Peripheral neuropathy is damage to the peripheral nervous system, affecting around 2-8% of adults. It can be caused by diseases of the nerves or systemic illness. There are different types including mononeuropathy (single nerve), mononeuritis multiplex (multiple nerves), and polyneuropathy (widespread symmetrical damage). Common causes include diabetes, vitamin deficiencies, toxins, genetics, and infections. Symptoms vary depending on the nerves affected but may include numbness, tingling, pain, and muscle weakness starting in the extremities. Diagnosis involves clinical evaluation plus nerve conduction tests and biopsy. Treatment focuses on the underlying cause as well as managing neuropathic pain with medications like amitriptyline and pregabalin.

1. Peripheral NeuropathyPeripheral Neuropathy
DR SAIDI WAZIR PGDME/B.PHARMDR SAIDI WAZIR PGDME/B.PHARM

2. IntroductionIntroduction
 Peripheral neuropathy is the term forPeripheral neuropathy is the term for
damage to nerves of the peripheraldamage to nerves of the peripheral
nervous system, which may benervous system, which may be
caused either by diseases of thecaused either by diseases of the
nerve or from the side-effects ofnerve or from the side-effects of
systemic illness.systemic illness.

3. IntroductionIntroduction
 Peripheral neuropathy affects ~2–Peripheral neuropathy affects ~2–
8% of adults; the incidence increases8% of adults; the incidence increases
with age.with age.
 Peripheral nervous system isPeripheral nervous system is
composed of 12 pairs of cranialcomposed of 12 pairs of cranial
nerves and 31 pairs of spinal nerves.nerves and 31 pairs of spinal nerves.

4. IntroductionIntroduction
 Cranial nerves 3-12 share sameCranial nerves 3-12 share same
compositions as spinal nerves, anycompositions as spinal nerves, any
pathology involving peripheralpathology involving peripheral
nervous system may affect 3-12nervous system may affect 3-12
cranial nerves.cranial nerves.

6. Peripheral nervous systemPeripheral nervous system
 The peripheral nervous system isThe peripheral nervous system is
made up of three main types ofmade up of three main types of
nerves, each with its own specificnerves, each with its own specific
function:function:
- Automatic nerves help regulate the- Automatic nerves help regulate the
automatic functions of the body,automatic functions of the body,
such as blood pressure, bladdersuch as blood pressure, bladder
function and sweat levels.function and sweat levels.

7. Peripheral nervous systemPeripheral nervous system
- Motor nerves control the muscles of- Motor nerves control the muscles of
the body.the body.
- Sensory nerves pass sensations,- Sensory nerves pass sensations,
such as cold, heat or pain, from thesuch as cold, heat or pain, from the
affected area of the body to theaffected area of the body to the
brain.brain.

8. ClassificationClassification
 Peripheral neuropathy may bePeripheral neuropathy may be
classified in a varieties of ways-classified in a varieties of ways-
 according to theaccording to the
1.number of nerves affected1.number of nerves affected
• MononeuropathyMononeuropathy
• Mononeuritis multiplexMononeuritis multiplex
• PolyneuropathyPolyneuropathy

9. ClassificationClassification
2.the type of nerve cell affected2.the type of nerve cell affected
motormotor
sensorysensory
autonomicautonomic

10. ClassificationClassification
3. the process affecting the nerves3. the process affecting the nerves
DemyelinatingDemyelinating
AxonalAxonal
NeuronalNeuronal

11. DefinitionsDefinitions
 NeuropathyNeuropathy simply means asimply means a
pathological processpathological process
affecting a peripheral nerve oraffecting a peripheral nerve or
nerves.nerves.
 MononeuropathyMononeuropathy means a processmeans a process
affecting a single nerve.affecting a single nerve.

