SlideShare ist ein Scribd-Unternehmen logo
1 von 30
Downloaden Sie, um offline zu lesen
MANAGEMENT OF LEPROUS
NEURITIS
Introduction
• Inflammation of the pereipheral nerves
(Dermal / Cutaneous / Nerve Trunks)
• Centripetal, Ascending in nature (KGK Dehio)
akin to ‘fish swimming upstream’ (Khanolkar)
• Lepra Bacilli invades Peripheral Nerves 
Inflammation  NFI ( S / M / A )
• Mediated by
– Schwann cell bacillation
– Contact Demyelination
– Immune / Inflamm reactions
– Mechanical Compression by Intra / Perineural
edema
– Segmental demyelination  Wallerian / Axonal
degeneration
Stages of nerve involvement
• Stage of parasitization
• Host response

• Clinical involvement
• Nerve damage
• Nerve destruction
CLINICAL FEATURES
• Neuritis/neuropathy :
Acute/ subacute/
chronic, demyelinating, nonremitting event
involving cutaneous nerves and larger trunks
• NFI :
sensory, motor & autonomic nerve deficits
due to pathological processes from infection
of nerve
NFI
early

Late

Sensory :
Altered heat & cold
sensitivity, hypoesthesia

Sensory :
Hypoesthesia, anesthesia leading to
neuropathic ulcers

Motor :
Mild motor weakness

Motor :
Severe motor weakness progressing to
paralysis

Autonomic :
Decreased sweating

Autonomic :
Severe dryness with fissuring of skin
• Silent (Quiscent) neuritis :
progressive sensory or motor impairment
without pain, paraesthesia or tenderness of
nerve & no signs of reaction
• Neuropathic pain :
Pain initiated or caused by a primary lesion or
dysfunction in peripheral or central nervous
system
Grading of neuropathic pain
Grade

Degree

Description

0

None

No nerve pain

1

Mild

Complains of nerve pain even when not asked

2

Moderate

Complains severe nerve pain, sleep not disturbed, it is
aggravated by repeated use of the limb

3

Severe

Pain is severe & it interferes with sleep; patient keeps the
limb in rest position & avoids movement
Classification of Neuritis
• Acute neuritis : swelling due to nerve abscess
or recent onset rapidly progressing
neurological deficit < 06 mo

• Chronic neuritis : long standing > 06 mo of
gradually progressive neurological deficit with
nerve tenderness or pain
• Recurrent neuritis : an episode of neuritis
recurring after a symptom free interval of min
03 mo
• Catastrophic paralysis : sudden paralysis

• Completely destroyed nerves : no residual
nerve function and electrophysiological
studies show no conduction
Principles of Therapy
• MDT continuation
• Treating complicating Reactional States
• Prolonged Anti-inflammatory therapy
• Surgery
• Rest / Physical Therapy

• Physiotherapy
Anti-inflammatory Therapy
• Corticosteroids
• Clofazimine
• Thalidomide
• AZA
• CsA
• NSAIDs
• Intraneural Drugs
Corticosteroids
• Anti-inflammatory + Immunosuppressive
• Genomic Action (Nuclear Receptors) – Immediate
Action (Dec Edema / Pro-inflamm CKs)
• Non-Genomic Action (Cystoplamic Receptors) Immunosuppressive Action
• Indicated in ACUTE NEURITIS ; as early as detected
WHO regime
Initiate Prednisolone at 40 mg – taper every 02
weeks over 12 weeks (40-30-20-15-10-5-X)
Prolonged Therapy (24 weeks) OR
High-dose Therapy (02 mg/kg)

Favourable Response :
Sensory > Motor NFI (BANDS)
Acute > Chronic > Recurrent Neuritis (AMFES)
ADRs (TRIPOD)
• Minor (20%)
Gastric Intolerance / Fungal Inf / Acne
Major (02%)
Peptic Ulcer / Bacterial Sepsis / DM
Immunosuppression may interfere with killing
of Bacilli and reduction in Antigenic Load ;
Concomitant CLOFAZIMINE
Clofazimine
• Phenazine derivative
• Dec Granulocyte Chemotaxis / stabilizes
Lysosomes ; binds to Mycobacterial DNA

• Steroid-sparing agent = Anti-inflamm + Antileprosy agent
• ENL / Reduces incidence of T1R
• Slower onset of action
REGIME
• 300 mg daily PO X 12 weeks

