6. CIDP
• Subacute onset
• Ascending nearly symmetrical ,proximal and distal
• Wasting with glove and stocking paresthesias
• Progression at least 8 weeks
• Cranial nerves involvement
• Inflammatory markers
• CSF
• Electrodiagnostic criteria
• MRI and USG
7. MMNC WITH CONDUCTION
BLOCK
• Weakness mainly distal within specific nerve territory with
affection of lower limbs in the same manner in absence of
UMN signs
• To differentiate with MND
• Electrophysiologically normal sensory conduction studies
with reduced CMAPS
• Severe and diffuse in. MND with negative ibching for
conduction block
• Denervation potentials were more prouse in MND and mild
in MMNCB with a neurogenic pattern MUPS related to
territory in MMNCB and diffuse in MND.
9. NON-DEMYELINATING
• Hereditary neuropathy –CMT
• Clinically, childhood or young age , positive family history, bilateral symmetrical
ascending distal weakness and wasting (inverted champagne bottle ), mild glove and
stoke paresthesia, skeletal deformities (pes-cavus )
• Electrophysiologically : diffuse symmetrical sensorimotor demyelinating with secondary
axonopathy .
10. NON-DEMYELINATING
• In mononeuritis multiplex, subacute sensorimotor in specific nerves with
electrophysiologic evidence of sensorimotor axonopathy in separate nerves in upper and
lower limbs
• Clinically, asymmetrical severe sensorimotor axonal loss more in upper limbs or presence
of conduction block
• Primary etiologies- RA, Psoriasis , vasculitis abuse of n-hexane -
11. NON-DEMYELINATING
• Diabetic-elderly, long standing , gradual onset nearly symmetrical distal sensorimotor
weakness
• Electrophysiologically, symmetrical predominant length dependent neuropathy with
prominent sensorimotor axonopathy and neurogenic pattern in distal muscles of upper
and lower limbs .
14. HEREDITARY
• DM-Clincally characteristic facies, progressive distal and proximal muscle weakness,
stiffness and wasting involving legs, hands, neck and face
• Other signs and symptoms as cataracts , type 2dm, cardiac conduction defects and
harmonal changes that may cause balding or infertility.
• EMG- myogenic potentials.
• MC-mild ,progressive , distal weakness that induced by movement after rest and relieved
by repetitive movement known as “the warm-up effect ’’ without wasting
• EMG-normal MUPS with average recruitment
15. HEREDITARY
• In chronic polymyositis clinically myalgia at onset, symmetrical proximal weakness
started in lower than upper limbs, neck muscle and late distal muscles.
• Electrophysiologically, only motor axonopathy and denervation potentials as MND but
with myopathic pattern .
• ESR and CPK commonly presents with distal weakness over weeks to months
16. HEREDITARY
Myopathy with distal weakness –Inclusion body myopathy and distal myopathy.
IBM- progressive asymmetrical onset muscle weakness and wasting involving distal
forearm muscles and proximal leg with sparing of facial muscles.
Distal myopathy –gradual symmetrical hand weakness with characteristic fingers drop (4,5 )
with distal and proximal lower limb weakness and wasting as late onset weakness of finger
extensors followed by intrinsic hand and distal lower limb muscles.
17. HEREDITARY
• Electrographically –presence of denervation potentials with mixed myopathic and
neurogenic pattern in affected muscles in IBM
• Myopathic pattern in distal myopathy and mildly elevated CPK
18. HEREDITARY
• Myasthenic myopathy
• History of fatigable symmetrical proximal weakness is present.
• Clinically, hand affection was a part of generalized weakness and wasting can be because
of long standing disease
• Fluctuation phase followed by active phase then inactive and finally burnt-out phase
(15-20 yrs) in which weakness becomes fixed and muscles become atrophic.
19. COMPRESSIVE
• Carpel tunnel syndrome
• Radial nerve entrapment at spiral groove
• Ulnar nerve entrapment at the elbow
• Pronator teres syndrome
• Thoracic outlet syndrome
• Pan plexopathy
• C8-T1 radiculopathy
• Cervical syringomyelia
• Lower cervical myelopathy due to C5,C6,C7 disc prolapsed
• Polyradiculopathy of both upper limbs.
