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Sensory

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Charcot foot = xerosis, venous distension, ... Foot ulceration and amputation are the most common consequences ... Daily foot exam by patient is essential ... – PowerPoint PPT presentation

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Title: Sensory


1
Sensory Peripheral Neuropathies
  • Steve Sager, MPAS, PA-C

2
Learning Objectives
  • List common neuropathies
  • List the common toxins which produce neuropathies
  • Discuss the etiologies of common neuropathies
  • Differentiate between common neuropathies
  • Discuss the symptoms, signs, and treatments
  • Diabetic neuropathies
  • Alcoholic neuropathies
  • Uremic neuropathies
  • Autonomic neuropathies

3
Harrisons on Neuropathies
  • The manifestations of such a disorder may be so
    bewildering and complex that it is difficult for
    a physician to know where to begin or how to
    proceed.

4
General Information
  • More than 100 types of peripheral neuropathy have
    been identified
  • Each has its own characteristic set of symptoms,
    pattern of development, and prognosis
  • May involve sensory, motor, and/or autonomic
    nerves
  • A thorough patient history is critical

5
Common Neuropathies
  • Trigeminal neuralgia (tic douloureux)
  • Postherpetic neuralgia
  • Carpal Tunnel Syndrome
  • Sciatica
  • Guillain-Barré syndrome
  • Peroneal Muscular Atrophy
  • Diabetic Neuropathy Syndromes
  • Alcoholic Neuropathy
  • Uremic Neuropathy

6
Etiology of Neuropathies
  • Peripheral neuropathy may be
  • Inherited (C-M-T disease)
  • Acquired
  • Diabetes mellitus is a leading cause of
    peripheral neuropathy in the United States
  • 60-70 of people with diabetes have mild to
    severe forms of nervous system damage.
  • Neuropathies with no apparent cause are termed
    idiopathic

7
Etiology of Neuropathies
  • Causes of acquired peripheral neuropathy include
  • Physical injury (trauma) to a nerve
  • Tumors (neurofibromatoses)
  • Toxins
  • Heavy metals
  • Medications
  • Infections
  • Viral - HIV, EBV, HSV, CMV
  • Bacterial Lyme disease

8
Etiology of Neuropathies
  • Causes of acquired peripheral neuropathy include
  • Kidney disease
  • Autoimmune disease
  • Nutritional deficiencies
  • Vitamins E, B1, B6, B12, and niacin
  • Alcoholism
  • Thiamine deficiency
  • Vascular, metabolic, and endocrine disorders

9
Symptoms of Peripheral Neuropathies
  • Symptoms are related to the type of affected
    nerve and may be seen over a period of days,
    weeks, or years
  • Muscle weakness is the most common symptom of
    motor nerve damage
  • Sensory nerve damage causes a more complex range
    of symptoms because sensory nerves have a wider,
    more highly specialized range of functions

10
Symptoms of Peripheral Neuropathies
  • Sxs of autonomic nerve damage are diverse and
    depend upon the affected organs/glands
  • Autonomic nerve dysfunction can become life
    threatening and may require emergency medical
    care in cases when breathing becomes impaired or
    when the heart begins beating irregularly
  • Common symptoms of autonomic nerve damage
    include
  • unable to digest food easily
  • an inability to sweat normally, which may lead to
    heat intolerance
  • a loss of bladder control, which may cause
    infection or incontinence
  • an inability to control muscles that expand or
    contract blood vessels to maintain safe blood
    pressure levels
  • organ failure may occur.

11
Symptoms of Peripheral Neuropathies
  • Because every peripheral nerve has a highly
    specialized function in a specific part of the
    body, a wide array of symptoms can occur when
    nerves are damaged
  • Temporary numbness
  • Tingling/pricking sensations (paresthesia)
  • Sensitivity to touch
  • Burning pain (especially at night)
  • Muscle wasting
  • Paralysis
  • Organ or gland dysfunction

12
Symptoms of Peripheral Neuropathies
13
Radiculopathies
  • Cervical due to stenosis or HNP
  • Sensory sxs
  • Neck, shoulder, or scapular pain increases with
    movement
  • Motor sxs
  • Loss of reflex based on nerve root involved
  • Lumbosacral onset after heavy lifting
  • Sensory sxs
  • Pain in lower back, hip or buttocks /- radiation
  • Increases with prolonged sitting, coughing,
    sneezing or straining
  • HNP is generally unilateral
  • Spondylolysis/spondylolithesis typically presents
    with bilateral sxs
  • Motor sxs
  • Loss of reflex
  • Dx/Tx X-rays, CT/MRI, NSAIDs, bed rest, traction