• 200 mg daily PO for a few months
• 100 mg daily PO continued

ADRs

Cutaneous / Mucosal pigmentation
Gastrointestinal Intolerance
Ichthyosis
Thalidomide
• Glutamic Acid derivative
• Anti TNF-A
• Immunomodulatory / Anti-inflamm /
Hypnosedative effects
• FDA-approved for ENL
• 100-400 mg daily till pain subsides  decrease by 50mg
every 02-04 weeks
• ADRs

Paradoxical Peripheral Neuropathy
50% Reduction in SNAP-a with Normal NCV
Teratogenicity
Proximal Muscle Weakness
Somnolence
Leukopenia
AZA
• Immunosuppessive + Anti-inflamm + SSA
• 6-TP (Guanine) ; purine analogue inhibits cell
division , T & B cell function

• 2nd Line Treatment for T1R (ILEP)
• 03 mg/kg/day x 12 weeks with Prednisolone
40mg tapered over 08 weeks
• Pancytopenia / Hepatotoxicity / GI Intolerance
CsA
• Immunosuppressant

• Calcineurin Inhibitor  Calcium-Calmodulin complex
 dec activity of NFAT-1  inhibit IL-2 production 
Dec activity of CD4+ T-cells ; Reduction of Anti-Nerve
Growth Factor (NGF) ABs
• Chronic ENL / T1R / Chronic Neuritis
• 5 mg/kg (upto 7.5 mg/kg) tapered over 12 months
• Nephrotoxicity / Hypertension / Dyselectrolemia /
Hypertriglycidemia / Gum Hyperplasia
Intraneural Therapy
• Severe Uncontrolled Neuritic Pain
• Isoxsurpine / Tolazoline (VASODILATORS) help
spread Corticosteroids under LA
• Treatment of Claw Hand in 60 yr old over 06
months by Nashed et al
• Intense pain, Nerve fibre damage potential
Chr Neuropathic Pain
• Primary lesion / dysfunction of Nerve produces
pain – continuous, burning, Glove-and-Stocking
distt
• Late complication of Hansen’s
• Small fibre neuropathy / Persistent Intraneural
Inflamm

• MDT-completion + Not in Reaction + No NFI
• NSAIDs not effective
• TCAs (NTP / Amytriptyline)
• AEDs (CBZ)

• GABA–analogues (Gabapentin / Pregablin)
• Opioids - Tramadol
Surgical Correction
• Nerve Sx - improves function
Recon Sx – improves disability
• Corticosteroid coverage ?

Indications
• Corticosteroid failure (No improvement /
Contraindicated / ADRs)
• Intractable pain despite Medical Management
• Nerve Abscess
• Sudden paralysis (Catastrophic / Hyperacute Neuritis)
EXTRA-NEURAL NEUROLYSIS
Decompression Sx – removes fibrotic bands / ligaments to
open fibro-osseous channels – relives external pressure
INTRA-NEURAL NEUROLYSIS
Longitudnal Incisons in Nerve Sheath Epineurium
INTERFASCICULAR NEUROLYSIS
Individual Nerve Fibres dissected and separated ; risk of
damaging Vasa Nervorum , Fibrosis
NERVE ABSCESS DRAINAGE
Longitudnal incision  drain Caseous material

NERVE TRANSPOSITION
Medial Epicondylectomy for Ulnar Nerve
General Measures
•
•
•
•
•
•
•

Rest for Acutely inflamed Nerve
Avoidance of trauma
Immobilization with padded splints
Graduated Exercises in Recovery phase
SWD / UST / TENS for added pain control
Hand / Foot Care
Counselling and MDT
PREVENTION
• Early Detection of Hansen’s / Reactions
• Prompt initiation of MDT
PROPHYLAXIS
• 20mg/day Prednisolone with 1st 04 months of
MDT lowered risk of T1R
• 300mg/day Clofazimine for 1st 03 months of MDT
lowered incidence of Neuritis
EXPERIMENTAL THERAPY
• Drugs and Vaccines blocking Mycobacterial
attachment to Schwann Cell-Axon Unit /
Specific Bacterial Unit causing Nerve tropism

• Neutrotropic Factors (NTFs)
Regulate Schwann Cells to regenerate Axons in PNS
by increasing Impulse Transmission across Axons
blocked by Mycobacterial AGs
THANK YOU

Weitere ähnliche Inhalte

Was ist angesagt? (20)

Spinal Arachnoiditis ppt.pptx
Spinal Arachnoiditis ppt.pptxSpinal Arachnoiditis ppt.pptx
Spinal Arachnoiditis ppt.pptx
 