12. DefinitionsDefinitions
 Mononeuritis multiplexMononeuritis multiplex (multiple(multiple
mononeuropathy and/or multifocalmononeuropathy and/or multifocal
neuropathy) affects several orneuropathy) affects several or
multiple nerves.multiple nerves.
 PolyneuropathyPolyneuropathy describes diffuse,describes diffuse,
symmetrical disease, usuallysymmetrical disease, usually
commencing peripherally.commencing peripherally.

13. PolyneuropathyPolyneuropathy
 The course may beThe course may be
- acute, chronic, static, progressive,- acute, chronic, static, progressive,
relapsing or towards recovery.relapsing or towards recovery.
Polyneuropathies are motor, sensory,Polyneuropathies are motor, sensory,
sensorimotor and autonomic.sensorimotor and autonomic.

14. PolyneuropathyPolyneuropathy
 They are classified broadly intoThey are classified broadly into
demyelinating and axonal types,demyelinating and axonal types,
depending upon which principaldepending upon which principal
pathological process predominates.pathological process predominates.

15. PolyneuropathyPolyneuropathy
 Many systemic diseases causeMany systemic diseases cause
neuropathies. Widespread loss ofneuropathies. Widespread loss of
tendon reflexes is typical, with distaltendon reflexes is typical, with distal
weakness and distal sensory loss.weakness and distal sensory loss.

16. DefinitionsDefinitions
 RadiculopathyRadiculopathy means diseasemeans disease
affecting nerve roots andaffecting nerve roots and
 plexopathy,affecting the brachial orplexopathy,affecting the brachial or
lumbosacral plexus.lumbosacral plexus.

17. MononeuropathyMononeuropathy
 MononeuropathyMononeuropathy is a type ofis a type of
neuropathy that only affects a singleneuropathy that only affects a single
nerve.nerve.
 The most common cause ofThe most common cause of
mononeuropathy is by physicalmononeuropathy is by physical
compression of the nerve, known ascompression of the nerve, known as
compression neuropathy.compression neuropathy.

18. MononeuropathyMononeuropathy
 Nerve compression and entrapmentNerve compression and entrapment
 NerveNerve Entrapment/compressionEntrapment/compression
sitesite
 MedianMedian Carpal tunnelCarpal tunnel
(wrist)(wrist)
 UlnarUlnar Cubital tunnelCubital tunnel
(elbow)(elbow)
 RadialRadial Spiral groove (ofSpiral groove (of
humerus)humerus)
 Posterior interosseousPosterior interosseous Supinator muscleSupinator muscle
(forearm)(forearm)
 Lateral cutaneous of thighLateral cutaneous of thigh Inguinal ligamentInguinal ligament
 Common peronealCommon peroneal Neck of fibulaNeck of fibula
 Posterior tibialPosterior tibial Tarsal tunnelTarsal tunnel
(flexor retinaculum foot)(flexor retinaculum foot)

19. Mononeuritis multiplexMononeuritis multiplex
Mononeuritis multiplexMononeuritis multiplex isis
simultaneous or sequentialsimultaneous or sequential
involvement of individualinvolvement of individual
noncontiguous nerve trunks, eithernoncontiguous nerve trunks, either
partially or completely, evolving overpartially or completely, evolving over
days to years and typically presentsdays to years and typically presents
with acute or subacute loss ofwith acute or subacute loss of
sensory and motor function ofsensory and motor function of
individual peripheral nerves.individual peripheral nerves.

20. Mononeuritis multiplexMononeuritis multiplex
 This occurs in:This occurs in:
 ■■ diabetes mellitusdiabetes mellitus
 ■■ leprosyleprosy
 ■■ vasculitisvasculitis
 ■■ sarcoidosissarcoidosis

21. Mononeuritis multiplexMononeuritis multiplex
 ■■ amyloidosisamyloidosis
 ■■ malignancymalignancy
 ■■ neurofibromatosisneurofibromatosis
 ■■ HIV infectionHIV infection
 ■■ Guillain–Barré syndrome – usuallyGuillain–Barré syndrome – usually
polyneuropathy.polyneuropathy.
 ■■ idiopathic multifocal motoridiopathic multifocal motor
neuropathy.neuropathy.

