2. Introduction
• Peripheral neuropathy describes damage
to the peripheral nervous system.
• More than 100 types of peripheral
neuropathy have been identified, each
with its own characteristic set of
symptoms, pattern of development, and
prognosis.
3. • Impaired function and symptoms depend
on the type of nerves
– motor, sensory, or autonomic
• that are damaged.
Introduction
4. • Motor nerves
– control movements of all muscles under conscious
control, such as those used for walking, grasping
things, or talking.
• Sensory nerves
– transmit information about sensory experiences, such
as the feeling of a light touch or the pain resulting
from a cut.
• Autonomic nerves
– regulate biological activities that people do not control
consciously, such as breathing, digesting food, and
heart and gland functions.
Introduction
5. • Although some neuropathies may affect all
three types of nerves, others primarily
affect one or two types.
– Therefore, terms such as
• predominately motor neuropathy
• predominately sensory neuropathy
• sensory-motor neuropathy
• autonomic neuropathy
– are often used to describe a patient's
condition.
Introduction
6. • Because every peripheral nerve has a
highly specialized function in a specific
part of the body, a wide array of symptoms
can occur when nerves are damaged.
• Some people may experience temporary
numbness, tingling, and pricking
sensations (paresthesia), sensitivity to
touch, or muscle weakness.
Introduction
7. • Others may suffer more extreme
symptoms, including burning pain
(especially at night), muscle wasting,
paralysis, or organ or gland dysfunction.
Introduction
8. • People may become unable to digest food
easily, maintain safe levels of blood
pressure, sweat normally, or experience
normal sexual function.
• In the most extreme cases, breathing may
become difficult or organ failure may
occur.
Introduction
9. • Some forms of neuropathy involve
damage to only one nerve and are called
mononeuropathies.
• More often though, multiple nerves
affecting all limbs are affected-called
polyneuropathy.
Introduction
10. • Occasionally, two or more isolated nerves
in separate areas of the body are affected-
called mononeuritis multiplex.
Introduction
11. • In acute neuropathies, such as Guillain-
Barré syndrome, symptoms appear
suddenly, progress rapidly, and resolve
slowly as damaged nerves heal.
• In chronic forms, symptoms begin subtly
and progress slowly.
Introduction
12. • Some people may have periods of relief
followed by relapse.
• Others may reach a plateau stage where
symptoms stay the same for many months
or years.
Introduction
13. • Some chronic neuropathies worsen over
time, but very few forms prove fatal unless
complicated by other diseases.
• Occasionally the neuropathy is a symptom
of another disorder.
Introduction
14. • In the most common forms of
polyneuropathy, the nerve fibers most
distant from the brain and the spinal cord
malfunction first.
• Pain and other symptoms often appear
symmetrically, for example, in both feet
followed by a gradual progression up both
legs.
Introduction
15. Introduction
• Next, the fingers, hands, and arms may
become affected, and symptoms can
progress into the central part of the body.
• Many people with diabetic neuropathy
experience this pattern of ascending nerve
damage.
16. Anatomy
• The body’s nervous system is made up of
two parts.
– The central nervous system (CNS)
– The peripheral nervous system (PNS)
17. Anatomy
• The peripheral nerves include:
– cranial nerves
• (with the exception of the second)
– spinal nerve roots
– dorsal root ganglia
– peripheral nerve trunks and their terminal
branches
– peripheral autonomic nervous system
18. Diagnostic Approach
• The differential diagnosis of peripheral
neuropathy is significantly narrowed by a
focused clinical assessment that addresses
several key issues –
– Does the patient actually have a neuropathy?
– What is the pattern of involvement?
– Is the neuropathy focal, multifocal or symmetric?
– If the neuropathy is symmetric, is it proximal or distal?
19. • Does the patient actually have a neuropathy?
– Causes of generalized weakness include motor
neuron disease, disorders of the neuromuscular
junction and myopathy.
– Peripheral neuropathy can also be mimicked by
myelopathy, syringomyelia or dorsal column
disorders, such as tabes dorsalis.
– Hysterical symptoms can sometimes mimic a
neuropathy.
Diagnostic Approach
20. • Is the neuropathy focal, multifocal or symmetric?
– Focal neuropathies include common compressive
neuropathies such as carpal tunnel syndrome, ulnar
neuropathy at the elbow or peroneal neuropathy at
the fibular head
– A multifocal neuropathy suggests a mononeuritis
multiplex that may be caused, for example, by
vasculitis or diabetes
Diagnostic Approach
21. • If the neuropathy is symmetric, is it proximal or
distal?
– Most toxic and metabolic neuropathies present as a
distal symmetric or dying-back process.
– Proximal sensory neuropathies are rare and include
porphyria.
