Neurology Collection

Neuropathies

Allan H. Ropper, MD
Executive Vice Chair, Department of Neurology
Brigham and Women's Hospital
Professor of Neurology
Harvard Medical School
Symptomatic Characteristics of
Polyneuropathy
Sensory almost always ahead of motor
Distal sensory symptoms most common
Paresthesias
Numbness
Pain (actually uncommon)
Trophic changes
Special cases of imbalance
Examination features
Signature feature is dropped reflexes-ankle
jerks in particular
No Babinski signs
Subsidiary sensory features may be Romberg
sign
Distal sensory loss—pinprick/thermal or joint
position/vibration or both
Distal muscle atrophy-especially Extensor
Digitorum Brevis
Temporal Course and Signature Type
Two best axes for classification and diagnosis
are:
Evolution-acute, subacute, chronic
Axonal vs. demyelinating
Age somewhat helpful
Latter can be distinguished by symptoms and
exam and by EMG
Pain, atrophy, distal predominance=axonal
Paresthesias, proximal weakness, absence of
atrophy and reflex loss=demyelinating
Common neuropathies are common
Mid-life-diabetes, toxins
Older men-paraproteinemic
Older women-Sjögren
Young with high arches-CMT/genetic
 Chronic polyneuropathies that must be
distinguished from diabetic neuropathy
Acquired
Paraproteinemic-amyloid
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
(inflammatory)
Nutritional
Toxic and drug induced
SLE and related autoimmune processes (including) Sjogren
syndrome
Summated vasculitic (e.g., cryoglobulinemia)
Others: Lyme, AIDS, sarcoid, etc.
Heredofamilial (Charcot-Marie Tooth—CMT) many types
Workup for Polyneuropathy
Glucose and HgbA1c
BUN/Cr
IEP/immunofixation
ESR, ANA, Sjögren antibody
B12
Special cases-TTR (amyloid), genetic testing
for CMT
Heavy metal toxicology
NOT Lyme
Types of Diabetic Neuropathy
Most common is a distal, predominantly
sensory (numb-painful variety) in the feet-a
major management problem; less frequent is
large fiber imbalance syndrome—both are
polyneuropathies
Other varieties are: mononeuritis (III, VI,
thoracic, femoral), autonomic, and lumbar
radiculopathy (“diabetic amyotrophy”)
Diabetic Polyneuropathy
The most frequent polyneuropathy in general
medicine
Incidence:
~7.5% at time of discovery of DM; rises to 50% after 25
years
Newly detected cases ~ 3%/pt year without retinopathy;
7%/pt year with retinopathy (NEJM 1993;329:977-DCCTRC)
Rochester longitudinal study: polyneuropathy in 54%
(Neurology 1993;43:827)
Diabetic microvascular skin disease and
macrovascular occlusive disease occur far more often
in the presence of neuropathy
Diabetic Polyneuropathy

A major management problem and source of

comorbidity with diabetic peripheral vascular
disease
Glycemic control slows progression somewhat
but is not preventative
Main symptomatic treatment is inadequate:
gabapentin and other anticonvulsants for pain
and dysesthesias; imbalance and weakness
not treatable
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