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Sensory Sensory Presentation Transcript

  • Sensory & Peripheral Neuropathies Steve Sager, MPAS, PA-C
  • Learning Objectives
    • List common neuropathies
    • List the common toxins which produce neuropathies
    • Discuss the etiologies of common neuropathies
    • Differentiate between common neuropathies
    • Discuss the symptoms, signs, and treatments
      • Diabetic neuropathies
      • Alcoholic neuropathies
      • Uremic neuropathies
      • Autonomic neuropathies
  • Harrison’s on Neuropathies
    • “ The manifestations of such a disorder may be so bewildering and complex that it is difficult for a physician to know where to begin or how to proceed.”
  • General Information
    • More than 100 types of peripheral neuropathy have been identified
    • Each has its own characteristic set of symptoms, pattern of development, and prognosis
    • May involve sensory, motor, and/or autonomic nerves
    • A thorough patient history is critical
  • Common Neuropathies
    • Trigeminal neuralgia (tic douloureux)
    • Postherpetic neuralgia
    • Carpal Tunnel Syndrome
    • Sciatica
    • Guillain-Barré syndrome
    • Peroneal Muscular Atrophy
    • Diabetic Neuropathy Syndromes
    • Alcoholic Neuropathy
    • Uremic Neuropathy
  • Etiology of Neuropathies
    • Peripheral neuropathy may be
      • Inherited (C-M-T disease)
      • Acquired
    • Diabetes mellitus is a leading cause of peripheral neuropathy in the United States
      • ~60-70% of people with diabetes have mild to severe forms of nervous system damage.
    • Neuropathies with no apparent cause are termed idiopathic
  • Etiology of Neuropathies
    • Causes of acquired peripheral neuropathy include:
      • Physical injury (trauma) to a nerve
      • Tumors (neurofibromatoses)
      • Toxins
        • Heavy metals
        • Medications
      • Infections
        • Viral - HIV, EBV, HSV, CMV
        • Bacterial – Lyme disease
  • Etiology of Neuropathies
    • Causes of acquired peripheral neuropathy include:
      • Kidney disease
      • Autoimmune disease
      • Nutritional deficiencies
        • Vitamins E, B1, B6, B12, and niacin
      • Alcoholism
        • Thiamine deficiency
      • Vascular, metabolic, and endocrine disorders
  • Symptoms of Peripheral Neuropathies
    • Symptoms are related to the type of affected nerve and may be seen over a period of days, weeks, or years
      • Muscle weakness is the most common symptom of motor nerve damage
      • Sensory nerve damage causes a more complex range of symptoms because sensory nerves have a wider, more highly specialized range of functions
  • Symptoms of Peripheral Neuropathies
    • Sx’s of autonomic nerve damage are diverse and depend upon the affected organs/glands
    • Autonomic nerve dysfunction can become life threatening and may require emergency medical care in cases when breathing becomes impaired or when the heart begins beating irregularly
      • Common symptoms of autonomic nerve damage include:
        • unable to digest food easily
        • an inability to sweat normally, which may lead to heat intolerance
        • a loss of bladder control, which may cause infection or incontinence
        • an inability to control muscles that expand or contract blood vessels to maintain safe blood pressure levels
        • organ failure may occur.
