Peripheral Nerve Disease
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Contents |
More Specific Terms
- brachial plexus neuropathy (Parsonage-Turner syndrome)
- chronic idiopathic ataxic neuropathy
- chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
- cranial nerve palsy (cranial neuropathy)
- diabetic polyneuropathy
- entrapment neuropathy; nerve entrapment syndrome; pinched nerve
- facial nerve disorder
- glossopharyngeal neuralgia
- Guillain-Barre syndrome (GBS)
- inflammatory demyelinating polyneuropathy
- mental neuropathy
- mononeuritis multiplex
- multifocal motor neuropathy
- nerve injury
- occipital neuralgia
- plexopathy
- Poems syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, & Skin changes); Crow-Fukase syndrome
- polyneuropathy
- post Herpetic neuralgia
- pyridoxine neuropathy
- radiculopathy
Classification
- symmetrical distal polyneuropathy
- focal or mononeuropathy
- proximal sensorimotor neuropathy
Etiology
- axonal neuropathies
- diabetes mellitus
- alcohol & other toxins
- vitamin B12 deficiency
- paraneoplastic syndromes
- hereditary, type II
- dysproteinemias & paraproteinemias
- pharmacologic agents (several, see selection)
- segmental demyelination
- diabetes mellitus
- Guillain-Barre syndrome
- chronic inflammatory polyradiculopathy
- dysproteinemia & paraproteinemia
- hereditary, type I
- pharmacologic agents (several, see selection)
- focal & multifocal neuropathies
- diabetes mellitus
- entrapment
- vasculitis
- infection
- herpes zoster
- Lyme disease ( Borrelia burgdorferi)
- acquired immune deficiency syndrome ( AIDS)
- leprosy
- sensory neuropathy
- small fiber neuropathy
- impaired glucose tolerance
- Sjogren syndrome
- familial burning feet syndrome
- acquired sensorimotor neuropathy
- diabetes mellitus
- monoglonal gammopathy
- chemotherapy
- hereditary sensorimotor neuropathy
- polyradiculopathy
- motor neuropathy
- multifocal motor neuropathy
- motoneuron disease
Pathology
- disorder of axons vs disorder of neurons ( neuronopathy)
Clinical-manifestations
- paresthesias
- tingling
- itching
- numbness
- burning
- electrical sensation
- muscle cramps
- pain
- foot ulcers & deformity
- decreased sense of vibration
- muscle weakness/ foot drop
- skin dryness/ hair loss
- decreased stretch reflexes ( deep tendon reflexes)
- decreased sense of pain & temperature
- decreased sense of touch & pressure
Laboratory
Diagnostic-procedures
-
- axonal neuropathies
- nerve conduction is normal or slightly reduced
- electromyography shows muscle denervation
- demyelinating neuropathies
- nerve conduction is slowed
- electromyography reveals no muscle denervation
- combined axonal & demyelinating neuropathies are common
- 3 mm punch biopsy may reveal small fiber neuropathy [4]
- distal calf biopsy for nerve conduction study-negative neuropathic feet
Radiology
Management
-
- avoid benzodiazepines: they lower pain threshold
- analgesics:
- aspirin
- acetaminophen
- non-steroidal anti-inflammatory agents ( NSAIDs)
- opiates - morphine in combination with gabapentin [5]
- amitriptyline
- nortriptyline
- may be used in conjunction with fluphenazine ( Prolixin)
- often effective at lower doses than those used for treatment of depression
- paroxetine ( Paxil)
- fluoxetine ( Prozac)
- clonidine ( Catapres)
- clonazepam ( Klonopin)
- gabapentin ( Neurontin), pregabalin
- mexiletine 200-400 mg PO TID
- capsaicin (topical) applied several times/day
- physical measures:
- warm baths; b) ; c) appropriate clothing
- control of diabetes
- workup for occult malignancy if no cause found
- patient education
- symptoms usually improve with time
- symptoms sometimes appear to worsen as nerves begin to repair themselves & recover functionality
- placebo effects
- pregabalin & placebo significantly & equally effective in HIV-related neuropathy [8]
More General Terms
Additional Terms
- age-associated changes in the peripheral nervous system
- nerve conduction study (NCS); electroneuronography
- peripheral nerve
- peripheral nervous system
- pharmaceutical agents causing peripheral neuropathy
References
- Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1046-47
- Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
- Journal Watch 25(9):74, 2005 Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med. 2005 Mar 31;352(13):1324-34. PMID: [1]
- Journal Watch, Mass Med Soc 20(1):11 (Jan 1) 2000
- England JD et al Practice Parameter: evaluation of distal symmetric polyneuropathy: role of laboratory and genetic testing (an evidence-based review). Neurology 2009 Jan 13;72(2):185-92 PMID: [2]
- England JD et al Practice Parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Neurology 2009 Jan 13;72(2):177-84 PMID: [3]
- Simpson DM et al. Pregabalin for painful HIV neuropathy: A randomized, double-blind, placebo-controlled trial. Neurology 2010 Feb 2; 74:413. PMID: [4]
- NINDS Peripheral Neuropathy Information Page [5]
- Peripheral Neuropathy Fact Sheet [6] - National Guideline Clearinghouse Guideline for management of wounds in patients with lower- extremity neuropathic disease. ngc-guideline: [7]
- EFNS guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy. European Federation of Neurological Societies ngc-guideline: [8]
- Practice parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). American Academy of Neurology ngc-guideline: [9]
- Practice parameter: evaluation of distal symmetric polyneuropathy: role of laboratory and genetic testing (an evidence-based review). American Academy of Neurology ngc-guideline: [10]
- Practice advisory for the prevention of perioperative peripheral neuropathies. An updated report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. ngc-guideline: [11]