Polyneuropathy
PolyneuropathyPolyneuropathy
Polyneuropathy
 
Motor Neuron Disease
Motor Neuron DiseaseMotor Neuron Disease
Motor Neuron Disease
 
Peripheral nerve injuries
Peripheral nerve injuriesPeripheral nerve injuries
Peripheral nerve injuries
 
Myasthenia gravis rehabilitation
Myasthenia gravis rehabilitationMyasthenia gravis rehabilitation
Myasthenia gravis rehabilitation
 
Entrapment neuropathies
Entrapment neuropathiesEntrapment neuropathies
Entrapment neuropathies
 
Reconstructive surgery in Leprosy
Reconstructive surgery in LeprosyReconstructive surgery in Leprosy
Reconstructive surgery in Leprosy
 
Modified ashworth scale application
Modified ashworth scale applicationModified ashworth scale application
Modified ashworth scale application
 
Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome
 
Dystonia: Causes, Types, Symptoms, and Treatments
Dystonia: Causes, Types, Symptoms, and TreatmentsDystonia: Causes, Types, Symptoms, and Treatments
Dystonia: Causes, Types, Symptoms, and Treatments
 
Entrapment neuropathies
Entrapment neuropathiesEntrapment neuropathies
Entrapment neuropathies
 
Guillian barre syndrome
Guillian barre syndromeGuillian barre syndrome
Guillian barre syndrome
 
Cerebellar ataxia
Cerebellar ataxiaCerebellar ataxia
Cerebellar ataxia
 
Mononeritis multiplex
Mononeritis multiplex Mononeritis multiplex
Mononeritis multiplex
 
Vestibular rehabilitation
Vestibular rehabilitationVestibular rehabilitation
Vestibular rehabilitation
 
Frozen shoulder
Frozen shoulderFrozen shoulder
Frozen shoulder
 
SPASTICITY
SPASTICITYSPASTICITY
SPASTICITY
 
Spinal arachnoiditis
Spinal arachnoiditisSpinal arachnoiditis
Spinal arachnoiditis
 
Tabes Dorsalis and Physiotherapy
Tabes Dorsalis and PhysiotherapyTabes Dorsalis and Physiotherapy
Tabes Dorsalis and Physiotherapy
 
Myopathies
MyopathiesMyopathies
Myopathies
 

Ähnlich wie Leprous neuritis management by aseem

Neuropathic pain revised 2010
Neuropathic pain revised 2010Neuropathic pain revised 2010
Neuropathic pain revised 2010yury
 
Myasthenia gravis and anaesthesia
Myasthenia gravis and anaesthesiaMyasthenia gravis and anaesthesia
Myasthenia gravis and anaesthesiaUmang Sharma
 
Crps ppt 2017 (1)
Crps ppt 2017 (1)Crps ppt 2017 (1)
Crps ppt 2017 (1)Sami Halim
 
Myasthenia gravis CTVA presentation
Myasthenia gravis CTVA presentationMyasthenia gravis CTVA presentation
Myasthenia gravis CTVA presentationKundan Ghimire
 
Skeletal muscle relaxants
Skeletal muscle relaxantsSkeletal muscle relaxants
Skeletal muscle relaxantsChintan Doshi
 
Sue Barnes - Pain management and Multiple Sclerosis
Sue Barnes - Pain management and Multiple SclerosisSue Barnes - Pain management and Multiple Sclerosis
Sue Barnes - Pain management and Multiple SclerosisMS Trust
 
Differential diagnosis of orofacial pain
Differential diagnosis of orofacial painDifferential diagnosis of orofacial pain
Differential diagnosis of orofacial painsailesh kumar
 
Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)
Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)
Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)Monique Canonico
 
ANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptx
ANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptxANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptx
ANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptxSumit Tyagi
 
Headache : Causes and management
Headache : Causes and managementHeadache : Causes and management
Headache : Causes and managementDr.Anees Kurikkal
 
Pathophysiology Chapter 45
Pathophysiology Chapter 45Pathophysiology Chapter 45
Pathophysiology Chapter 45TheSlaps
 
MYASTHENIA GRAVIS (1).pptx
MYASTHENIA GRAVIS (1).pptxMYASTHENIA GRAVIS (1).pptx
MYASTHENIA GRAVIS (1).pptxchetanpattar7
 

Ähnlich wie Leprous neuritis management by aseem (20)

Neuropathic pain revised 2010
Neuropathic pain revised 2010Neuropathic pain revised 2010
Neuropathic pain revised 2010
 