14
Toxic Neuropathies (ICD 357.7)
  • Organophosphates
  • Toxins/Heavy metals
  • Lead
  • Arsenic
  • Chronic uremia
  • Due to excessive levels of parathormone
  • Medications (ICD 357.6)
  • Antimetabolic/ChemoTx

15
Diabetic Polyneuropathies (ICD 357.2)
  • Diabetes affects 6 of the population
  • Vascular and neurological complications are the
    most common causes of morbidity mortality
  • Neuropathy affects 25-50
  • Directly related to the length of time that nerve
    fibers are exposed to hyperglycemia
  • Mixed polyneuropathy
  • Usually affects motor, sensory autonomic

16
Diabetic Neuropathy Syndromes
  • Glucose becomes incorporated into proteins
  • AGEs are formed (irreversible)
  • Reactive oxidants are produced
  • Cause damage to collagen structure, basement
    membrane thickening, increased inflammatory
    responses and vascular permeability

17
Diabetic Neuropathy Syndromes
  • Two types
  • Peripheral
  • Focal
  • Mononeuropathy affecting PNS or CNs
  • Generalized
  • Symmetric, peripheral, sensory polyneuropathy
  • Insidious and progressive
  • Autonomic
  • May result in erectile dysfunction, gastropathy,
    or hypoglycemia
  • Cardiovascular complications
  • Orthostatic hypotension
  • Myocardial infarction
  • Malignant arrhythmia
  • Sudden death

18
Diabetic Neuropathy Syndromes
  • Focal or multifocal
  • Occur secondary to vasculitis/ischemia
  • Acute onset of pain
  • Resolves spontaneously lt6 weeks
  • May involve
  • CN III, IV, VI, VII
  • Ulnar or median nerve
  • Peroneal, sural, sciatic, or femoral nerve
  • Amyotrophy of proximal thigh muscles
  • Diabetic truncal radiculoneuropathy

19
Diabetic Neuropathy Syndromes
  • Can be detected during a routine exam
  • Inspect feet for deformities and sensory loss
  • Loss of ankle reflexes
  • Loss of Hot/Cold sensation
  • Loss of vibratory sense
  • 128Hz tuning fork to hallux
  • Monofilament test
  • Use 10 gauge monofilament
  • Charcot foot xerosis, venous distension,
    multiple
  • bony deformities
  • EMG and NCS confirm the diagnosis

20
Monofilament Test
  • There is a risk of ulcer formation if the patient
    is unable to feel the monofilament when it is
    pressed against the foot with just enough
    pressure to bend the filament
  • The patient is asked to say "yes" each time he or
    she feels the filament
  • Failure to feel the filament at four of 10 sites
    is 97 percent sensitive and 83 percent specific
    for identifying loss of protective sensation

21
Diabetic Mononeuropathies
  • CN III or CN VI are commonly affected
  • NOT associated with pupillary abnormalities
  • CTS (median neuropathy)
  • Occurs in 6 of diabetics
  • Acute onset of painful paresthesias in fingers
    with radiating ache to forearm
  • Worse HS
  • Motor weakness is progressive with thenar wasting
  • Positive Phalen test and/or Tinel sign

22
Diabetic Autonomic Neuropathy
  • GI-related
  • Characterized by gastroparesis, nausea/emesis and
    diarrhea
  • Improve overall glycemic control
  • /- improvement of GI sxs with Metoclopramide
  • Tx diarrhea with Clonidine QD (/- TCN)
  • GU-related
  • Characterized by impotence, impaired sensation to
    voiding, and retrograde ejaculation

23
Treatment of Diabetic Neuropathy Syndromes
  • Improved metabolic control is the main goal of
    treatment
  • Control lipids
  • Manage HTN (ACE inhibitors)
  • Lifestyle intervention
  • Intensive insulin therapy
  • 3-4 injections QD or an insulin pump reduced
    electrophysiologic evidence by up to 64
  • ASA
  • Magnesium oxide 250-750mg HS

24
Treatment of Diabetic Neuropathy Syndromes
  • Analgesics
  • Tramadol
  • Neuromodulators
  • Gabapentin
  • Carbamazepine (Tegretol)
  • Capsaicin
  • Tx neuropathic pain rub in for 5 minutes BID
  • TCAs
  • Daily foot exam by patient!!!
  • Use mirrors
  • Annual PCP examination is required

