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Peripheral Nerve Diseases

Peripheral Nerve Diseases. Prof. Dr. Ece AYDOĞ Physical Medicine and Rehabilitation. Learning objectives :. be able to define parts of peripheral nervous system be able to describe injuries in the peripheral nervous system ( neuropraxia , aksonotmezis , nörotmezis ,)

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Peripheral Nerve Diseases

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  1. Peripheral Nerve Diseases Prof. Dr. Ece AYDOĞ PhysicalMedicineandRehabilitation

  2. Learning objectives: • be ableto define parts of peripheralnervoussystem • be abletodescribeinjuries in theperipheralnervoussystem (neuropraxia, aksonotmezis, nörotmezis,) • be abletodescribeclinicalsigns of peripheralneuropathy (somaticandautonomic) • be abletoclassifyperipheralneuropathyaccordingtothecauses • 5.5 be abletodescribediagnosis, pharmacologicalandnonpharmacologicaltreatmentapproachesforperipheralneuropathy.

  3. Peripheral Nervous System (PNS) • The function of the PNS is to carry impulses to and from to central nervous system • These impulses regulate motor, sensory and automotic activities • The peripheral nervous system is comprised of structures which lie outside the pial membrane of the brainstem and spinal cord and can be divided into cranial, spinal and autonomic componenets.

  4. The structure of the NERVE CELL and AXON

  5. Peripheral Nervous System

  6. 􀁻 Endoneurium – loose connective tissue that surrounds axons 􀁺 Perineurium– coarse connective tissue that bundles fibers into fascicles 􀁺 Epineurium– tough fibrous sheath around a nerve Structure of a Peripheral Nerve

  7. PNS in the Nervous System

  8. Receptor Classification byStimulus Type 􀁻 Mechanoreceptors– respond to touch, pressure, vibration, stretch, and itch 􀁻 Thermoreceptors– sensitive to changes in temperature 􀁻 Photoreceptors– respond to light energy (e.g., retina) 􀁻 Chemoreceptors– respond to chemicals (e.g., smell, taste, changes in blood chemistry) 􀁻 Nociceptors– sensitive to pain causing stimuli

  9. The somatic system consists of • 12 pairs of cranial nerves • 31 pairs of spinal nerves: • 8 cervical (C1-C8) • 12 thoracic (T1-T12) • 5 Lumbar (L1-L5) • 5 Sacral (S1-S5) • 1 Coccygeal (C0)

  10. Spinal Nerves: Roots 􀁻 Each spinal nerve connects to the spinal cord via two medial roots 􀁻 Ventral rootsarise from the anterior horn and contain motor (efferent) fibers 􀁻 Dorsal rootsarise from sensory neurons in the dorsal root ganglion and contain sensory (afferent) fibers

  11. Nerve Plexuses • All ventral rami except T2-T12 form interlacing nerve networks called plexuses • Plexuses are found in the cervical, brachial, lumbar, andsacralregions • Each resulting branch of a plexus contains fibers from several spinal nerves • Each muscle receives a nerve supply from more than one spinal nerve • Damage to one spinal segment cannot completely paralyze a muscle

  12. Brachial Plexus • Formed by C5-C8 and T1 (C4 and T2 may also contribute to this plexus) • It gives rise to the nerves that innervate the upper limb

  13. Arises from L1-L4 and innervates the thigh, abdominal wall, and psoas muscle The major nerves are the Femoral nerves for anterior thigh muscles Obturator nerves for adductors muscles Lumbar Plexus

  14. Sacral Plexus • Arises from L4-S4 and serves the buttock, lower limb, pelvic structures, and the perineum (pudendal nerve) • The major nerve is the sciatic, the longest and thickest nerve of the body • tibial • common fibular (peroneal)

  15. A dermatome is the area of skin innervated by the cutaneous branches of a single spinal nerve All spinal nerves except C1 participate in dermatomes Dermatomes

  16. Pathologies of peripheral nerves Nerves (Seddon and Sunderland Classification) • Neurapraxia • Axonotmesis • Neurotmesis

  17. Total conduction failure (neurapraxia) No function Recovers spontaneously over days or weeks (when the cause is resolved) Results of spontaneous recovery are almost always good

  18. Neurapraxia

  19. Interruption of axons (axonotmesis) No function New axon grows from cell body (spontaneously)

  20. Axonotmesis Nerve may regenerate from injured location away from the cell body Regeneration: 1 mm per day (approx. 1 inch per month) Results of spontaneous recovery are good to moderate depending on distance

  21. Axonotmesis Type 2 Neurotmesis Type 3 Type 4 Type 5

  22. Interruption of nerve trunk (neurotmesis) • No function • Does not regenerate spontaneously • Irreversible, grafting is required

  23. Axonotmesis Type 2 Neurotmesis Type 3 Type 4 Type 5

  24. Peripheral NeuropathyMode of Onset • Acute • Subacute • Chronic

  25. Peripheral Neuropathy Acute: (A few days-4 weeks) • Guillain-Barre Syndrome (GBS) • Traumatic • Vasculitis • Herpes Zoster • Diphtheria • Porphyria • Toxic (Thallium)

  26. Peripheral Neuropathy Sub-acute: (Devolop over weeks) • Symmetric..Sensory-motor Toxic Nutritional (Alcohol) Paraneoplastic (Sensory neuronopathy) • Asymmetric...Motor-sensory Vasculitis Diabetic amyotrophy

  27. Peripheral Neuropathy Chronic:(Devolop over months, years) 1-Acquired • Diabetic distal sensory neuropathy • Leprosy • Autoimmune neuropathies • Para-Neoplastic • Others ( uremia….)