Neuropathic pain
Neuropathic painNeuropathic pain
Neuropathic pain
 
Myasthenia gravis and anaesthesia
Myasthenia gravis and anaesthesiaMyasthenia gravis and anaesthesia
Myasthenia gravis and anaesthesia
 
Headache
HeadacheHeadache
Headache
 
Crps ppt 2017 (1)
Crps ppt 2017 (1)Crps ppt 2017 (1)
Crps ppt 2017 (1)
 
Myasthenia gravis CTVA presentation
Myasthenia gravis CTVA presentationMyasthenia gravis CTVA presentation
Myasthenia gravis CTVA presentation
 
Neurophatic pain presentation
Neurophatic pain presentationNeurophatic pain presentation
Neurophatic pain presentation
 
GBS.pptx
GBS.pptxGBS.pptx
GBS.pptx
 
Skeletal muscle relaxants
Skeletal muscle relaxantsSkeletal muscle relaxants
Skeletal muscle relaxants
 
Headace
HeadaceHeadace
Headace
 
Sue Barnes - Pain management and Multiple Sclerosis
Sue Barnes - Pain management and Multiple SclerosisSue Barnes - Pain management and Multiple Sclerosis
Sue Barnes - Pain management and Multiple Sclerosis
 
Differential diagnosis of orofacial pain
Differential diagnosis of orofacial painDifferential diagnosis of orofacial pain
Differential diagnosis of orofacial pain
 
Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)
Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)
Trigeminal Neuralgia Headache and CSF Hypotension and Hypertension(Pseudotumor)
 
Toxidromes.pptx
Toxidromes.pptxToxidromes.pptx
Toxidromes.pptx
 
Cipn
CipnCipn
Cipn
 
ANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptx
ANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptxANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptx
ANAESTHESIA MANAGEMENT IN PATIENTS OF NEUROMUSCULAR DISORDERS.pptx
 
Diabetic Neuropathy
Diabetic Neuropathy Diabetic Neuropathy
Diabetic Neuropathy
 
Headache : Causes and management
Headache : Causes and managementHeadache : Causes and management
Headache : Causes and management
 
Pathophysiology Chapter 45
Pathophysiology Chapter 45Pathophysiology Chapter 45
Pathophysiology Chapter 45
 
MYASTHENIA GRAVIS (1).pptx
MYASTHENIA GRAVIS (1).pptxMYASTHENIA GRAVIS (1).pptx
MYASTHENIA GRAVIS (1).pptx
 

Mehr von Dr. Aseem Sharma (20)

Montelukast by aseem
Montelukast by aseemMontelukast by aseem
Montelukast by aseem
 
Blaschkoid dermatitis
Blaschkoid dermatitisBlaschkoid dermatitis
Blaschkoid dermatitis
 
Antihistaminics
AntihistaminicsAntihistaminics
Antihistaminics
 
Mrsa by aseem
Mrsa by aseemMrsa by aseem
Mrsa by aseem
 
Borrelia by aseem
Borrelia by aseemBorrelia by aseem
Borrelia by aseem
 
Targeted therapy psoriasis
Targeted therapy psoriasisTargeted therapy psoriasis
Targeted therapy psoriasis
 
Leprosy vaccines by aseem final
Leprosy vaccines by aseem finalLeprosy vaccines by aseem final
Leprosy vaccines by aseem final
 
Epidermal nevus
Epidermal nevusEpidermal nevus
Epidermal nevus
 
Myiasis by aseem
Myiasis by aseemMyiasis by aseem
Myiasis by aseem
 
Lonafarnib by aseem
Lonafarnib by aseemLonafarnib by aseem
Lonafarnib by aseem
 
Acd by aseem
Acd by aseemAcd by aseem
Acd by aseem
 
Oral Sub Mucous Fibrosis by aseem
Oral Sub Mucous Fibrosis by aseemOral Sub Mucous Fibrosis by aseem
Oral Sub Mucous Fibrosis by aseem
 
Sjogren syndrome by aseem
Sjogren syndrome by aseemSjogren syndrome by aseem
Sjogren syndrome by aseem
 
Pellagra by aseem
Pellagra by aseemPellagra by aseem
Pellagra by aseem
 
Leprosy tests by aseem
Leprosy tests by aseemLeprosy tests by aseem
Leprosy tests by aseem
 
Wood's lamp by aseem
Wood's lamp by aseemWood's lamp by aseem
Wood's lamp by aseem
 