20. COMPRESSIVE
• Sensorimotor weakness were CTS, PTS, spiral grove injury, ulnar nerve lesion at elbow,
brachial plexus lesion , cervical radiculopathy, myelopathy, syringomyelia, mononeuritis
multiplex, TOS, CIDP,MADSAM,HN, sensorimotor axonal neuropathy and
polyradiculopathy
• Clinically, CTS and PS ; paresthesia distribution lateral 3.5 fingers only in CTS while in , PS,
lateral 2/3 rd of palm and sensory loss is variable.
• CTS – delayed sensorimotor distal latencies or sensorimotor axonopathy of median nerve
with chronic neurogenic pattern in APB .
• PS- conduction will be normal, neurogenic pattern in APB, FPL and median half of FDP.
21. COMPRESSIVE
• Clinically in UNEE, paresthesias in medial one and half fingers and medial third of hand
with proximal elbow pain followed by progressive weakness and wasting of intrinsic
muscles with ulnar claw.
• C8 radiculopathy-medial aspect of arm, forearm, hand and little finger
• TOS –paresthesias of medial aspect of forearm, 4th and 5 th digits as well as medial
forearm with global hand weakness and wasting in hypothenar and lateral thenar
muscles.
22. COMPRESSIVE
• Electrophysiologically , in UNEE conduction block at elbow with absence of its SNAP, and
neurogenic pattern in FDI, ADM and FCU
• C8 radiculopathy, NCS may be normal and neurogenic pattern in APB,FDI and EIP.
• In TOS, SNAPS of ulnar and medial antebrachial nerves were normal with low CMAP of
median nerve, and neurogenic pattern was more in median (APB) and less ulnar
innervated FDI and EIP.
• Imaging – C-spine shows C7-T1 disc bulge in radiculopathy and cervical rib in TOS.
23. COMPRESSIVE
• Spiral groove injury –clinically, mild paresthesia in the back of hand and forearm, wrist
and finger drop was the presenting symptom in radial entrapment
• Traumatic brachial plexus injury / radial lesion at the arm includes weakness in
brachioradialis, supinator, extensor carpi radialis longus and brevis with sensory loss in
posterior forearm, dorsum of hand and lateral 3and half fingers.
24. COMPRESSIVE
• Electrophysiologically, in radial entrapment, conduction block at spiral groove with
normal SNAP and reduced recruitment in EIP, EDC, ECR and BR will be found in brachial
panplexopathy at cord levels
• In C8-T1 lesion showed absent SNAPs from little finger with neurogenic pattern in EDC,
EIP, FPL, Lumbricals, Interossei, thenar and hypothenar
• In C5-T1 lesions, SNAPS from all fingers will be absent and neurogenic pattern in proximal
and distal muscles.
26. TRAUMATIC NERVE INJURY
• Clinical presentation: Lesion in back of arm led to radial injury with resulting fingers and
wrist drop
• Lesion at medial elbow and medial forearm showed led to ulnar injury with resulting
partial ulnar claw hand and wasting in hypothenar muscles.
• Electrophysiologically, there were mixed sensorimotor axonopathy with neurogenic
pattern in muscles distal to injury.
27. TRAUMATIC NERVE INJURY
• Cervical MRI showed focal cord lesion as degenerative lower cervical myelopathy and
cervical syringomyelia.
• In myelopathy, old age, gradual onset of radicular paresthesia, followed by fine motor
skills dysfunction, weakness and wasting, and late spastic paraparesis with sphincteric
disturbances
• Electrophysiologically, normal conductions with chronic neurogenic pattern in lower
cervical roots ( C7,C8,T1 ) muscles.
28. COMPRESSIVE
• Cervical syringomyelia , gradual onset jacket paresthesia, proximal and distal upper limb
weakness and wasting in asymmetrical with later spastic paraparesis, normal
conductions with chronic neurogenic pattern in distal and proximal muscles of upper
limbs and long syrinx extending from C2-T1 with Arnold chiari malformation in cervical
MRI.
