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Clinical Medicine > Peripheral neuropathy > Flashcards

Peripheral neuropathy Flashcards

1
Q

Peripheral neuropathy

A
  • disturbance in function of one or more peripheral nerves
  • motor, sensory, autonomic nerves or mixture of any of above can be affected
  • clinically see mixed deficits
  • sensory nerves are the first ones to be affected
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2
Q

Classification of peripheral nerve lesions

A
  • bases on number and pattern of nerves involved
  • mononeuropathy simplex
  • mononeuritis multiplex
  • polyneuropathy (axonal and myelinopathies)
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3
Q

Mononeuropathy simplex

A
  • focal involvement of a single nerve
  • due to trauma, compression, or entrapment
  • most often entrapment (soft tissue around it trap it )
  • usually unilateral
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4
Q

Common entrapment neuropathies

A
  • media
  • ulnar
  • facial (Bell palsy)
  • Radial
  • Peroneal
  • Posterior tibial
  • Femoral
  • Lateral femoral cutaneous nerve
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5
Q

Median neuropathy

A
  • AKA: carpal tunnel syndrome
  • most common mononeuropathy
  • compression of the median nerve as it passes through the carpal tunnel
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6
Q

Median neuropathy symptoms

A
  • pain and parasthesias in distribution median nerve-thumb, middle and 1/2 ring finger
  • more at night
  • weakness later symptoms
  • parasethsias: numbness, tingling, but also can be pain and burning
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7
Q

Median neuropathy exam, testing, tx

A

exam: decreased sensation in thumb, index, middle, and 1/2 ring finger, weakness & wasting abductor pollicis brevis & opponens pollicis
- testing: slowed nerve conduction tests
- tx: splint (at night), injection (steroids - only last 6 months), surgery
- if they can shake their hand and it makes the numbness better it will most likely be carpal tunnel.

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8
Q

Ulnar neuropathy

A
  • most often trapped at below: pain & parasthesias along ulnar border hand and 5th finger, worse with elbow flexion, weak adductor pollicis, often due to external compression
  • tx: can split, but if bad need to surgically transpose nerve
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9
Q

Radial neuropathy

A
  • from pressure from crutches in axilla, or falling alseep on arm
  • motor deficit: wrist drop and lack of supination (waiter’s tip palsy, Erb’s palsy)
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10
Q

Peroneal nerve neuropathy

A
  • from trauma or pressure at knee over head of fibula
  • too tight LE cast is most common cause
  • clinically can’t extend foot or evert foot
  • brace foot and support until gets better
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11
Q

Posterior tibial neuropathy

A
  • AKA tarsal tunnel

- analogous to carpal tunnel, but trapped behind medial malleolus

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12
Q

Lateral femoral cutaneous neve

A
  • AKA: meralgia paresthetica
  • supplies sensation to outer part of thigh
  • from compression of nerve as it passes through inguinal canal
  • common in pregnancy or obesity
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13
Q

Mononeuritis multiplex

A
  • simultaneous or sequential loss of non contiguous nerve trunks
  • noncontinguous important b/c means systemic process as opposed to local/mechanical process
  • clinically get deficit attributable to involvement of one or more isolated nerves (a bunch of mononeuropathies put together)
  • more than one compression = systemic process
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14
Q

Mononeuritis multiplex causes

A
  • infarction of multiple nerve
  • DM
  • hypothyroidism
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15
Q

Mononeuritis multiplex pathology

A
  • cell mediated immunity and immune complex deposition are most common and serious cause
  • diabetes can also cause b/c underlying nerve dysfunction makes susceptible to multiple compression neuropathies
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16
Q

Mononeuritis multiplex history/presentation

A
  • step wise loss in discrete nerve distribution
  • weakness is a major feature (along w/ sensory sx)
  • often presents with foot drop (peroneal nerve) or wrist drop (radial nerve)
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17
Q

Mononeuritis multiplex evaluation

A
  • Think systemic

- nerve bx tends to be more helpful here than in polyneuropathy

18
Q

Mononeuritis multiplex tx

A
  • underlying disease: if immune bases process need to suppress immune system, if DM, control sugar
  • relieve compression, if caused by compression
  • sx: meds for neuropathic pain (i.e. gabapentin)
  • can also use Topamax
19
Q

Polyneuropathy

A
  • multiple nerves affected at the same time (all nerves)

- subclassification: axonal and myelinopathies

20
Q

Axonal polyneuropathy

A
  • lesion in the nerve itself
  • generalized, homogenous
  • affects all nerve fiber types (sensory, motor, autonomic), but manifests more in certain types
  • sensory fibers show sx first and more b/c smaller caliber axons
  • fibers that innervate distally are longest and manifest abnormalities first
  • classic example is diabetic axonal neuropathy
21
Q