  • Symptoms of Peripheral Neuropathies
    • 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
      • Temporary numbness
      • Tingling/pricking sensations (paresthesia)
      • Sensitivity to touch
      • Burning pain (especially at night)
      • Muscle wasting
      • Paralysis
      • Organ or gland dysfunction
  • Symptoms of Peripheral Neuropathies Hyperhidrosis Orthostasis, anhidrosis, impotence, incontinence Autonomic “ burning”, “tingling”, “ pins-and-needles” dysesthesia Paresthesia, ataxia, clumsiness Sensory Twitching, cramps Weakness, atrophy, hypotonia, fatigability, clumsiness, Motor Positive phenomena (excessive firing) Negative phenomena (loss of function) Fiber Type
  • Radiculopathies
    • Cervical – due to stenosis or HNP
      • Sensory sx’s
        • Neck, shoulder, or scapular pain increases with movement
      • Motor sx’s
        • Loss of reflex based on nerve root involved
    • Lumbosacral – onset after heavy lifting
      • Sensory sx’s
        • Pain in lower back, hip or buttocks +/- radiation
        • Increases with prolonged sitting, coughing, sneezing or straining
        • HNP is generally unilateral
        • Spondylolysis/spondylolithesis typically presents with bilateral sx’s
      • Motor sx’s
        • Loss of reflex
    • Dx/Tx: X-rays, CT/MRI, NSAIDs, bed rest, traction
  • Toxic Neuropathies (ICD 357.7*)
    • Organophosphates
    • Toxins/Heavy metals
      • Lead
      • Arsenic
    • Chronic uremia
      • Due to excessive levels of parathormone
    • Medications (ICD 357.6*)
      • Antimetabolic/ChemoTx
  • Diabetic Polyneuropathies (ICD 357.2)
    • Diabetes affects ~6% of the population
    • Vascular and neurological complications are the most common causes of morbidity & mortality
    • Neuropathy affects 25-50%
      • Directly related to the length of time that nerve fibers are exposed to hyperglycemia
      • Mixed polyneuropathy
      • Usually affects motor, sensory & autonomic
  • Diabetic Neuropathy Syndromes
    • Glucose becomes incorporated into proteins
      • AGEs are formed (irreversible)
      • Reactive oxidants are produced
      • Cause damage to collagen structure, basement membrane thickening, increased inflammatory responses and vascular permeability
  • Diabetic Neuropathy Syndromes
    • Two types:
      • Peripheral
        • Focal
          • Mononeuropathy affecting PNS or CNs
        • Generalized
          • Symmetric, peripheral, sensory polyneuropathy
          • Insidious and progressive
      • Autonomic
        • May result in erectile dysfunction, gastropathy, or hypoglycemia
        • Cardiovascular complications
          • Orthostatic hypotension
          • Myocardial infarction
          • Malignant arrhythmia
          • Sudden death
  • Diabetic Neuropathy Syndromes
    • Focal or multifocal
    • Occur secondary to vasculitis/ischemia
    • Acute onset of pain
      • Resolves spontaneously <6 weeks
    • May involve:
      • CN III, IV, VI, VII
      • Ulnar or median nerve
      • Peroneal, sural, sciatic, or femoral nerve
      • Amyotrophy of proximal thigh muscles
      • Diabetic truncal radiculoneuropathy
  • Diabetic Neuropathy Syndromes
    • Can be detected during a routine exam
    • Inspect feet for deformities and sensory loss
      • Loss of ankle reflexes
      • Loss of Hot/Cold sensation
      • Loss of vibratory sense
        • 128Hz tuning fork to hallux
      • Monofilament test
        • Use 10 gauge monofilament
      • Charcot foot = xerosis, venous distension, multiple
      • bony deformities
    • EMG and NCS confirm the diagnosis
  • Monofilament Test
    • There is a risk of ulcer formation if the patient is unable to feel the monofilament when it is pressed against the foot with just enough pressure to bend the filament
    • The patient is asked to say &quot;yes&quot; each time he or she feels the filament
    • Failure to feel the filament at four of 10 sites is 97 percent sensitive and 83 percent specific for identifying loss of protective sensation
  • Diabetic Mononeuropathies
    • CN III or CN VI are commonly affected
      • NOT associated with pupillary abnormalities
    • CTS (median neuropathy)
      • Occurs in ~6% of diabetics
      • Acute onset of painful paresthesias in fingers with radiating “ache” to forearm
        • Worse HS
        • Motor weakness is progressive with thenar wasting
        • Positive Phalen test and/or Tinel sign
  • Diabetic Autonomic Neuropathy
    • GI-related:
      • Characterized by gastroparesis, nausea/emesis and diarrhea
      • Improve overall glycemic control**
      • +/- improvement of GI sx’s with Metoclopramide
      • Tx diarrhea with Clonidine QD (+/- TCN)
    • GU-related:
      • Characterized by impotence, impaired sensation to voiding, and retrograde ejaculation
  • Treatment of Diabetic Neuropathy Syndromes
    • Improved metabolic control is the main goal of treatment
      • Control lipids
      • Manage HTN (ACE inhibitors)
      • Lifestyle intervention
    • Intensive insulin therapy
      • 3-4 injections QD or an insulin pump reduced electrophysiologic evidence by up to 64%
    • ASA
    • Magnesium oxide 250-750mg HS
  • Treatment of Diabetic Neuropathy Syndromes
    • Analgesics
      • Tramadol
    • Neuromodulators
      • Gabapentin
    • Carbamazepine (Tegretol)
    • Capsaicin
      • Tx neuropathic pain: rub in for 5 minutes BID
    • TCAs
    • Daily foot exam by patient!!!