25
Diabetic Autonomic Neuropathy
  • Avoid medications that can cause syncope
  • Alpha-blockers, anti-HTN, antidepressants
  • Frequent accuchecks
  • Maintain adequate hydration
  • Minimize cardiac-related AN
  • Monitor for orthostatic hypotension
  • Increased risk of sudden death/silent ischemia
  • Improve mgmt of glucose, lipids, and HTN
  • Use ACE inhibitors

26
Diabetic Neuropathy Syndromes
  • Foot ulceration and amputation are the most
    common consequences
  • Risk factors for amputation
  • Poor glycemic control
  • Alcohol abuse
  • Obesity
  • Loss of protective sensation
  • Altered biomechanics/foot deformities
  • Diagnosis gt10 years
  • Gender
  • Peripheral vascular disease

27
Neuropathy Disability Score
28
Alcoholic Polyneuropathy (ICD 357.5)
  • Establish Dx of alcohol abuse
  • Preoccupation
  • Increased tolerance
  • Drinking alone
  • Use as a medication
  • Blackouts
  • Physical/Social/Family issue
  • CAGE questionnaire
  • ? Vitamin deficiency

29
Alcoholic Polyneuropathy
  • Wernicke-Korsakoff syndrome
  • CNS injury related to thiamine deficiency
  • Nystagmus, ataxia, confusion, EOM paralysis
  • Peripheral polyneuropathy
  • Earliest symptom of chronic alcoholism
  • Mostly sensory with /- motor involvement
  • Burning sensation in feet
  • Dementia due to cerebral atrophy
  • Cerebellar degeneration truncal ataxia
  • Myopathy proximal muscle wasting
  • Hepatic encephalopathy
  • Altered consciousness/lethargy
  • Ataxia/dysarthria/asterixis

30
Alcoholic Polyneuropathy
  • Delirium Tremens (DTs)
  • Alcohol withdrawal syndrome
  • Occurs 72-96 hours after cessation
  • Often fatal
  • Similar to withdrawal from barbiturates/benzos
  • Mild tremors seizures
  • Jittery and easily startled
  • Hallucinations
  • Autonomic hyperactivity

31
Alcoholic Polyneuropathy
  • Seizures are common
  • Generalized (Rum fits)
  • Occur 12-48 hours after decreased ETOH intake
  • Focal
  • Occur during periods of intoxication
  • Tx
  • Supportive (diet, vitamins, etc.)
  • Librium
  • Diazepam
  • Thiamine (50mg IV and 50mg IM QD)

32
Uremic Neuropathy (Uremia) (ICD 357.4)
  • Presents with altered mental status
  • Variable
  • Irritability
  • Difficulty concentrating
  • Psychosis
  • May have convulsions
  • Secondary to acidosis, hypokalemia, hyponatremia
  • Often occurs postdialysis/postdiuresis
  • Most patients with BUNgt60 have EEG changes
  • R/O infection and subdural hematoma

33
Uremic Neuropathy
  • Additional (late) symptoms
  • Peripheral neuropathy
  • Restless leg syndrome
  • Burning paresthesias of the feet
  • Sensory loss in digits
  • Asterixis
  • Fasciculations
  • Myoclonus
  • Muscle cramps
  • Amaurosis
  • Cerebral emboli
  • Dementia

34
Autonomic Neuropathies
  • Parasympathetic neuropathies typically involve
    the cranial nerves or sacral nerves
  • Sympathetic neuropathies involve the medulla
    oblongata, spinal cord, or sympathetic ganglia
  • Both involve receptors in the smooth muscles and
    glands

35
Clinical Manifestations of Autonomic Neuropathies
  • Sudden death
  • Tremors
  • Hyperthermia
  • Altered sweating
  • Tachycardia
  • Orthostatic hypotension
  • Syncope
  • Gastroparesis
  • GU dysfunction

36
Conditions Associated with Autonomic Neuropathies
  • Poisoning
  • Atropine
  • Anticholinesterase inhibitors
  • Horners syndrome
  • Oculosympathetic paralysis
  • Ptosis
  • Miosis
  • Anhidrosis
  • Shy-Dragger syndrome
  • Progressive autonomic failure
  • Multiple system atrophy
  • Progressive and fatal

