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Acute Peripheral Neurological Lesions


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Acute Peripheral Neurological Lesions

  1. 1. Acute Peripheral Neurological Lesions George Filiadis, D. O. November 17, 2005
  2. 2. Peripheral Nervous System <ul><li>Serves sensory, motor, and autonomic functions </li></ul><ul><li>Sensory symptoms-numbness, tingling, dysesthesias, pain, and ataxia, due to proprioceptive dysfunction </li></ul><ul><li>Motor symptoms-weakness </li></ul><ul><li>Autonomic symptoms-orthostatic symptoms, bowel or bladder dysfunction, gastroparesis, and sexual dysfunction. </li></ul>
  3. 3. Peripheral Nervous System <ul><li>In peripheral nerve process there is reduction or absence of reflexes. </li></ul><ul><li>When the sensory component is involved, test for proprioception, vibratory sensation, and pain and temperature sensibility </li></ul><ul><li>When the motor system is involved there is wasting, fasciculations, and weakness. </li></ul><ul><li>Autonomic dysfunctions may cause anhidrosis, pupillary dysfunction, orthostatic hypotension, and tachy- and bradyarrhythmias. </li></ul>
  4. 4. Localization of neurological disease <ul><li>See Figure 233-1 </li></ul><ul><li>Most muscle-related processes result in weakness of large proximal muscles along as pain, tenderness, and elevation of CK. </li></ul><ul><li>Diseases that affect other components of the peripheral nervous system seldom cause tenderness and elevation of CK. </li></ul><ul><li>Neuromuscular junction processes can affect large proximal muscles and affect bulbar musculature resulting in pupillary dysfunction, diplopia, dysarthria, or dysphagia. </li></ul>
  5. 5. Myopathies <ul><li>Polyomyositis -Inflammatory myopathy -chronic complaints of proximal symmetric weakness -may have muscle pain and tenderness -may have dysphagia and few progress to respiratory failure -no sensory loss, reflexes should be intact </li></ul>
  6. 6. Polyomyositis <ul><li>Management -should be assessed for potential respiratory compromise and aspiration risk. -long term treatment-immunosuppressive agents such as steroids and methotrexate </li></ul><ul><li>Differential diagnosis includes Lambert-Eaton myasthenic syndrome, inclusion body myositis, toxic myopathies, and dermatomyositis. </li></ul>
  7. 7. Myopathies <ul><li>Dermatomyositis -Can affect children -similar to polyomyositis except for violaceous rash over face and hands -muscle weakness -no sensory or reflex abnormalities -treatment is immunosuppression -elevated sed rate and CPK </li></ul>
  8. 8. Other Myopathies <ul><li>Drug induced –see table 233-1 </li></ul><ul><li>Viral myositis causes an acute myopathy involving the heart, associated with febrile illness, myalgia, and elevated CK levels. </li></ul><ul><li>Suspect trichinosis in pt with myalgias, proximal and bulbar muscle weakness, facial edema, and eosinophilia. </li></ul>
  9. 9. Disorders of the Neuromuscular junction- Botulism <ul><li>Ingestion of food contaminated with Clostridium botulinum. </li></ul><ul><li>Adults often report exposure to home canned foods </li></ul><ul><li>Infants exposure to honey </li></ul><ul><li>Bulbar weakness </li></ul><ul><li>Exraoccular movements are sometimes abnormal </li></ul>
  10. 10. Botulinism <ul><li>Absence of pupillary light reflex </li></ul><ul><li>Proximal limb weakness </li></ul><ul><li>Sensation is intact, normal mentation, reflexes are usually normal </li></ul><ul><li>Treatment-antibiotics in infants and immune serum and admission to the hospital </li></ul>
  11. 11. Guillain-Bare Syndrome <ul><li>Most common form of acute generalized neuropathy </li></ul><ul><li>Patients often report recent viral illness, especially gastroenteritis </li></ul><ul><li>Associated with Campylobacter jejuni </li></ul>
  12. 12. Guillain-Barre Syndrome <ul><li>Numbness and tingling of the lower extremities followed by weakness of the legs and then arms. </li></ul><ul><li>Weakness more pronounced in the legs </li></ul><ul><li>Lack of deep tendon reflexes </li></ul><ul><li>May be facial weakness involving the forehead </li></ul><ul><li>Chance of respiratory failure and lethal autonomic fluctuations </li></ul>