  28. Peripheral Neuropathy 2-Hereditary • HMSN ( Charcot-Marie-Tooth ) • Refsum’s disease • Hypertrophic polyneuropathy (Dejerine-Sottas disease)

  29. Causes 1. Nutritional, metabolic and toxic neuropathies; the most common causes are diabetes mellitus and alcoholism • Vitamin deficiencies, • Renal failure, • Chronic liver disease, • Drugs (e.g. vincristine), • Heavy metals, • Toxins (e.g. diptheria), • Chemicals (e.g. Hexane, glue) Diabetes - distal symmetric, autonomic and focal or multifocal asymmetric presentations

  30. 2-Inflammatory neuropathies • Infectious - shingles (VZV), leprosy • Vasculitic - polyarteritis, SLE • Guillain-Barré • Chronic inflammatory demyelinating polyradiculopathy

  31. 3. Hereditary neuropathies • Hereditary sensory, motor and autonomic neuropathies • Leukodystrophies • Porphyria

  32. 4. Miscellaneous neuropathies • Amyloid • Paraneoplastic • Compression

  33. Mononeuropathies • Median nerve- Carpal tunnel Syndrome • Ulnar nerve-Cubital tunnel syndrome • Radial nerve- Spiral oluk tuzak Posterior interosseous neuropathy • Toracicus longus nerve-Serratus anterior Winging scapula • Common Peroneal nerve-Fibula head • Lateral femoral cutaneous nerve-Meralgia paresthetica • Tibial nerve-Tarsal tunnel syndrome

  34. Plexopathies • Brachial plexus-Erb palsy, Klumpke palsy, Personage-Turner syndrome (idiopathic brachial neuritis) • Lumbosacral plexus

  35. Polyneuropathies Diabetic neuropathies • Polyneuropathy (Sensory loss and distal weakness) • Autonomic neuropathy (Postural hypotension, impotence, nocturnal diarrhoea) • Mononeuropathy (Diabetic amytrophy)

  36. Polyneuropathies • Guillain-Barre Syndrome (GBS): Acute inflammatory demyelination polyradiculopathy

  37. Peripheral NeuropathySymptomatology-Motor Weakness: • Lower motor-neuron type • hypotonia & hyporeflexia • fasiculation • wasting (chronic) • distal distribution

  38. Peripheral NeuropathySymptomatology-Motor Wasting & Deformities: Chronic > 3 months duration Kypho-scoliosis Pes cavus – Clawing of hands & feet Hereditary Motor-Sensory Neuropathy

  39. Peripheral NeuropathySymptomatology-Sensory Sensory Changes: Hyposthesia Parastheasia Dysthesia Allodynia Hyperalgesia

  40. Peripheral NeuropathySymptomatology-Sensory Distribution of sensory changes: gloves & stocking root or nerve distribution

  41. Peripheral NeuropathySymptomatology-Autonomic Autonomic manifestations: • Anhydrosis • Postural Hypotension • Bladder Atonia…incontinence • Gut Atonia….diarrhea • Sexual dysfunction

  42. History • Time course (acute, subacute,chronic, episodic) • Negative: numbness • Postive: tingling, pain • Weakness and loss of function • Balance • Postural dizziness • DM • Medication • Social, toxins, diet • Family history

  43. Examination/Evaluation • Observation of skin color, integrity, temperature • Presence of pressurepointsorulceration • Strengthtesting • ROM/flexibilitytesting • Neurologicaltesting • Reflexes • Sensation • Proprioception • Balance/coordination • Footwearassessment

  44. Diagnosis A strong clinical suspicion will suffice to make a clinical diagnosis. To support the diagnosis some investigatios are necessary these include: • Electromyography • Nerve biopsy • Nerve conduction studies • Magnetic resonance imaging • Computed tomography

  45. Special InvestigationNerve conduction studies • Motor conduction velocity • Sensory conduction velocity Demyelination: Marked slowing of conduction velocity (30% at least reduced) with progressive reduction of amplitude. Axonal change: Reduced amplitude or absence of response to stimulation with mild slowing of conduction velocity Localized compression of nerve: Slowing conduction in region of block e.g. Over the elbow when ulnar nerve is compressed there.

  46. Special InvestigationElectromyography (EMG) • A fine needle is inserted into the muscle and the recorded activity displayed on an oscilloscope. • Primarily of value in muscle disease but can also give indirect evidence of a neropathic process. • If chronic denervation has occured, re-innervation may be present with long duration high amplitude motor unit potentials.

  47. Special InvestigationNerve biopsy • In neuropathies of uncertain cause, light and electron microscopy examination occasionally help diagnosis. • The sural nerve is usually chosen for biopsy.

  48. Treatment Non pharmacological • Patient education • Maintaining optional weight • Avoiding exposure to toxins • Eating a balanced diet • Correcting nutritional deficiencies • Avoiding alchohol consumption • Exercise • Quitting smoking

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