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Symptom Scenario: Tingling

Symptom Scenario: Tingling. Tom Gamble and Jo Swallow 20/11/13. Common Mononeuropathies. Describe the presentation and causes of the following: Median nerve (carpal tunnel syndrome) Ulnar nerve Radial nerve Sciatic nerve Lateral cutaneous nerve Common peroneal nerve Tibial nerve

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Symptom Scenario: Tingling

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  1. Symptom Scenario: Tingling Tom Gamble and Jo Swallow 20/11/13

  2. Common Mononeuropathies Describe the presentation and causes of the following: • Median nerve (carpal tunnel syndrome) • Ulnar nerve • Radial nerve • Sciatic nerve • Lateral cutaneous nerve • Common peroneal nerve • Tibial nerve • Bell’s Palsy • Ramsay Hunt

  3. Split into pairs and discuss/research a mononeuropathy

  4. Radial nerve • The radial nerve may be damaged anywhere in its course. It is most commonly affected in the upper arm where it winds round the humerus • Finger and wrist drop are common, their severity depending upon the site of the lesion. • sensory loss on the dorsum of hand and forearm appropriate to the cutaneous distribution - see radial nerve anatomy

  5. Common peroneal nerve • terminal of the sciatic nerve, providing motor supply to the muscles of the anterior and lateral leg. • most commonly damaged nerve in the lower limb and traverses the lateral aspect of the head of the fibula. • foot drop • weakness of dorsiflexion and eversion of the foot • weakness of extensor hallucis longus • inversion and plantar flexion are normal • anaesthesia over the lower lateral part of the leg and dorsum of the foot; often with little or no sensory loss • all reflexes are intact - the ankle jerk is lost in a sciatic nerve lesion

  6. entrapment of the lateral cutaneous nerve of the thigh is named meralgia paraesthetica • Damage to the tibial nerve is uncommon. Most usually, there is paralysis of gastrocnemius which is easily tested by asking the patient to stand on tiptoe

  7. Ramsay hunt • The Ramsay Hunt Syndrome is characterised by sensorineural deafness, vertigo and facial paralysis following Herpes Zoster infection. The patient is usually elderly. ?Treatment • otalgia - pain in the ear and the mastoid region - often with few signs on examination • a vesicular eruption involving the external ear • facial paralysis, deafness and vertigo • ipsilateral loss of taste in the anterior two-thirds of tongue

  8. Mononeuritis multiplex is a condition which is characterised by multiple individual nerve palsies, for example an ulnar nerve palsy in one arm, a radial nerve palsy in the other arm, and an asymmetrical foot drop due to a lateral popliteal nerve lesion.

  9. Causes of polyneuropathy: • Metabolic: Diabetes; renal failure; hypothyroidism; hypoglycaemia; mitochondrial disorders • Inflammatory: Guilain Barre; sarcoid • Vasculitis: PAN; Rheumatoid arthritis; Wegener’s • Malignancy • Infection: Lyme disease; HIV; syphilis; leprosy • Vitamin deficiency (Vit B1,6,12 – alcoholism) • Drugs: alcohol; isoniazid; nitrofurantoin; phenytoin • Inherited porphyria; Charcot Marie Tooth

  10. Blood Tests for Polyneuropathy • Glucose; FBC; U&E; B12, TFTs +/- LFTs, autoimmune profile,syphilis serology

  11. Polyneuropathy • ?Motor – eg guillain – barre • ?sensory • Painful – eg diabetic, alcoholic, B12 defic Other, demyelenation, axonal

  12. Guillain-Barre • Guillain-Barre syndrome is an acute, inflammatory, postinfectious polyneuropathy. • A prodromal malaise with vomiting, headache, fever and limb pains is rapidly surmounted by a progressive and ascending paralysis. This can lead to respiratory dysfunction, and as such, the acute presentation can be a neurological emergency. • The incidence is 2 per 100 000 per year. • Usually within 3 wks of a viral illness • Muscle weakness evolves over 3-21 days. It may be generalised, proximal in distribution, or commence distally and ascend

  13. Treatment for Guillain-Barre syndrome is supportive. Early tracheostomy is indicated if there is progressive bulbar and respiratory weakness • Specific treatment for Guillain-Barre syndrome consists of high-dose intravenous immunoglobulin (IvIg) or plasma exchange

  14. Myasthenia Gravis • Myasthenia gravis is an acquired autoimmune disorder characterised by weakness, typically of the periocular, facial, bulbar, and girdle muscles. • serum IgG antibodies to acetylcholine receptors in the postsynaptic membrane of the neuromuscular junction. Classically, the muscles are easily fatigued. • It affects 5 people in every 100 000 • external ocular muscles - affected in over 90% of cases, and are the muscles first affected in 65% of cases; diplopia or ptosis, often asymmetrical, are typical • lower limbs are rarely affected

  15. Management of myasthenia gravis • oral anticholinesterase medication, e.g. pyridostigmine or neostigmine • thymectomy - required if there is a thymoma because of the risk of local infiltration • immunosuppression with corticosteroids +/- cytotoxic agents is also highly effective in inducing remission of disease

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