53.Diabetic and Other Peripheral Neuropathies

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53.Diabetic and Other Peripheral Neuropathies

• R1 ???

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DEFINITION

• Neuropathy
• Nerve function?? structure? disturbance
• Many different etiologies
• Painful(e.g. Diabetic neuropathy)
• or painless(e.g. Neuropathy of Chr. Renal
  failure)

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CLASSIFICATION

• Neuropathic Pains
• Peripheral Neuropathies

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• 1.Neuropathic Pains

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2.Peripheral Neuropathies

• Metabolic
• Diabetes mellitus
• Amyloidosis
• Multiple myeloma
• Hyperhydroidism
• Nutritional
• beriberi
• Alcoholic
• Pellagra

• Toxic
• Isoniazid
• Arsenic
• Cisplatin
• Thallium
• Genetic
• Farbrys disease
• Hereditary sensory neuropathy
• Infectious
• AIDS
• Acute inflammatory polyneuropathy

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MECHANISM OF NEUROPATHIC PAIN

• ltPeripheral mechanism gt
• 1)Nerve? ??-gtsodium channel injury
• -gt hypersensitivity(nerve? ectopic foci)
• 2) Tx.? sodium channel blockers?
• membrane stabilizers? ????? ??
• 3)????? ??? ???
• alpha-adrenoreceptors? expression? ????
• -gt??? ??? pain? ????
• 4) ??? pain? sympathetic blockers?? sympathetic
  
• alpha-adrenoreceptor antagonists(phentolami
  ne)?
• ???? block????

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MECHANISM OF NEUROPATHIC PAIN

• ltCentral mechanismgt
• 1) CNS? pph. Nerve injury??? ???
• 2) Pph. Neuropathy? ????? CNS input? ?? ???
• (Ex. postherpetic neuralgia, diabetic
  neuropathy )
• 3) Several potential mechanism? ??
• (1) Loss of large fiber(A-beta) sensory input
  
• non-nociceptive sensory input?
  ??
• (2) Lamina II? dorsal horn interneurons?
  death
• dorsal horn? nociceptive
  transmission? inhibition
• ( By excitatory amino acids?
  overexposure )
• 4)Another central mechanism
• allodynia???
• Some peripheral neuropathies involves

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EVALUATION OF THE PATIENT WITH NEUROPATHIC PAIN
(1)

• 1.History
• 1)Almost always multiple
• (e.g. varying combinations of burning,
  stabbing, aching ??)
• 2)Location of the pain and other symptom?
• ?? ??? ??? ??
• 2.Neurologic Examination
• 1) Sensory evaluation? focus? ???
• 2) Strength and deep tendon reflexes?
• polyneuropathy?????? ????
• 3) Sensory examination light touch,
  rubbing, ice,
• single
  pinprick, and multiple pinpricks

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EVALUATION OF THE PATIENT WITH NEUROPATHIC PAIN
(2)

• 3.Electodiagnostic Testing
• 1) Electromyography(EMG) and nerve
  conduction(NCV) studies
• 2) Demyelinating(reductions in nerve
  conduction velocities) or
• axonal neuropathy
• (reductions in the amplitude of evoked
  responses)
• ??? large fiber? involve?? ? ??? ? ????
• small fiber? involve??? normal? ??? ? ??
• 3) Quantitive sensory testing(QST)
• painful pph. Neuropathies? tracking? ??
• large fiber sensory threshold to
  vibration
• small fiber heats, painful heat, cold,
  painful cold stimuli
•  

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DIFFERENTIAL DIAGNOSIS
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1.Metabolic Cause of Peripheral Polyneuropathy
Diabetes

• 1) most often metabolic disorder
• most common DM
• duration? ??? incidence? ???? ( up to 66 )
  
•  2) painful neuropathy incidence IDDM -11.6,
  NIDDM -32.1
• 3) cause
• current hypothesis metabolic and ischemic
  nerve injury
• (1) metabolic abnormailities
• (a) accumulation of sorbitol in diabetic
  nerve
• (b) autooxidation of glucose resulting
• in receive
  oxygen molecules
• (c) inappropriate activation of protein
  kinase C
• other theories impaired nerve
  regeneration
• 4) therapeutic strategies
• reducing sorbitol accumulation
  (aldose-reductase inhibitors)
• -gt5?? aggressive glycemic control? ??
  incidence? 60 ??