Scleroderma by aseem
Scleroderma by aseemScleroderma by aseem
Scleroderma by aseem
 
Phosphodiesterase-Inhibitors by Aseem
Phosphodiesterase-Inhibitors by AseemPhosphodiesterase-Inhibitors by Aseem
Phosphodiesterase-Inhibitors by Aseem
 
Erythema multiforme by aseem
Erythema multiforme by aseemErythema multiforme by aseem
Erythema multiforme by aseem
 
Demodex by aseem
Demodex by aseemDemodex by aseem
Demodex by aseem
 

Leprous neuritis management by aseem

  • 2. Introduction • Inflammation of the pereipheral nerves (Dermal / Cutaneous / Nerve Trunks) • Centripetal, Ascending in nature (KGK Dehio) akin to ‘fish swimming upstream’ (Khanolkar) • Lepra Bacilli invades Peripheral Nerves  Inflammation  NFI ( S / M / A )
  • 3. • Mediated by – Schwann cell bacillation – Contact Demyelination – Immune / Inflamm reactions – Mechanical Compression by Intra / Perineural edema – Segmental demyelination  Wallerian / Axonal degeneration
  • 4. Stages of nerve involvement • Stage of parasitization • Host response • Clinical involvement • Nerve damage • Nerve destruction
  • 5. CLINICAL FEATURES • Neuritis/neuropathy : Acute/ subacute/ chronic, demyelinating, nonremitting event involving cutaneous nerves and larger trunks • NFI : sensory, motor & autonomic nerve deficits due to pathological processes from infection of nerve
  • 6. NFI early Late Sensory : Altered heat & cold sensitivity, hypoesthesia Sensory : Hypoesthesia, anesthesia leading to neuropathic ulcers Motor : Mild motor weakness Motor : Severe motor weakness progressing to paralysis Autonomic : Decreased sweating Autonomic : Severe dryness with fissuring of skin
  • 7. • Silent (Quiscent) neuritis : progressive sensory or motor impairment without pain, paraesthesia or tenderness of nerve & no signs of reaction • Neuropathic pain : Pain initiated or caused by a primary lesion or dysfunction in peripheral or central nervous system
  • 8. Grading of neuropathic pain Grade Degree Description 0 None No nerve pain 1 Mild Complains of nerve pain even when not asked 2 Moderate Complains severe nerve pain, sleep not disturbed, it is aggravated by repeated use of the limb 3 Severe Pain is severe & it interferes with sleep; patient keeps the limb in rest position & avoids movement
  • 9. Classification of Neuritis • Acute neuritis : swelling due to nerve abscess or recent onset rapidly progressing neurological deficit < 06 mo • Chronic neuritis : long standing > 06 mo of gradually progressive neurological deficit with nerve tenderness or pain
  • 10. • Recurrent neuritis : an episode of neuritis recurring after a symptom free interval of min 03 mo • Catastrophic paralysis : sudden paralysis • Completely destroyed nerves : no residual nerve function and electrophysiological studies show no conduction
  • 11. Principles of Therapy • MDT continuation • Treating complicating Reactional States • Prolonged Anti-inflammatory therapy • Surgery • Rest / Physical Therapy • Physiotherapy
  • 12. Anti-inflammatory Therapy • Corticosteroids • Clofazimine • Thalidomide • AZA • CsA • NSAIDs • Intraneural Drugs
  • 13. Corticosteroids • Anti-inflammatory + Immunosuppressive • Genomic Action (Nuclear Receptors) – Immediate Action (Dec Edema / Pro-inflamm CKs) • Non-Genomic Action (Cystoplamic Receptors) Immunosuppressive Action • Indicated in ACUTE NEURITIS ; as early as detected
  • 14. WHO regime Initiate Prednisolone at 40 mg – taper every 02 weeks over 12 weeks (40-30-20-15-10-5-X) Prolonged Therapy (24 weeks) OR High-dose Therapy (02 mg/kg) Favourable Response : Sensory > Motor NFI (BANDS) Acute > Chronic > Recurrent Neuritis (AMFES)
  • 15. ADRs (TRIPOD) • Minor (20%) Gastric Intolerance / Fungal Inf / Acne Major (02%) Peptic Ulcer / Bacterial Sepsis / DM Immunosuppression may interfere with killing of Bacilli and reduction in Antigenic Load ; Concomitant CLOFAZIMINE
