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Peripheral Neuropathy Clinical Management Course February 12, 2007

Peripheral Neuropathy Clinical Management Course February 12, 2007. Peter D. Donofrio, M.D. Professor of Neurology. What is Peripheral Neuropathy?. Common Mononeuropathies. Median at the Wrist (CTS) Ulnar at the Elbow (Tardy Ulnar Palsy) Peroneal Palsy at the Fibular Head.

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Peripheral Neuropathy Clinical Management Course February 12, 2007

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  1. Peripheral NeuropathyClinical Management CourseFebruary 12, 2007 Peter D. Donofrio, M.D. Professor of Neurology

  2. What is Peripheral Neuropathy?

  3. Common Mononeuropathies • Median at the Wrist (CTS) • Ulnar at the Elbow (Tardy Ulnar Palsy) • Peroneal Palsy at the Fibular Head

  4. Median NerveInnervation of the Hand and Sensory Loss Kopell, Thompson, 1963

  5. Carpal Tunnel SyndromeAtrophy of APB Muscle Dawson,Hallett, Millender, 1990

  6. Carpal Tunnel SyndromeX-Section View of Wrist Kopell, Thompson, 1963

  7. Ulnar NeuropathySensory Loss, Nerve Innervation Kopell, Thompson, 1963

  8. Ulnar NeuropathyClaw Hand Haymaker, Woodhall, 1953

  9. Common Peroneal InjuryRight Foot Drop and Sensory Loss Haymaker, Woodhall, 1953

  10. Length Dependent Motor and Sensory Polyneuropathy Schaumburg 1983

  11. Peripheral NeuropathyEtiologies • Diabetes mellitus • Alcohol Abuse • Nutritional: Deficiency of B1, B6, B6, B12, malabsorption syndromes • Uremia • Vasculitis • Genetic/Inherited • Inflammatory • Toxic • Industrial agents • Therapeutic agents

  12. DiabetesCompelling Facts • 7-8 % of U.S. population (23.6 million) • 8.9 million unaware of diagnosis • Total annual economic cost (1997) $98 billion • $44 billion direct medical and treatment • $54 billion indirect costs (disability and mortality) • 7th leading cause of death • High prevalence in Afro-Americans, Hispanics, Native Americans

  13. Diabetic NeuropathyPrevalence • >60% of diabetics-signs/electrodiagnostic evidence of polyneuropathy (depressed ankle reflexes, absent or diminished distal nerve amplitudes) • 25%- neuropathic pain which can be severely disabling • Majority of Type II diabetics are symptomatic or have signs of neuropathy at diagnosis

  14. Diabetic NeuropathyInsensate Foot

  15. Charcot-Marie-Tooth Disease

  16. Charcot-Marie-Tooth Disease

  17. PolyneuropathyB12 (Cobalamin) deficiency • Neurologic manifestations: • Large-fiber sensory loss • Corticospinal tract involvement • EMG reveals a polyneuropathy • Serum levels of B12 below 100 pg/ml diagnostic, between 100 and 200 pg/ml suggestive • Elevated methylmalonic acid level more sensitive than B12 level. • Shilling’s test rarely done anymore • Treatment may not reverse all symptoms

  18. Guillain-Barre(-Strohl) SyndromeClinical Features • Ascending, symmetric, subacute (days) polyneuropathy-weakness/paresthesias • About 1/3 require mechanical ventilation • Parainfectious: C. jejuni, M. pneumoniae, CMV, EBV, HIV, Hep A, others • Loss of DTRs • CSF: albumino-cytologic dissociation • Treatment: supportive, PEx, IVIG

  19. Diagnostic CriteriaTypical Guillain-Barré Syndrome • Clinical features: • Weakness that is approximately symmetric in all the limbs • Paresthesias in the feet and hands • Areflexia or hyporeflexia in all limbs by 1 week • Progression of the these three features over several days to 1 month • Laboratory abnormalities that confirm the diagnosis: • Elevated CSF protein concentration (more than 45 mg/dL) within 3 weeks from onset • Abnormalities on electrophysiologic studies

  20. PolyneuropathyInitial Evaluation • CBC • Comprehensive Metabolic Profile • Fasting blood sugar • Glucose tolerance test (if needed) • Vitamin B12 • ESR • SPEP • Nerve Conduction Studies and EMG

  21. Motor Nerve Conductions Nerve Conduction Velocity = Distance (mm)/ time difference (ms)

  22. Summary • Definition of Peripheral Neuropathy • Common Mononeuropathies • Polyneuropathy-emphasis on diabetes • Evaluation of polyneuropathy • Nerve conduction studies.

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