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• Clinical Classification of Neuropathy
• 1) distal symmetric polyneuropathy (m/c form)
• ?? leg, feet
• sx.? toe ?? ???? ?? ???? ????
• finger tip? hands? ??? involve
• allodynia? burning pain? ??? ?? ????
• examination graded distal sensory loss
• (vibration, position
  sensation)
• reflexes - diminished or absent
• electrophysiologic testing evoked
  response? amplitude? ??
• severe sensory loss ? foot ulcer?
• diabetic neuroarthropathy(charcots
  joint)? ???
• 2) acute painful diabetic neuropathy
• Rapid onset of severe pain in
  distal lower extremities
• by constant
  burning in the feet
• Dysesthesiae, allodynia, lancinating
  leg pains
• Blood sugar control? ?? ??

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• 3 ) autonomic polyneuropathy
• DM??? 20-40?? ??
• Postural hypotension, impaired heart rate
  control, esophageal dysmotility, gastroparesis,
  and erectile dysfunction
• 4)lower extremity proximal motor neuropathy
• Uncommon
• Acute or subacute onset of moderate to
  marked weakness and
• wasting of pelvifemoral muscles
• (back, hip, thigh pain? ??)
• 5) diabetic lumbosacral radiculoplexus
  neuropathy(DLRPN)
• Asymmetric weakness associated with pain
  in the leg
• Subacute?? ???? ???????? ????
•  

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• 6)diabetic truncal neuropathy
• chest? abdomen? unilateral ? pain?
• acute?? subacute?? ??
• myocardiac infarction, intra-abdominal
  pathology
• or spinal disorder? ??
• 7)cranial mononeuropathies
• Oculomotor, abducens, trochlear, and facial
  nerves? involve
• -gt opthalmoplegia and ptosis
•  
• 8)entrapment neuropathies
• More frequent in DM
• Ex. Carpal tunnel syn - DM???? ????? 2???

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• 2.Metabolic Cause of
• Peripheral Polyneuropathy Other
• Uncommon
• Amyloidosis
• Multiple myeloma
• Patient with untreated hypothyroidism

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• 3.Nutritional Cause of
• Peripheral Polyneuropathy
• 1) Thiamine deficiency
• Alcoholics, chronic dialysis pt.
• and restrictive diet?? people?? ????
• Beriberi? ?? heart failure,
  vasodilatation,
• pph. Neuropathy? ??
• Neuropathy hand, foot, and calf pain
• with allodynia, decreased sensation, and motor
  involvement
• thiamine ??? ??,pain??
• 2)Pellagra (niacin deficiency)

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• 4.Toxic Cause of Peripheral Polyneuropathy
• Isoniazid
• Initial Sx. Distal numbness and
  tingling paresthesias
• Late Sx. pain - deep ache or
  burning
• Cisplastin
• Arsenic
• Thallium

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• 5. Genetic Cause of
• Peripheral Polyneuropathy
• 1) Fabry disease X-linked recessive dis.
• Tender feet, burning in the calves
• Abd. Pain, angiokeratomas, anhidrosis, renal
  failure,
• corneal and lenticula opacities,
  hypertension, stroke, MI
• 2) Dominantly inherited hereditary sensory
  neuropathy
• Feet? distal leg? ?? ?? cellulitis?
  osteomyelitis ??

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• 6.Infectious Cause of Peripheral Polyneuropathy
• AIDS or AIDS-related complex
• Acute inflammatory polyneuropathy
• ( AIP or Guillain-Barre synd.)
• -  Areflexic motor paralysis
• -  tachycardia, orthostatic
  hypotension
• -  pain ache, strain,
• or deep burning
  sensation in thigh or buttocks

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• 7.Neuroma
• Complete pph. nerve? disruption ,end of axon?
  grow Thermosensitive and mechanosensitive  
• 8. Idiopathic Small-Fiber Neuropathy 60? ??,
  painful feet

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TRAETMENT OF NEUROPATHIC PAIN