37
Conditions Associated with Autonomic Neuropathies
  • Pheochromocytoma
  • Tumors arising from chromaffin cells in the
    sympathetic nervous system
  • Release Epinephrine and NE into circulation
  • Cause autonomic hyperactivity
  • Paroxysmal hypertension
  • Diaphoresis
  • Flushing
  • Tachycardia
  • Anxiety
  • Test blood/urine for catecholamines,
    metanephrines and vanillylmandelic acid (VMA)

38
Assessment of Possible Autonomic Neuropathies
  • Orthostatic VS
  • ECG
  • Look for R-R variability
  • Tilt test
  • Cold pressor test
  • Sweat provocation

39
Treatment of Neuropathies
  • Several classes of drugs have recently proved
    helpful to many patients suffering from more
    severe forms of chronic neuropathic pain
  • Antiepileptic drugs
  • Phenytoin (Dilantin)
  • Carbamazepine (Tegretol)
  • Some classes of antidepressants (Tricyclics)
  • Gabapentin (Neurontin)
  • Mexiletine (Mexitil)
  • developed to correct irregular heart rhythms
  • sometimes associated with severe side effects

40
Treatment of Neuropathies
  • Neuropathic pain is often difficult to control
  • Use smallest effective dose and titrate
  • Mild pain may sometimes be alleviated by OTC
    analgesics
  • Limit narcotic use
  • Corticosteroids may help reduce inflammation
  • Injections of local anesthetics such as lidocaine
    or topical patches containing lidocaine may
    relieve more intractable pain
  • In the most severe cases, doctors can surgically
    destroy nerves
  • The results are often temporary and the procedure
    can lead to complications.

41
Information Resources
  • Neuropathy Association 60 East 42nd Street Suite
    942 New York, NY   10165-0999 http//www.neuropath
    y.org Tel 212-692-0662 800-247-6968 Fax
    212-692-0668
  • National Chronic Pain Outreach Association
    (NCPOA) P.O. Box 274 Millboro, VA  
    24460 http//www.chronicpain.org Tel
    540-862-9437 Fax 540-862-9485
  • American Chronic Pain Association (ACPA) P.O. Box
    850 Rocklin, CA   95677-0850 http//www.theacpa.or
    g Tel 916-632-0922 800-533-3231 Fax 916-632-3208

42
Information Resources
  • Charcot-Marie-Tooth Association (CMTA) 2700
    Chestnut Parkway Chester, PA   19013-4867 http//w
    ww.charcot-marie-tooth.org Tel 610-499-9264
    800-606-CMTA (2682) Fax 610-499-7267
  • American Pain Foundation 201 North Charles
    Street Suite 710 Baltimore, MD  
    21201-4111 http//www.painfoundation.org Tel
    888-615-PAIN (7246) 410-783-7292 Fax
    410-385-1832
  • National Foundation for the Treatment of
    Pain P.O. Box 70045 Houston, TX  
    77270 http//www.paincare.org Tel
    713-862-9332 Fax 713-862-9346

43
Summary
  • List common neuropathies
  • Etiologies of common neuropathies
  • Differentiate between common neuropathies
  • Discuss treatment options for common neuropathies
  • List the common toxins which produce neuropathies
  • Symptoms, signs, and treatments of
  • Guillain-Barré syndrome
  • Peroneal Muscular Atrophy
  • Diabetic neuropathies
  • Alcoholic neuropathies
  • Uremic neuropathies
  • Autonomic neuropathies

44
Summary
  • Diabetes mellitus is a leading cause of
    peripheral neuropathy in the United States
  • Diabetic Neuropathy Syndromes
  • Vascular and neurological complications are the
    most common causes of morbidity mortality
  • Foot ulceration and amputation are the most
    common consequences
  • CTS (median neuropathy) occurs in 6
  • Improved metabolic control is the main goal of
    treatment
  • Daily foot exam by patient is essential

45
Summary
  • Alcoholic Neuropathy
  • Peripheral polyneuropathy is the earliest symptom
    of chronic alcoholism
  • Wernicke-Korsakoff syndrome results from CNS
    injury related to thiamine deficiency
  • Seizures are common
  • Uremic Neuropathy
  • Presents with altered mental status
  • Often occurs postdialysis/postdiuresis

46
Summary
  • Autonomic neuropathies affect receptors in the
    smooth muscles and glands
  • Clinical manifestations of autonomic neuropathies
    include sudden death, hyperthermia, altered
    sweating, orthostatic hypotension, and
    gastroparesis
  • Neuropathic pain is difficult to control
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