22. PolyneuropathyPolyneuropathy
 Polyneuropathy-Polyneuropathy- The termThe term
"peripheral neuropathy" is"peripheral neuropathy" is
sometimes used loosely to refer tosometimes used loosely to refer to
polyneuropathy. Most cases ofpolyneuropathy. Most cases of
peripheral neuropathy affect theperipheral neuropathy affect the
sensory and motor nerves..sensory and motor nerves..

23. PolyneuropathyPolyneuropathy
 Longest fibres are affected first soLongest fibres are affected first so
symptoms usually first develop in thesymptoms usually first develop in the
extremities of your body, such asextremities of your body, such as
your feet, legs and hands and arms.your feet, legs and hands and arms.
This type of neuropathy is calledThis type of neuropathy is called
generalised sensorimotorgeneralised sensorimotor
polyneuropathypolyneuropathy

24. TYPES AND CAUSES OF PERIPHERALTYPES AND CAUSES OF PERIPHERAL
NEUROPATHYNEUROPATHY
AcuteAcute ChronicChronic
Guillain-BarréGuillain-Barré
AlcoholAlcohol
Guillain-Barré variantsGuillain-Barré variants
ToxinsToxins
PorphyriaPorphyria
ParaneoplasticParaneoplastic
HereditaryHereditary
CIDPCIDP
LymphomaLymphoma
Osteoclastic myelomaOsteoclastic myeloma
IgM paraproteinaemiaIgM paraproteinaemia
Arsenic toxicityArsenic toxicity
Amiodarone toxicityAmiodarone toxicity
Diphtheria/AlcoholDiphtheria/Alcohol
Metabolic/endocrine diseasesMetabolic/endocrine diseases
(including diabetes)(including diabetes)
Drugs and toxinsDrugs and toxins
Vitamin deficiencyVitamin deficiency
HereditaryHereditary
IgG paraproteinaemiaIgG paraproteinaemia
ParaneoplasticParaneoplastic
Primary amyloidosisPrimary amyloidosis

25. Common causesCommon causes
 A - Alcohol,Arsenic toxicityA - Alcohol,Arsenic toxicity
 B - Vit.deficiency-B1,6,12 def.B - Vit.deficiency-B1,6,12 def.
 C - CRF,Carcenomatous –C - CRF,Carcenomatous –
lymphoma,myeioma, connectivelymphoma,myeioma, connective
tissue disease-RAtissue disease-RA
 D - Diabetes, Drugs-INH,D - Diabetes, Drugs-INH,
MetronidazoleMetronidazole
 H-HereditaryH-Hereditary
 I-Infection-leprosy, GBSI-Infection-leprosy, GBS

26. Clinical featuresClinical features
 Sensorimotor polyneuropathySensorimotor polyneuropathy
 Symptoms of generalisedSymptoms of generalised
sensorimotor polyneuropathy cansensorimotor polyneuropathy can
include:include:
 prickling and tingling sensation in theprickling and tingling sensation in the
affected body part (pins and needles)affected body part (pins and needles)
 numbness and a reduced ability tonumbness and a reduced ability to
feel pain or changes in temperature,feel pain or changes in temperature,
particularly in your feetparticularly in your feet

27. Clinical featuresClinical features
 a burning pain, usually in the feeta burning pain, usually in the feet
and legs, followed by the hands andand legs, followed by the hands and
arms as the neuropathy progressesarms as the neuropathy progresses
 sharp stabbing pain, which is oftensharp stabbing pain, which is often
worse at night (again, the feet andworse at night (again, the feet and
legs are affected first, followed bylegs are affected first, followed by
the hands and arms)the hands and arms)

28. Clinical featuresClinical features
 muscle weaknessmuscle weakness
 loss of co-ordinationloss of co-ordination
 muscle paralysismuscle paralysis
 increased risk of developingincreased risk of developing
problems that affect the feet, such asproblems that affect the feet, such as
skin infections and foot ulcersskin infections and foot ulcers