  13. 13. Guillain-Barre Syndrome <ul><li>Management -Lumbar puncture (high CSF protein, nl cell count and glucose) -Should be admitted for monitoring -When vital capacity is under 1 liter, intubate. -Plasma exchange or IV immunoglobulin </li></ul>
  14. 14. Focal neuropathies-Carpal Tunnel Syndrome <ul><li>Most commonly see entrapment neuropathy. </li></ul><ul><li>Intermittent pain and/or numbness in the thumb and first two fingers. </li></ul><ul><li>Symptoms reproduced with compression of the nerve over the carpal tunnel or by tapping over the nerve. </li></ul><ul><li>Treatment-wrist splints and ortho referral </li></ul>
  15. 15. Focal neuropathies <ul><li>Ulnar neuropathy -Numbness of the fourth and fifth fingers -weakness and wasting of hypothenar eminence is late finding </li></ul><ul><li>Entrapment of deep peroneal nerve -at the fibular head causing foot drop and numbness of the web between great and second toe </li></ul>
  16. 16. Focal Neuropathies <ul><li>Meralgia paresthetica -entrapment of lateral femoral cutaneous nerve of the thigh. -numbness and dysesthesias on lateral aspect of upper leg. -usually after weight loss or pelvic procedures </li></ul>
  17. 17. Focal neuropathies <ul><li>Mononeuritis multiplex -multiple nerve dysfunctions caused by vasculitis -usually affects both sides of the body -differential diagnosis includes multiple compression neuropathies and multifocal motor neuropathy </li></ul>
  18. 18. Focal Neuropathies-Bell’s Palsy <ul><li>Most common cause of acute facial paralysis </li></ul><ul><li>Sudden facial weakness, difficulty with articulation, problems keeping an eye closed, or inability to keep food in the mouth one side. </li></ul><ul><li>One sided weakness of the face involving the forehead </li></ul>
  19. 19. Bell’s Pulsy <ul><li>Treatment -acyclovir -Steroid controversial -Eye care to avoid corneal abrasions -lacrilube and patching </li></ul>
  20. 20. Focal neuropathies-Lyme disease <ul><li>Multiple neurologic manifestations </li></ul><ul><li>Arthralgias and fatique initially </li></ul><ul><li>Common neurologic sign is seventh nerve pulsy </li></ul><ul><li>Weakness in the limbs </li></ul><ul><li>May see selected decreased deep tendon reflexes </li></ul>
  21. 21. Lyme Disease <ul><li>Management -serum and CSF lyme antibodies -CSF pleocytosis and increased protein with a normal glucose -treat with 3 week course of IV antibiotics either rocephin or doxycycline </li></ul>
  22. 22. Plexopathies-Brachial Neuritis <ul><li>Affects younger individuals </li></ul><ul><li>Excruciating back, shoulder, or arm pain followed by weakness of arm or shoulder girdle. </li></ul><ul><li>On exam there is weakness along the distribution of brachial plexus. </li></ul><ul><li>Differential diagnosis includes cervical radiculopathies, Pancoast tumor </li></ul>
  23. 23. Plexopathies-lumbar <ul><li>Occurs in diabetic patients </li></ul><ul><li>Presents with back pain followed by weakness. </li></ul><ul><li>Sensory findings are absent </li></ul><ul><li>Deep tendon reflexes are diminished on the affected side. </li></ul><ul><li>Bowel and bladder function are not affected </li></ul>
  24. 24. HIV-Associated Peripheral Neurologic Disease <ul><li>CMV radiculitis -may be seen in the latter stages of AIDS -Acutely weak -Primarily lower extremity involvement -Varying degrees of bowel and bladder dysfunction -Hyporeflexia and decreased sensation -Rectal tone may be impaired </li></ul>
  25. 25. CMV Radiculitis <ul><li>Management -lumbar puncture reveals pleocytosis and increased protein -MRI of lumbarosacral spine demonstrates swelling and clumping of cauda equina -IV gancyclovir started at 5mg/kg q 12 h X 14 d </li></ul>
  26. 26. Questions <ul><li>Which of the following includes bulbar muscle weakness, absent pupillary reflex, and proximal muscle weakness a. polyomyositis b. botulism c. Guillain-Barre d. Lyme disease </li></ul>
  27. 27. Questions <ul><li>All of the following are associated with Lyme disease except </li></ul><ul><li>a. Tick Exposure b. Seventh nerve pulsy c. Arthralgias and fatigue d. abnormal mentantion e. treatment with rocephin or doxycycline. </li></ul><ul><li>Answers: b, f, t, d </li></ul>
  28. 28. Questions <ul><li>In Guillain-Barre Syndrome, deep tendon reflexes are intact T/F </li></ul><ul><li>Myalgias, proximal and bulbar muscle weakness, facial edema and eosinophilia are associated with Trichinosis T/F </li></ul>