• Wide variety of medication and proposed
  algorithms
• 1) Antidepressants
• automonic neuropathy????? anticholinergic side
  effect ??
• SSRI ??
• 2) Anticonvulsants (gabapentin? ?? ????? ??)
• 3) Sympatholytic Agents
• Pph, neuropathic pain? ??? ??? ??
• phentolamine analgesic response
• regional sympathetic
  ganglion blockade,
• oral or transdermal
  sympatholytic agents
• clonidine alpha2-adrenergic agonist ,
  useful analgesic
• 4) corticosteroids systemically and peripheral
  application
• 5) opioid controversial
• most universally effect, addictionand
  tolerance

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• 54.Entrapment neuropathies

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• Five of these synd
• 1) Carpal tunnel synd.
• 2) Cubital tunnel synd
• 3) Thoracic outlet synd
• 4) Meralgia paresthetica
• 5) Tarsal tunnel synd.
• Weakness? sensory loss pattern ? ??
• nerve? injured ? site ? localize ?? ??
• Confirm Dx.gt electrodiagnosis test
• MRI? small compression? miss ????
• surgical exploration ? ????? ??
• Electrodiagnostic test prognostic information
  ? ??
• (axon damage? ?? myelin dysfunction?
  differentiate)

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lt carpal tunnel synd. gt

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• m/c 11,000
•  
• Pathologygt median nerve? carpal tunnel ???
  compress
• site floor wrist bone / roof
  flecor retinaculum
• nine flexor tendon? tunnel? ???
•  
• Symptomsgt
• Classically, numbness on palmar surface of
• thumb index, middle half
  the ring finger
• In practice, only portion of median
  distribution.
• Especially, middle or index finger
• Fifth finger spared
• Pain both distal proximal to the site of
  compression
• wrist? flexion or extension?, pain?
  numbness? ????
• Flick sign hand? shake ?? numbness? relieve
• common situation 1gt wrist flexion ??? sleep?
  awake?
• 2gt driving
• ??? weakness? complain? ???? ???
• - Mild thenar weakness and sensory loss?
  complain

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• Physical findingsgt
• Two-point discrimination and pin prick testing
• - elicit sensory deficits in parts of
  the median sensory
• Strength of abductor pollicis brevis test
• - push tumb
• Phalens maneuver
• - pts wrist? hyperextension or
  hyperflexion ? pressure? ??
• Tinels sign tapping over carpal tunnel
• Electrodiagnosisgt
• very sensitive (95)
• Median nerve conduction? distal latency?
  delay

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• Tx.gt
• Splint wrist? neutral position?? ??
• Carpal tunnel? pressure? ???
• Anti-inflammatory Tx steroid injection
• Surgical decompression
•  
• Risk factorgt
• Repeated flexion and extension at wrist
• Obesity, arthritis, diabetes, and
  hypothyroidism

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• lt cubital tunnel synd. gt

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• Ulnar nerve entrapment at elbow
• 2nd m/c
•  
• Pathologygt
• Site Ligamentous band
• (from medial epicondyle to
  olecranon of ulna)
• Flexor carpi ulnaris muscle?
  aponeurosis
• Elbow? flexion? ulnar nerve? ???
  superficial?? ??
• ?? compress? ? ??
• ?? bony deformicy or scar formation? ???? ??
  
• ?? supracondylar Fx. Hx.? ?? ??? ??
• deformity? ?? ???? -?? tardy ulnar palsy?
  ??
•  
• Sxgt
• Ulnar n. distribution? intermittent numbness
  and tingling
• First Sx ulnar palsy
• Elbow pain? fifth digit? radiation
• Elbow flexion? ??? ? ??

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• Physical findings gt
• Sensory deficits ulnar nerve supply
• (fifth finger, both palmar and dorsal
  surfaces, and half of ring finger)
• C8 root lesion ? DDx?? ???
• Light touch and two-point discrimination
• Weal-grasp and pinch strength
• first dorsal interosseous and
  abductor digiti minimi
• Hypothenar eminence ? first dorsal
  interosseous? atrophy
• Chr.?? ring and little finger? clawing
• Elbow? 90? ?? flexion ? sensory complaints or
  pain??
• Electrodiagnosisgt
• Confirm Dx.
• R/o other cause brachial plexopathy,
  cervical radiculopathy
• ulnar entrapment at
  wrist
• Nerve conduction slow across the elbow

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• treatment gt
• mild case elbow pad -gt nerve trauma ??
• prolonged flexion ? avoid
• surgery
•  
• risk factor gt
• Hard surface? elbow? bent?? resting? ? ??? ???
• ex.)trunk drivers, long-distance airline
  passengers
• Direct trauma including elbow Fx.