29. Clinical featuresClinical features
 SignsSigns-It depends on the types,-It depends on the types,
severity and nerve cells involved.severity and nerve cells involved.
 Motor signs- lower motor neuronMotor signs- lower motor neuron
lesion-wasting ,fasciculation and losslesion-wasting ,fasciculation and loss
of reflexsof reflexs
 Sensory signs-diminished or loss ofSensory signs-diminished or loss of
sensation of all modalities ofsensation of all modalities of
sensationsensation

30. DiagnosisDiagnosis
 Diagnosis-Diagnosis- is largely clinical,is largely clinical,
supported by electrical studies.supported by electrical studies.
 A number of tests can be used toA number of tests can be used to
confirm peripheral neuropathy .confirm peripheral neuropathy .
These include:These include:
 nerve conduction test andnerve conduction test and
electromyography (EMG)electromyography (EMG)
 nerve biopsynerve biopsy

31. DiagnosisDiagnosis
 Other investigations to detect underlyingOther investigations to detect underlying
causes-causes-
 Blood testsBlood tests
• Blood sugar,HbA1cBlood sugar,HbA1c
• Urea and electrolytes,Urea and electrolytes,
• Thyroid function testsThyroid function tests
• Vitamin B12Vitamin B12
• Venereal Diseases Reasearch LaboratoryVenereal Diseases Reasearch Laboratory
(VDRL) test(VDRL) test
• ANA, anti-dsDNAANA, anti-dsDNA
 Chest X-rayChest X-ray

32. TreatmentTreatment
 Treatment for peripheralTreatment for peripheral
neuropathy will first address theneuropathy will first address the
condition’s underlying causes.condition’s underlying causes.
 For example, in cases of diabeticFor example, in cases of diabetic
polyneuropathy, a number of lifestylepolyneuropathy, a number of lifestyle
changes and treatment are taken tochanges and treatment are taken to
prevent further nerve damage. Thisprevent further nerve damage. This
may be:may be:
 giving up smokinggiving up smoking

33. TreatmentTreatment
 cutting down on your alcoholcutting down on your alcohol
consumption, or ideally not drinkingconsumption, or ideally not drinking
alcohol at allalcohol at all
 maintaining a healthy weight, if youmaintaining a healthy weight, if you
are overweight or obeseare overweight or obese
 taking plenty of exercisetaking plenty of exercise
 tight glycaemic controltight glycaemic control

34. Neuropathic painNeuropathic pain
 As well as addressing the underlyingAs well as addressing the underlying
causes of peripheral neuropathy,causes of peripheral neuropathy,
give additional medication to treatgive additional medication to treat
the symptoms of nerve pain. Thethe symptoms of nerve pain. The
medical term for nerve pain ismedical term for nerve pain is
neuropathic pain.neuropathic pain.

35. Neuropathic painNeuropathic pain
 Unlike most other types of pain,Unlike most other types of pain,
neuropathic pain does not usuallyneuropathic pain does not usually
respond well to treatment withrespond well to treatment with
widely used painkillers, such aswidely used painkillers, such as
paracetamol and ibuprofen.paracetamol and ibuprofen.
Therefore, alternative medicationsTherefore, alternative medications
are usually required.are usually required.

36. Neuropathic painNeuropathic pain
 Initial treatmentsInitial treatments
 Medications called amitriptyline andMedications called amitriptyline and
pregabalin are the initial treatmentspregabalin are the initial treatments
for people with neuropathic pain.for people with neuropathic pain.

37. PROGNOSISPROGNOSIS
 In 1/3In 1/3rdrd
cases cause is identified andcases cause is identified and
treatabletreatable
 In 1/3In 1/3rdrd
cases cause is identified butcases cause is identified but
not amenable to treatment.not amenable to treatment.
 In another 1/3In another 1/3rdrd
cause is notcause is not
identifiedidentified