Peripheral Neuropathy Ali Alrefai, MD

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Introduction
Classification Approach to PN Pathology Mononeurpathies Polyneuropathies: Hereditary Acquired Plexus lesions Myelopathies
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Classification
Anatomical: Peripheral nerve lesion Root & plexus Cord lesion Pathological: Demyelinating Axonal Etiology Hereditary Acquired
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Clinical History
Time course: GBS, diphtheria, porphyria CIDP, hereditary, metabolic Age of onset: Medical history: Drug & alcohol history: see Table 6-2 FH Occupational history

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Symptoms Motor Sensory Autonomic Weakness ramps Paresthesia Dysesthesia Fasciculation Pain Loss of sensation Postural hypotension B/B dysfunction Impotence Impaired sweating 8/9/2011 .

Autonomic: Predominantly motor Predominantly Sensory Autonomic involvement 8/9/2011 . Sensory.Physical Examination Localize the deficit: Mononeuropathy Mononeuropathy multiplex Polyneuropathy Motor.

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B12. TSH. ESR. UPEP. SPEP. FBS. LFT. Toxicology screen Autoantibodies: Anti-GM1 Anti-MAG Paraneoplastic: Anti-Hu NCS/EMG CSF Genetic Nerve biopsy 8/9/2011 . Hep screen.Laboratory CBC.

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RF.Pathology (1) Axonal Loss: Most common DM. Hereditary Distal weakness Absent reflexes Distal sensory loss NCS Partial recovery 8/9/2011 .

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(2) Myelin loss: Hereditary Immune-mediated neuropathies compression Weakness Absent reflexes Better prognosis NCS Onion bulb 8/9/2011 .

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Phagocytes.Wallerian Degeneration Sequence of axonal & myelin loss Distal segment of transected nerve 4-10 days after axonal loss Proliferation of schwann cells. Fibroblasts 8/9/2011 .

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Mononeuropathies 8/9/2011 .

pregnancy Nocturnal numbness or pain Dropping things: APB + Tinel·s.(1) Median Neuropathy Most common CTS: Most common Women 3:1. hypothyroidism. rheumatoid arthritis. phalen·s signs NCS/EMG Splinting vs. DM. surgical decompression 8/9/2011 .

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leprosy. surgery 8/9/2011 .(2) Ulnar Neuropathy Elbow Trauma. bone deformity. idiopathic Elbow pain Intrinsic hand muscle weakness Paresthesia NCS/EMG Conservative vs.

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(3) Radial Neuropathy Humerus fracture Pressure palsy Crutches Wrist drop. other extensors Triceps & brachialis reflexes Dorsal sensory loss NCS/EMG 8/9/2011 .

prolonged bed rest. crossed legs Trauma Systemic disorders: HNPP. steppage gait NCS/EMG Rx: 8/9/2011 .(4) Common Peroneal Neuropathy Compression: Coma. DM. Leprosy Foot drop.

Polyneuropathies 8/9/2011 .

Hereditary Neuropathies (1) Charcot-Maries-Tooth Distal weakness Wasting Absent reflexes Pes cavus Demyelinating (CMT1). X-linked 8/9/2011 . Axonal (CMT2) AD. AR.

(2) Friedreich·s Ataxia: AR Trinucleotide repeat (9q13-21) Sensory loss Absent reflexes (3) HNPP: AD Simple or multiple mononeuropathies at compression sites 8/9/2011 .

Acquired Neuropathies 8/9/2011 .

Vaccine.(1) Acute Idiopathic Inflammatory Polyneuropathy (GBS or AIDP) Clinical Features: Acute to subacute Preceding illness (Flue. GI..) Distal ascending symmetric weakness Respiratory involvement Sensory complaints>finding Absent reflexes Autonomic CN 8/9/2011 .

IVIG Symptomatic: Respiratory... Prognosis: 8/9/2011 .Cont GBS Dx: CSF protein Normal CSF cell count (<10) NCS: Slow motor velocity HIV-1 in suspected patients Rx: Plasmapharesis. Autonomic.. Nutrition. DVT.

IVIG Immunosuppression 8/9/2011 .(2) Chronic inflammatory Demyelinating Polyneuropathy (CIDP) Chronic progressive or relapsing course Similar to GBS Similar CSF Electrodiagnosis: Demyelinating & axonal Steroids Plasma exchange.

(3) Diabetic Neuropathies 0-93% may develop PN Symmetric PN: Mixed (most common) Predominantly sensory Autonomic Asymmetric neuropathy: Mononeuropathy multiplex Lumbar radiculopathy (2nd common) Cranial Neuropathy 8/9/2011 .

Diabetic Neuropathy Rx: Control blood glucose Symptomatic: Neuropathic pain Dysautonomia 8/9/2011 .Cont.

entrapment neuropathy PAN. RF. ANCA.. Steroids 8/9/2011 . SLE. Wegener·s granulomatosis NCS/EMG ESR. Mononeuropathy multiplex...(4) Vasculitic Neuropathy Polyneuropathy.. Rheumatoid arthritis...

Plexopathies 8/9/2011 .

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Brachial Plexopathy ØC/F: Weakness Pain Sensory loss Reflex changes ØEtiology: Trauma Compression: Tumors Idiopathic: Parsonage Turner 8/9/2011 .

Myelopathies 8/9/2011 .

Clinical Features Motor. combination C5: Unilateral or quadriparesis T1: LL paraparesis Spasticity 8/9/2011 . sensory or bladder.

VITAMIN Traumatic Demyelinating Infectious: Epidural abscess TB AIDS HTLV-1 Vascular: Infarction AVM 8/9/2011 .

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