      • Use mirrors
    • Annual PCP examination is required
  • Diabetic Autonomic Neuropathy
    • Avoid medications that can cause syncope:
      • Alpha-blockers, anti-HTN, antidepressants
    • Frequent accuchecks
    • Maintain adequate hydration
    • Minimize cardiac-related AN:
      • Monitor for orthostatic hypotension
        • Increased risk of sudden death/silent ischemia
      • Improve mgmt of glucose, lipids, and HTN
      • Use ACE inhibitors*
  • Diabetic Neuropathy Syndromes
    • Foot ulceration and amputation are the most common consequences
    • Risk factors for amputation:
      • Poor glycemic control
      • Alcohol abuse
      • Obesity
      • Loss of protective sensation
      • Altered biomechanics/foot deformities
      • Diagnosis >10 years
      • Gender
      • Peripheral vascular disease
  • Neuropathy Disability Score A total score (for both feet) of 6 or greater is predictive of foot ulceration. 0-5 Total for one foot 0 1 2 Present Present with reinforcement Absent Achilles reflex 0 1 Apply pin proximal to great toenail Normal = can distinguish sharpness Abnormal Pinprick 0 1 Apply temperature variants to dorsum of foot Normal = can distinguish temperature variants Abnormal Temperature 0 1 Apply 128-Hz tuning fork to apex of great toe Normal = can distinguish presence/absence of vibration Abnormal Vibration Score Sensation
  • Alcoholic Polyneuropathy (ICD 357.5)
    • Establish Dx of alcohol abuse
      • Preoccupation
      • Increased tolerance
      • Drinking alone
      • Use as a “medication”
      • Blackouts
      • Physical/Social/Family issue
    • CAGE questionnaire
    • ? Vitamin deficiency
  • Alcoholic Polyneuropathy
    • Wernicke-Korsakoff syndrome
      • CNS injury related to thiamine deficiency
      • Nystagmus, ataxia, confusion, EOM paralysis
    • Peripheral polyneuropathy
      • Earliest symptom of chronic alcoholism
      • Mostly sensory with +/- motor involvement
      • “ Burning” sensation in feet
    • Dementia – due to cerebral atrophy
    • Cerebellar degeneration – truncal ataxia
    • Myopathy – proximal muscle wasting
    • Hepatic encephalopathy
      • Altered consciousness/lethargy
      • Ataxia/dysarthria/asterixis
  • Alcoholic Polyneuropathy
    • Delirium Tremens (DTs)
      • Alcohol withdrawal syndrome
      • Occurs 72-96 hours after cessation
      • Often fatal
      • Similar to withdrawal from barbiturates/benzos
      • Mild tremors seizures
      • “ Jittery” and easily startled
      • Hallucinations
      • Autonomic hyperactivity
  • Alcoholic Polyneuropathy
    • Seizures are common
      • Generalized (“Rum fits”)
        • Occur 12-48 hours after decreased ETOH intake
      • Focal
        • Occur during periods of intoxication
    • Tx:
      • Supportive (diet, vitamins, etc.)
      • Librium
      • Diazepam
      • Thiamine (50mg IV and 50mg IM QD)
  • Uremic Neuropathy (Uremia) (ICD 357.4)
    • Presents with altered mental status
      • Variable
      • Irritability
      • Difficulty concentrating
      • Psychosis
    • May have convulsions
      • Secondary to acidosis, hypokalemia, hyponatremia
    • Often occurs postdialysis/postdiuresis
    • Most patients with BUN>60 have EEG changes
    • R/O infection and subdural hematoma
  • Uremic Neuropathy
    • Additional (late) symptoms:
      • Peripheral neuropathy
      • “ Restless leg syndrome”
      • “ Burning” paresthesias of the feet
      • Sensory loss in digits
      • Asterixis
      • Fasciculations
      • Myoclonus
      • Muscle cramps
      • Amaurosis
      • Cerebral emboli
      • Dementia
  • Autonomic Neuropathies
    • Parasympathetic neuropathies typically involve the cranial nerves or sacral nerves
    • Sympathetic neuropathies involve the medulla oblongata, spinal cord, or sympathetic ganglia
    • Both involve receptors in the smooth muscles and glands
  • Clinical Manifestations of Autonomic Neuropathies
    • Sudden death
    • Tremors
    • Hyperthermia
    • Altered sweating
    • Tachycardia
    • Orthostatic hypotension
    • Syncope
    • Gastroparesis
    • GU dysfunction
  • Conditions Associated with Autonomic Neuropathies
    • Poisoning
      • Atropine
      • Anticholinesterase inhibitors
    • Horner’s syndrome
      • Oculosympathetic paralysis
        • Ptosis
        • Miosis
        • Anhidrosis
    • Shy-Dragger syndrome
