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12/13/2022
Peripheral Neuropathy
Ali Alrefai, MD

12/13/2022
Introduction
?Classification
?Approach to PN
?Pathology
?Mononeurpathies
?Polyneuropathies:
Hereditary
Acquired
?Plexus lesions
?Myelopathies

12/13/2022
Classification
?Anatomical:
Peripheral nerve lesion
Root & plexus
Cord lesion
?Pathological:
Demyelinating
Axonal
?Etiology
Hereditary
Acquired

12/13/2022
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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Motor Sensory Autonomic
Weakness Paresthesia Postural
hypotension
Cramps Dysesthesia B/B
dysfunction
Fasciculation Pain Impotence
Loss of
sensation
Impaired
sweating
Symptoms

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?Localize the deficit:
Mononeuropathy
Mononeuropathy multiplex
Polyneuropathy
?Motor; Sensory; Autonomic:
Predominantly motor
Predominantly Sensory
Autonomic involvement
Physical Examination

12/13/2022
?CBC, ESR, FBS, TSH, B12, LFT, Hep screen,
SPEP, UPEP, Toxicology screen
?Autoantibodies:
Anti-GM1
Anti-MAG
Paraneoplastic: Anti-Hu
?NCS/EMG
?CSF
?Genetic
?Nerve biopsy
Laboratory

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Pathology
(1) Axonal Loss:
Most common
DM, RF, Hereditary
Distal weakness
Absent reflexes
Distal sensory loss
NCS
Partial recovery

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

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Wallerian Degeneration
?Sequence of axonal & myelin loss
?Distal segment of transected nerve
?4-10 days after axonal loss
?Proliferation of schwann cells; Phagocytes;
Fibroblasts

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

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

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

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

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Hereditary Neuropathies
(1) Charcot-Maries-Tooth
Distal weakness
Wasting
Absent reflexes
Pes cavus
Demyelinating (CMT1); Axonal (CMT2)
AD, AR, X-linked

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

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Acquired Neuropathies

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

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

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(2) Chronic inflammatory Demyelinating
Polyneuropathy (CIDP)
?Chronic progressive or relapsing course
?Similar to GBS
?Similar CSF
?Electrodiagnosis:
Demyelinating & axonal
?Steroids
?Plasma exchange, IVIG
?Immunosuppression

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(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

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Cont. Diabetic Neuropathy
?Rx:
Control blood glucose
Symptomatic:
Neuropathic pain
Dysautonomia

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(4) Vasculitic Neuropathy
?Polyneuropathy; Mononeuropathy multiplex,
entrapment neuropathy
?PAN, Rheumatoid arthritis, SLE, Wegener��s
granulomatosis
?NCS/EMG
?ESR, RF, ANCA.......
?Steroids

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Brachial Plexopathy
?C/F:
Weakness
Pain
Sensory loss
Reflex changes
?Etiology:
Trauma
Compression: Tumors
Idiopathic: Parsonage Turner

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Clinical Features
?Motor, sensory or bladder; combination
?C5: Unilateral or quadriparesis
?T1: LL paraparesis
?Spasticity

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VITAMIN
?Traumatic
?Demyelinating
?Infectious:
Epidural abscess
TB
AIDS
HTLV-1
?Vascular:
Infarction
AVM

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