– Predominantly motor neuropathies are often proximal
and include acquired inflammatory neuropathies such
as Guillain-Barré syndrome.
• An exception is lead neuropathy, which initially affects motor
fibers in radial and peroneal distributions.
Diagnostic Approach
25. • Neuropathies can be categorized
according to the fiber type that is primarily
involved.
• Most toxic and metabolic neuropathies are
initially sensory and later may involve the
motor fibers.
Diagnostic Approach
26. • Pure sensory neuropathies can result from
drug toxicity (e.g., thalidomide, cisplatin
[Platinol]), paraneoplastic syndromes or
nutritional deficiencies.
• Primarily motor neuropathies include
Guillain-Barré syndrome.
Diagnostic Approach
27. • Alcoholism and diabetes can both cause
small-fiber, painful neuropathies
Diagnostic Approach
28. • Autonomic involvement occurs in many
small-fiber neuropathies but can also
occur in Guillain-Barré syndrome and is
sometimes life-threatening.
Diagnostic Approach
29. • It is important to distinguish whether the
neuropathy is axonal, demyelinating, or
both.
• This differentiation is best achieved using
nerve conduction studies (NCS) and
electromyography (EMG).
Diagnostic Approach
30. • Diabetes, HIV infection and alcoholism can
cause several patterns of neuropathy.
• They most commonly cause a distal, symmetric
axonal sensorimotor neuropathy.
• The second most common presentation in these
conditions is a small-fiber, painful neuropathy.
Diagnostic Approach
31. History
• The temporal course of a neuropathy varies,
based on the etiology.
– With trauma or ischemic infarction, the onset will be
acute, with the most severe symptoms at onset.
– Inflammatory and some metabolic neuropathies have
a subacute course extending over days to weeks.
– A chronic course over weeks to months is the
hallmark of most toxic and metabolic neuropathies.
32. History
• A chronic, slowly progressive neuropathy
over many years occurs with most
hereditary neuropathies or with chronic
inflammatory demyelinating
polyradiculoneuropathy (CIDP).
• Neuropathies with a relapsing and
remitting course include Guillain-Barré
syndrome.
33. • Ischemic neuropathies often have pain as
a prominent feature.
• Small-fiber neuropathies often present
with burning pain, lightning-like or
lancinating pain, aching, or uncomfortable
paresthesias (dysesthesias).
History
34. • Dying-back (distal symmetric axonal)
neuropathies initially involve the tips of the
toes and progress proximally in a stocking-
glove distribution.
History
35. • Peripheral neuropathy can present as
restless leg syndrome.
• Proximal involvement may result in
difficulty climbing stairs, getting out of a
chair, lifting and swallowing, and in
dysarthria.
History
36. • The clinical assessment should include:
– careful past medical history, looking for
systemic diseases that can be associated with
neuropathy, such as diabetes or
hypothyroidism.
History
37. • Many medications can cause a peripheral
neuropathy, typically a distal symmetric
axonal sensorimotor neuropathy.
• Detailed inquiries about drug and alcohol
use, as well as exposure to heavy metals
and solvents, should be pursued.
History
38. • All patients should be questioned
regarding
– HIV risk factors
– foreign travel (leprosy)
– diet (nutrition)
– vitamin use (especially B6)
– possibility of a tick bite (Lyme disease)
History
39. • The review of systems may provide clues
regarding other organ involvement and the
presence of an underlying malignancy.
History
41. Physical Examination
• A cranial nerve examination can provide
evidence of mononeuropathies or proximal
involvement.
• Funduscopic examination may show
abnormalities such as optic pallor, which
can be present in leukodystrophies and
vitamin B12 deficiency.
42. • Direct strength testing of muscles
enervated by cranial nerves V, VII, IX/X, XI
and XII is important, as mild bilateral
weakness can be missed by observation
only.
Physical Examination
43. • The motor examination includes a search
for fasciculations or cramps, or loss of
muscle bulk.
• Tone is normal or reduced.
Physical Examination
44. • The pattern of weakness helps narrow the
diagnosis: symmetric or asymmetric, distal
or proximal, and confined to a particular
nerve, plexus or root level.
Physical Examination
45. • Deep tendon reflexes are reduced or
absent.
• A bilateral foot drop may result in a
steppage gait in which the patient must lift
the knees very high in order to clear the
toes.
• Proximal weakness results in an inability
to squat or to rise unassisted from a chair.
Physical Examination
46. • The general physical examination can
provide evidence of orthostatic
hypotension without a compensatory rise
in heart rate when autonomic fibers are
involved.
Physical Examination
47. • Respiratory rate and vital capacity should
be evaluated in Guillain-Barré syndrome to
assess for respiratory compromise.