      • Progressive autonomic failure
      • Multiple system atrophy
      • Progressive and fatal
  • Conditions Associated with Autonomic Neuropathies
    • Pheochromocytoma
      • Tumors arising from chromaffin cells in the sympathetic nervous system
      • Release Epinephrine and NE into circulation
      • Cause autonomic hyperactivity
        • Paroxysmal hypertension
        • Diaphoresis
        • Flushing
        • Tachycardia
        • Anxiety
      • Test blood/urine for catecholamines, metanephrines and vanillylmandelic acid (VMA)
  • Assessment of Possible Autonomic Neuropathies
    • Orthostatic VS
    • ECG
      • Look for R-R variability
    • Tilt test
    • Cold pressor test
    • Sweat provocation
  • Treatment of Neuropathies
    • Several classes of drugs have recently proved helpful to many patients suffering from more severe forms of chronic neuropathic pain
      • Antiepileptic drugs
        • Phenytoin (Dilantin)
        • Carbamazepine (Tegretol)
      • Some classes of antidepressants (Tricyclics)
      • Gabapentin (Neurontin)
      • Mexiletine (Mexitil)
        • developed to correct irregular heart rhythms
        • sometimes associated with severe side effects
  • Treatment of Neuropathies
    • Neuropathic pain is often difficult to control
      • Use smallest effective dose and titrate
      • Mild pain may sometimes be alleviated by OTC analgesics
      • Limit narcotic use
      • Corticosteroids may help reduce inflammation
    • Injections of local anesthetics such as lidocaine or topical patches containing lidocaine may relieve more intractable pain
    • In the most severe cases, doctors can surgically destroy nerves
      • The results are often temporary and the procedure can lead to complications.
  • Information Resources
    • Neuropathy Association 60 East 42nd Street Suite 942 New York, NY   10165-0999 http://www.neuropathy.org Tel: 212-692-0662 800-247-6968 Fax: 212-692-0668
    • National Chronic Pain Outreach Association (NCPOA) P.O. Box 274 Millboro, VA   24460 http://www.chronicpain.org Tel: 540-862-9437 Fax: 540-862-9485
    • American Chronic Pain Association (ACPA) P.O. Box 850 Rocklin, CA   95677-0850 http://www.theacpa.org Tel: 916-632-0922 800-533-3231 Fax: 916-632-3208
  • Information Resources
    • Charcot-Marie-Tooth Association (CMTA) 2700 Chestnut Parkway Chester, PA   19013-4867 http://www.charcot-marie-tooth.org Tel: 610-499-9264 800-606-CMTA (2682) Fax: 610-499-7267
    • American Pain Foundation 201 North Charles Street Suite 710 Baltimore, MD   21201-4111 http://www.painfoundation.org Tel: 888-615-PAIN (7246) 410-783-7292 Fax: 410-385-1832
    • National Foundation for the Treatment of Pain P.O. Box 70045 Houston, TX   77270 http://www.paincare.org Tel: 713-862-9332 Fax: 713-862-9346
  • Summary
    • List common neuropathies
    • Etiologies of common neuropathies
    • Differentiate between common neuropathies
    • Discuss treatment options for common neuropathies
    • List the common toxins which produce neuropathies
    • Symptoms, signs, and treatments of
      • Guillain-Barré syndrome
      • Peroneal Muscular Atrophy
      • Diabetic neuropathies
      • Alcoholic neuropathies
      • Uremic neuropathies
      • Autonomic neuropathies
  • Summary
    • Diabetes mellitus is a leading cause of peripheral neuropathy in the United States
    • Diabetic Neuropathy Syndromes
      • Vascular and neurological complications are the most common causes of morbidity & mortality
      • Foot ulceration and amputation are the most common consequences
      • CTS (median neuropathy) occurs in ~6%
      • Improved metabolic control is the main goal of treatment
      • Daily foot exam by patient is essential
  • Summary
    • Alcoholic Neuropathy
      • Peripheral polyneuropathy is the earliest symptom of chronic alcoholism
      • Wernicke-Korsakoff syndrome results from CNS injury related to thiamine deficiency
      • Seizures are common
    • Uremic Neuropathy
      • Presents with altered mental status
      • Often occurs postdialysis/postdiuresis
  • Summary
    • Autonomic neuropathies affect receptors in the smooth muscles and glands
    • Clinical manifestations of autonomic neuropathies include sudden death, hyperthermia, altered sweating, orthostatic hypotension, and gastroparesis
    • Neuropathic pain is difficult to control