• Dissociative paresthesias in a cape or half cape distribution, atrophy of hand muscles or
fasciculations may be an early finding. Signs of myelopathy in lower limbs as disease
progress.
29. CLINICAL APPROACH TO WASTED ARM
DISTAL WEAKNESS OF UPPER LIMB
UNILATERAL
MOTOR
WITHLLs
FOCAL WASTING+ MOTOR MYELINOPATHY
WITH CB AT NON ENTRAPMENT SITE +
NON SPECIFIC MRI FINDING
MMNCB
+ PROXIMAL WEAKNESS + WASTING +
NEUROPATHY+ NON SPECIFIC CERVICAL MRI
FINDING
MND
UMNL SIGNS ±
CRANIAL MS
ALS SMA
WITHOUTLLs
+ PROXIMAL WEAKNESS + WASTING +
NEUROPATHY + NON SPECIFIC CERVICAL
MRI
MND
UMNL SIGNS
MONOMELIC
SENSORIMOTOR
BILATERAL
30. DISTAL WEAKNESS OF UPPER LIMB
UNILATERAL
SENSORIMOTOR
WITH LLs
NERVE PARESTHESIS +
WASTING + SEMIMOTOR
NEUROPATHY OR MIXED
DEMYELINATING AXIAL
NEUROPATHY + NEUROGENIC
EMG IN NERVE TERTIARY
MONONEURITIS
MULTIPLEX
+ NERVE PARESTHESIS +
FOCAL WASTING +
SENSORIMOTOR
MYELINOPATHY AT NON
ENTRAPMENT SITE +
NEUROGENIC EMG IN NERVE
TERRITORY
MADSAM
WITHOUT LLs
MOTOR
BIL;ATERAL
31. WITHOUT LL
GRIP WEAKNESS +
THENAR WASTING +
LAST 3.5 FINGERS
PARESTHESIA +
SENSORIMOTOR
NEUROPATHY ±
WITH NEUROGENIC
PATTERN IN APB
CTS
GRIP WEAKNESS
+ THENAR
WASTING +
LAST 3.5
FINGERS
PARESTHESIA ±
NEUROGENIC
PATTERN IN
APB,FPL
ANDMEDIAN
HALF OF FDP
PS
GRIP WEAKNESS
+HYPOTHENAR
WASTING
+MEDAIN 1.5
FINGERS +-
PARESTHESIAS+C
ONDUCTION
BLOCK
+NEUROGENIC
PATTERN IN
FDI,ADM AND
FCU
UNEE
GRIP
WEAKNES
S
+PARESTH
ESIAS IN
MEDIAL
FOREARM
,4 AND 5
TH
DIGITIS
+THENAR
WASTING
+NEUROG
ENIC EMG
IN APB
AND FDI
AND EIP
TOS
MILD PARESTHESIA IN
BACK OF HAND AND
FORE ARM , WRIST AND
FINGER DROP AT SPIRAL
GROOVE+NEUROGENIC
EMG IN EDC, ,EDC,ER
AND BR
SG
PROXIMAL
WEAKNESS+-
WASTING+UL
PARESTHESIAS+
SENSORIMOTO
R
NEUROPATH+N
EUROGENIC
EMG IN UL
BP
PROXIMAL
WEAKNESS +-
WASTING
+RADICULAR
PARESRHESIA
+-MOTOR
NEUROPATHY+
NEUROGENIC
EMG+CERVICAL
MRI
CR
32. BILATERAL DISTAL WEAKNESS OF UPPER LIMB
MOTOR SENSORIMOTOR
SYMMETRICAL
WITH LLs
WASTING + GLOVE AND
STOCKING PARESTHESIA +
SKELETAL DEFORMITY + POSITIVE
FAMILY HISTORY +
SYMMETRICAL SENSORIMOTOR
MYELINOPATHY / AXONOPATHY
+ NEUROGENIC EMG
HERIDITARY
NEUROPATHY
WITHOUT LLs
-
ASYMMETRICAL
WITH LLs WITHOUT LLs
MONONEURITIS
MULTIPLEX
CERVICAL RADICULOPATHY