  • 16. Clofazimine • Phenazine derivative • Dec Granulocyte Chemotaxis / stabilizes Lysosomes ; binds to Mycobacterial DNA • Steroid-sparing agent = Anti-inflamm + Antileprosy agent • ENL / Reduces incidence of T1R • Slower onset of action
  • 17. REGIME • 300 mg daily PO X 12 weeks • 200 mg daily PO for a few months • 100 mg daily PO continued ADRs Cutaneous / Mucosal pigmentation Gastrointestinal Intolerance Ichthyosis
  • 18. Thalidomide • Glutamic Acid derivative • Anti TNF-A • Immunomodulatory / Anti-inflamm / Hypnosedative effects • FDA-approved for ENL
  • 19. • 100-400 mg daily till pain subsides  decrease by 50mg every 02-04 weeks • ADRs Paradoxical Peripheral Neuropathy 50% Reduction in SNAP-a with Normal NCV Teratogenicity Proximal Muscle Weakness Somnolence Leukopenia
  • 20. AZA • Immunosuppessive + Anti-inflamm + SSA • 6-TP (Guanine) ; purine analogue inhibits cell division , T & B cell function • 2nd Line Treatment for T1R (ILEP) • 03 mg/kg/day x 12 weeks with Prednisolone 40mg tapered over 08 weeks • Pancytopenia / Hepatotoxicity / GI Intolerance
  • 21. CsA • Immunosuppressant • Calcineurin Inhibitor  Calcium-Calmodulin complex  dec activity of NFAT-1  inhibit IL-2 production  Dec activity of CD4+ T-cells ; Reduction of Anti-Nerve Growth Factor (NGF) ABs • Chronic ENL / T1R / Chronic Neuritis • 5 mg/kg (upto 7.5 mg/kg) tapered over 12 months • Nephrotoxicity / Hypertension / Dyselectrolemia / Hypertriglycidemia / Gum Hyperplasia
  • 22. Intraneural Therapy • Severe Uncontrolled Neuritic Pain • Isoxsurpine / Tolazoline (VASODILATORS) help spread Corticosteroids under LA • Treatment of Claw Hand in 60 yr old over 06 months by Nashed et al • Intense pain, Nerve fibre damage potential
  • 23. Chr Neuropathic Pain • Primary lesion / dysfunction of Nerve produces pain – continuous, burning, Glove-and-Stocking distt • Late complication of Hansen’s • Small fibre neuropathy / Persistent Intraneural Inflamm • MDT-completion + Not in Reaction + No NFI
  • 24. • NSAIDs not effective • TCAs (NTP / Amytriptyline) • AEDs (CBZ) • GABA–analogues (Gabapentin / Pregablin) • Opioids - Tramadol
  • 25. Surgical Correction • Nerve Sx - improves function Recon Sx – improves disability • Corticosteroid coverage ? Indications • Corticosteroid failure (No improvement / Contraindicated / ADRs) • Intractable pain despite Medical Management • Nerve Abscess • Sudden paralysis (Catastrophic / Hyperacute Neuritis)
  • 26. EXTRA-NEURAL NEUROLYSIS Decompression Sx – removes fibrotic bands / ligaments to open fibro-osseous channels – relives external pressure INTRA-NEURAL NEUROLYSIS Longitudnal Incisons in Nerve Sheath Epineurium INTERFASCICULAR NEUROLYSIS Individual Nerve Fibres dissected and separated ; risk of damaging Vasa Nervorum , Fibrosis NERVE ABSCESS DRAINAGE Longitudnal incision  drain Caseous material NERVE TRANSPOSITION Medial Epicondylectomy for Ulnar Nerve
  • 27. General Measures • • • • • • • Rest for Acutely inflamed Nerve Avoidance of trauma Immobilization with padded splints Graduated Exercises in Recovery phase SWD / UST / TENS for added pain control Hand / Foot Care Counselling and MDT
  • 28. PREVENTION • Early Detection of Hansen’s / Reactions • Prompt initiation of MDT PROPHYLAXIS • 20mg/day Prednisolone with 1st 04 months of MDT lowered risk of T1R • 300mg/day Clofazimine for 1st 03 months of MDT lowered incidence of Neuritis
  • 29. EXPERIMENTAL THERAPY • Drugs and Vaccines blocking Mycobacterial attachment to Schwann Cell-Axon Unit / Specific Bacterial Unit causing Nerve tropism • Neutrotropic Factors (NTFs) Regulate Schwann Cells to regenerate Axons in PNS by increasing Impulse Transmission across Axons blocked by Mycobacterial AGs