  • Pronator teres or anterior interosseus syndrome
  • Ulnar nerve lesions
  • Radial nerve lesions
  • Femoral neuropathy
  • Meralgia paresthetica
  • Sciatic and common peroneal nerve palsies
  • Tarsal tunnel syndrome
  • Facial nerve palsy
47
Q

Carpal Tunnel Syndrome

A 
• Compression of the median nerve causing numbness, parasthesias and weakness in the hand
• Caused by repetitive motion injury 
• Weakness of the hand**
• Sensory disturbance of
the thumb and digits
48
Q

Carpal Tunnel Tx

A

– Wrist splint and rest

– Median nerve decompression

49
Q

Pronator Teres or Anterior Interosseus Syndrome (3)

A

• Motor branch of the median nerve (anterior
interosseus) descends between the two heads of the pronator teres
• No sensory loss (as long as the median nerve itself is not affected)
• Caused by trauma or compression

50
Q

Pronator Teres Syndrome Presentation (2)

A
  • Weakness confined to the pronator quadratus, flexor pollicis longus and flexor digitorum profundus to the 2nd and 3rd digits
  • May improve spontaneously, may need depcompressive surgery
51
Q

Ulnar Nerve Lesions

A

Occur at the elbow, nerve runs posterior to the medial epicondyle and descends in the cubital tunnel

52
Q

What are the causes of ulnar nerve lesions? (3)

A

– Impingement from trauma
– Change in carrying angle of the elbow
– Thickening of structures comprising the cubital tunnel

53
Q

Ulnar Nerve Lesion Presentation (4)

A 
• Weakness in the forearm and hand, sensory disturbance to medial 1 1⁄2 digits
• EMG/NCS used to evaluate
• Conservative measures
• Surgical treatment 
– ulnar nerve transposition
54
Q

Radial Nerve Lesions (3)

A
  • Prone to injury/compression in the axilla
  • Sensory deficit is small (back of hand between the thumb and index finger)
  • Weakness of all muscles supplied by the nerve distal to the site of injury
55
Q

Erb Palsy

A
  • Brachial plexopathy
  • Waiter’s tip
  • From trauma, shoulder dystocia
56
Q

Femoral Neuropathy (4)

A
  • Weakness and wasting of the quadriceps muscle and sensory impairment over the anteriomedian aspect of the thigh
  • Depressed or absent patellar reflex
  • Caused by pressure from retroperitoneal neoplasms or hematoma. Poor positioning in lithotomy during surgery can also cause it.
  • Also associated with diabetes
57
Q

Meralgia Paresthetica (6)

A
  • Irritation of the lateral femoral cutaneous nerve (usually unilateral)
  • Obese, diabetic, pregnant
  • Pain, parasthesia, numbness
  • No other deficits
  • Sometimes relieved by sitting
  • Treatment – remove insult, hydrocortisone injection, surgical transposition
58
Q

Sciatic Nerve Palsy (3)

A
  • Most commonly caused by misplaced deep IM injection, trauma can also cause
  • If part of the nerve is damaged, it is usually the peroneal part
  • Distinguished on EMG from peroneal nerve palsy by involvement of the short head of the biceps femoris
59
Q

Common Peroneal Nerve Palsy

A
  • Caused by compression or injury near the head and neck of the fibula
  • Weakness in dorsiflexion and eversion of the foot (foot drop)
  • Numbness in the anteriolateral aspect of the calf and dorsum of the foot
60
Q

Tarsal Tunnel Syndrome

A
  • Posterior tibial nerve goes through the tarsal tunnel (posterioinferior to the medial malleolus) and supplies motor and sensory to the foot
  • Compression leads to parasthesias, pain, and numbness over the bottom of the foot, especially at night (heel is spared)
  • Muscle weakness is often subclinical
  • Treatmentissurgicaldecompression
61
Q

Facial Nerve Palsies

A
  • Related to HIV infection, Lyme disease or sarcoidosis
  • Otherwise, it is called Bell palsy (idiopathic)
  • All cranial nerves except for VII (bilateral in upper distribution only) and XII receive bilateral innervation
62
Q

Bell’s Palsy

A
  • Sudden onset of lower motor neuron facial palsy
  • Impaired taste or hyperacusis may occur • No other neurological abnormalities
  • Attributed to an inflammatory reaction involving the facial nerve (stylomastoid foramen or in the bony facial canal)
  • HSV may be implicated
  • More common in pregnant women and diabetics
63
Q

Bell’s Palsy Presentation

A

– Comes on abruptly, may worsen over first day or two
– Pain about the ear is common but this subsides in 2-3 days
– Face feels stiff and pulled to one side
– Restriction of eye closure
– Difficulty eating
– Fine facial movements are impaired

64
Q

Bell’s Palsy Tx

A

– Corticosteroids may improve outcomes in patients with severe disease
– Must start within 5 days of onset
– Prednisone
– Protect the eye with lubricating drops and a patch if the eye cannot close

65
Q

Lasting deficits of Bell’s Palsy occur when?

A

Most severe initial symptoms are present:

  • Clinically complete Palsy on presentation
  • Advanced age
  • Hyperacusis
  • Severe initial pain
  • happens about 10% of the time

Neurology (12 decks)

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