• The presence of lymphadenopathy,
hepatomegaly or splenomegaly, and skin
lesions may provide evidence of systemic
disease.
Physical Examination
48. • Pale transverse bands in the nail beds,
parallel to the lunula (Mees' lines), suggest
arsenic poisoning.
Physical Examination
49. Laboratory Evaluation
• EMG and nerve conduction studies (NCS)
are often the most useful initial laboratory
studies in the evaluation of a patient with
peripheral neuropathy
50. • They can confirm the presence of a
neuropathy and provide information as to
the type of fibers involved (motor, sensory,
or both), the pathophysiology (axonal loss
versus demyelination) and a symmetric
versus asymmetric or multifocal pattern of
involvement.
Laboratory Evaluation
51. • The limitations of EMG/NCS should be taken
into account when interpreting the findings.
– There is no reliable means of studying proximal
sensory nerves.
– NCS results can be normal in patients with small-fiber
neuropathies
– Lower extremity sensory responses can be absent in
normal elderly patients.
• EMG/NCS are not substitutes for a good clinical
examination.
Laboratory Evaluation
52. • Subsequent studies should be tailored to the most likely
diagnostic possibilities, and to the acuteness and
severity of the neuropathy.
• With an acute progressive neuropathy, a neurologic
consultation early in the course of the evaluation is
essential.
• Further evaluation of these patients includes EMG/NCS,
lumbar puncture, chest radiograph, electrocardiogram
and determination of forced vital capacity.
Laboratory Evaluation
53. • The most common presentation is that of a distal
symmetric sensorimotor neuropathy.
• Initial evaluation should include:
– fasting serum glucose, glycosylated hemoglobin,
blood urea nitrogen, creatinine, complete blood cell
count, erythrocyte sedimentation rate, urinalysis,
vitamin B12 and thyrotropin stimulating hormone
levels.
– Neurologic assessment may be warranted if the initial
evaluation does not produce a diagnosis.
Laboratory Evaluation
54. • CSF is useful in evaluation of
myelinopathies and polyradiculopathies.
• An elevated total protein level with < 5
wbc(albuminocytologic dissociation) is
present in acquired inflammatory
neuropathy (e.g., Guillain-Barré syndrome,
CIDP).
Laboratory Evaluation
55. • Other studies useful in specific clinical
contexts are:
– cytology (lymphoma)
– special studies
• such as Lyme polymerase chain reaction and
cytomegalovirus branched chain DNA
(polyradiculopathy or mononeuritis multiplex in
AIDS).
Laboratory Evaluation
56. • Nerve biopsy is only helpful in very
specific cases to diagnose vasculitis,
leprosy, amyloid neuropathy,
leukodystrophies, sarcoidosis and,
occasionally, CIDP.
Laboratory Evaluation
57. • It can be difficult to document a small-fiber
neuropathy because the only
abnormalities on neurologic examination
may be loss of pinprick and temperature
sensation in a distal distribution.
Laboratory Evaluation
58. • EMG/NCS may be normal.
• Autonomic studies are only helpful if the
autonomic fibers are involved.
• As a result, small-fiber neuropathy
remains a primarily clinical diagnosis.
Laboratory Evaluation
59. • The evaluation should include the most
likely causes (i.e., diabetes, alcoholism,
AIDS).
• If these studies are normal, a neurologic
consultation is recommended.
Laboratory Evaluation
60. Treatment
• The goal of treatment is to manage the
underlying condition causing the
neuropathy and repair damage, as well as
provide symptom relief.
61. Treatment
• Controlling a chronic condition may not
eliminate the neuropathy, but it can play a
key role in managing it.
62. Treatment
• Neuropathic pain is often difficult to control.
• Medications :
– OTC analgesics .
– antiepileptic drugs, including gabapentin, phenytoin,
and carbamazepine
– some classes of antidepressants, including tricyclics
such as amitriptyline.
– Mexiletine
– local anesthetics such as lidocaine or topical patches
containing lidocaine
– Codeine/oxycodone
63. • Mechanical aids can help reduce pain and lessen the
impact of physical disability.
– Hand or foot braces can compensate for muscle weakness or
alleviate nerve compression.
– Orthopedic shoes can improve gait disturbances and help
prevent foot injuries in people with a loss of pain sensation.
• If breathing becomes severely impaired, mechanical
ventilation can provide essential life support.
Treatment
64. • Surgical intervention often can provide
immediate relief from mononeuropathies caused
by compression or entrapment injuries.
– Repair of a slipped disk can reduce pressure on
nerves where they emerge from the spinal cord; the
removal of benign or malignant tumors can also
alleviate damaging pressure on nerves.
– Nerve entrapment often can be corrected by the
surgical release of ligaments or tendons.
Treatment