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• lt Thoracic outlet synd. gt

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• Arm?? ???? brachial plexus? compress or impinge
  ??
• many structure? ??
• ?? ???? vascular structure? compress????
•  
• Pathology gt
• Cervical rib? ?? ?? source ?? x-ray? ??
• Last cervical vertebra ?? first rib? common
  cause of impingement
• ??, scalenes, subclavius, and pectoralis
  minor muscles?? ??
•  
• Symptomsgt
• Sx? ?? vascular or neurologic??? ?? ????
• shoulder position??? ????
• Neurologic symptoms numbness of medial forearm
  
• ulnar side
  of hand
• arching pain (arm and ant.
  chest)
• clumsiness or weakness in hands
  and fingers
• vascular symptoms coldness, aching muscles,
  loss of strength
• hand-pale or
  cyanotic with vascular compression

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• physical findingsgt
• ??? ulnar side of arm and hand? sensation?
  ??(affect )
• -gt whole hand and arm? sensory loss
• Adsons maneuver position change
• Loss of radial pulse and Sx ??
• Neurogenic Sx.? initially, median innervated
  hand muscles?
• weakness ??(cause)
• Later, ulnar innervated muscles
• Vascular compression ? loss of strength? ?????
  ???
• ??? hand muscle ??? ?? fatigue ??
•  
• Electrodiagnosisgt
• Medial antebrachial cutaneous sensory response
• ?Ulnar sensory response ??

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• Treatmentgt
• Shoulder posture? correction
• Rhomboid and trapezus muscles? ???? ??
• shoulder posture? ??
• Clavicle straps
• Surgery
• Surgical candidates? not clear
•  
• Risk factorsgt
• Poor shoulder posture
• Ex) professional musicians (string
  instruments)
• Nursing mothors
• Computer users
• Bony deformities clavicle Fx. cervical
  ribs, sloped shoulders

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• lt Meralgia Paresthetica gt

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• entrapment of lateral femoral cutaneous nerve of
  the thigh
• ????? meros-thigh
• Algo-pain
•  
• Pathologygt
• Thigh? lateral femoral cutaneous nerve?
  inguinal ligament? ?? ???? ?? trapped
•  
• Symptomsgt
• Unpleasant sensations and numbness in lateral
  thigh
• Walking, standing or lying flat? ??? ?????
•  
• Physical findingsgt
• Complete sensory

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• Electrodiagnosisgt
• ???? lateral femoral cutaneous nerve?
• sensory responses elicit? ????? ???
• Lumbar radiculopathy? ?? ??? ??? r/o? ??
•  
• Treatmentgt
• Medication pain control
• Risk factor? ???
• Surgical decompression? ???
•  
• Risk factorsgt
• Obesity, pregnancy, tight-fitting clothes

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• lt Tarsal Tunnel Synd. gt

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• Tarsal tunnel synd? two types
• Entrapment of deep peroneal nerve at ankle
  (anterior)
• Entrapment of posterior tibial nerves at
  ankle
•  
• Pathologygt
• Tarsal tunnel ankle bones? flexor
  retinaculum? ?? ??
• Ankle fx or sprain, arthritic change, arthritic
  changes,
• tenosynovitis or fluid
  collection? ?? ???
• Symptomsgt
• Burning
• ???, sole of foot? burning
•  
• Physical findingsgt
• Posterior tibial nerve 3 branches
• calcaneal, medial plantar, lateral plantar

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• Electrodiagnosisgt
• Nerve conduction (motor and sensory) slowly
•  
• Treatmentgt
• Anti-inflammatory medication tenosynovitis
  or arthritis
• Surgical decompression? ???
• Risk factorgt
• ankle trauma