Myelinopathies polyneuropathy

A
  • lesion in myelin sheath

- classic example: Guillain-Barre

22
Q

Axonal Polyneuropathy epidemiology

A
  • mild cases fairly common

- severe manifestations less common

23
Q

Axonal Polyneuropathy pathophysiology

A
  • most often toxin based or other systemic problem

- balance between damage and repair

24
Q

Axonal Polyneuropathy etiologies

A
  • DM
  • EtOH: chronic
  • B12 deficiency
  • Syphillis
  • HIV
  • Lyme
  • Uremia
  • Chemo: Taxol
  • Paraneoplastic
  • Amylidosis
25
Q

Axonal Polyneuropathy clinical presentation

A
  • can be fast or slow depending on cause
  • decreased sensation in feet first, longest, and most profoundly affected nerve fibers
  • vibration and proprioception first to go
  • stocking glove distribution (hands not involved until at knees)
  • sensory loss more common than weakness
  • if get autonomic dysfunction see: postural hypotension, erectile dysfunction and diarrhea
26
Q

Axonal Polyneuropathy PE

A
  • skin: can see loss of hair, shiny skin, if severe can get painless ulcers
  • autonomic: orthostatic hypotension
27
Q

Axonal Polyneuropathy neuro exam

A
  • sensory: decreased sensation, posterior columns first then spinothalamic tract
  • lose proprioception and vibration first
  • worst in toes and works way up
  • weakness if present tends to not be profound
  • maybe can’t walk on heels/toes
  • hyporeflexic often lose ankle jerks
  • if severe neuropathy can see atrophy and fasciculations
  • If you find sensory in the toes you can stop as the rest of the body will be intact it toes are
28
Q

Axonal Polyneuropathy diagnostic eval

A
  • EMG / nerve conduction can tell..
  • muscle vs. nerve
  • polyneuropathy vs. monoeuropathy vs. radiculopathy
  • axonal vs. demyelinating
  • Nerve bx
29
Q

Axonal Polyneuropathy labs

A
  • CBC: for anemia and B12 deficiency
  • Vitamin B12 levels
  • blood glucose, urinalysis, A1C for DM
  • TSH for hypothyroidism
  • ESR: increased in amyloid and connective tissue disease
  • ANA: CTD (rheumatologic cause)
  • Serum protein electrophoresis: multiple myeloma
30
Q

Axonal Polyneuropathy tx

A
  • tx underlying cause
  • physical therapy to prevent contractions and splint to maintain limbs in useful position
  • simple analgesics (acetaminophen and NSAIDs)
  • episodic stabbing pains: tricyclic antidepressants, carbamazepine, gaapentin, pregabalin, phenytoin, topiramate
  • Narcotics if nothing else works (Tramadol)
31
Q

Axonal Polyneuropathy pt education

A
  • more susceptible to other nerve trauma so no crossing legs or resting elbows
  • guard against burns if insensate: test hot water first, or lower temp use hot water heater
  • examine shoes and feet daily for pressure ulcers
32
Q

Demyelinating Polyneuropathy

A
  • classic ex: Guillian-Barrre syndrome
  • affects myelin sheath, tends to be more acute and tends to have more motor than sensory sx
  • “ascending paralysis”
33
Q

Diabetic peripheral neuropathy

A
  • many presentations
  • Axonal
  • mononeuropahty
  • autonomic neuropathy
34
Q

Diabetic peripheral neuropathy epidemiology

A
  • common in DM

- can be presenting sx in occult DM

35
Q

Diabetic peripheral neuropathy pathophysicology

A
  • nerve infarction or vascular insufficiency
  • longer axons first (feet first - hands only after it reaches knees)
  • sensory before motor sx
36
Q

Diabetic peripheral neuropathy clinical presnetation

A
  • stocking glove distribution of numbness and paresthesias
  • start: mild weakness of lower legs
  • slowly progressive, more in legs than arms
  • next: numb feet going up legs, when it reaches knees, hands start
  • severe cases reach intercostal nerves and numb over sternum
37
Q

Diabetic peripheral neuropathy PE

A
  • may see decreased DTRs and impaired vibration before any sx
  • found on good lower extremity PE
  • mild gait abnormalities (sensory ataxia)
  • loss of proprioception and vibration then pinpick and fine touch
  • reflexes ab sent starting at ankles
  • distal hair loss
  • wasting of intrinsic muscles of legs
38
Q

Diabetic peripheral neuropathy tx

A
  • CONTROL BLOOD SUGAR

- nerve growth factor possibly

39
Q

Diabetic peripheral neuropathy symptomatic tx

A
  • neuropathic pain sx: tricyclic antidepressants, SSRs, SNRIs, gabapentin or pregabalin
  • physical therapy: for splints and assistance devices
40
Q

Diabetic autonomic neuropathy

A
  • signs of autonomic dysfunction involving cholinergic system
  • sx: resting tachycardia, orthostatic hypotension, gastroparesis, erectile dysfunction

Clinical Medicine (19 decks)

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