Neuropathies

Question 1

Carpal tunnel Syndrome

S/Sx
Nerve affected?

Answer 1

Pain, burning, tingling and numbness to fingers in median nerve distribution
Typically increases with activity
Often report shaking the hand to help with symptoms
Weakness with more severe disease

Question 2

Carpal tunnel

PE
Signs

Answer 2

Diminished sensation to 1st-3rd fingers and radial half of 4th finger
Poor grip strength; thenar atrophy (late)

+Tinel sign- reproduction of symptoms with nerve percussion

+Phalen sign- reproduction of symptoms with flexing wrist to 90degrees for 60 sec

Question 3

carpal tunnel

Dx

Answer 3

Ultrasound may show flattening of nerve

Best test is EMG/NCV (electromyography/ nerve conduction velocity)- will give you a yes/no AND will give severity of disease (mild, moderate, severe)

Question 4

carpal tunnel

Tx

Answer 4

Relieve pressure on the nerve
Splint in neutral position
Reduce repetitive activity
PT for modalities and tendon glide exercises
NSAIDs or oral steroids
Steroid injection
Surgical release (endoscopic or open)

Question 5

Carpal tunnel

who is often affected? recovery? people with CT often have high rate of?

Answer 5

Often occurs in pregnancy
Odds of full recovery diminish with thenar atrophy
People with these diseases have high rate of CTS:
RA, myxedema, amyloidosis, sarcoidosis, leukemia, acromegaly, and hyperparathyroidism

Question 6

Ulnar neuropathy

General

Answer 6

Compression of the ulnar nerve in one of two places
At elbow (cubital tunnel)
At wrist (Guyon’s canal)
Can be from resting arm on things
Can also be from growth in wrist

Question 7

Ulnar neuropathy

S/Sx

Answer 7

Pain, tingling or numbness in the ulnar nerve distribution (1/2 4th finger and all of 5th finger)
Sometimes will have weakness and sometimes won’t (depends on location of compression)
Worse with elbow flexion (if compression is at elbow)

Question 8

Ulnar neuropathy

Tx

Answer 8

Depends on location, but still need to reduce compression:
Bracing elbow or wrist, especially while sleeping
NSAIDs or oral steroids
Avoid putting pressure on the nerve
Surgical release with relocation of nerve at elbow (ulnar nerve transposition)

When at wrist/ hand, often related to mass/ tumor and requires surgery

Question 9

Radial neuropathy

General

Answer 9

Damage to radial nerve with humerus fracture
Compression of radial nerve
Axilla, wrist

Question 10

Radial neuropathy

S/Sx

Answer 10

Numbness to back of hand
Weakness with wrist extension and at triceps
All symptoms and physical exam findings depend on location of problem (obviously won’t have weakness of triceps if problem is distal)

Compression at axilla is often from crutches
Saturday night palsy is usually radial nerve (arm over chair or head on hand)

Question 11

Radial neuropathy

PE and Dx

Answer 11

same as S/Sx

EMG/NCV

Question 12

Radial neuropathy

Tx

Answer 12

Remove compression or stop the thing/ activity causing compression
ALWAYS check radial nerve status with humerus shaft fracture

Question 13

tarsal tunnel syndrome

General

Answer 13

Compression of the posterior tibial nerve at the ankle/foot; sometimes due to nerve stretching

Often accompanied by over pronation of the foot (flat feet)- will get into this more in orthopedic lectures

Question 14

Tarsal tunnel sydrome

PE

Answer 14

Abnormal sensation to areas mentioned in signs/symptoms
Sometimes very tender over posterior tibial tendons and nerve in the tarsal tunnel
Rarely will have weakness and only in the foot

Question 15

tarsal tunnel

Dx and Tx

Answer 15

Same as all other compressive neuropathies but EMG/NCV is less accurate here than in upper extremity

Same as all other compressive neuropathies but EMG/NCV is less accurate here than in upper extremity

Question 16

Meralgia Paresthetica

general

Answer 16

Compression of lateral femoral cutaneous nerve

Typically happens in pregnant, obese or diabetic patients

Question 17

Meralgia Paresthetica

S/Sx

Answer 17

Numbness to lateral thigh that does not pass the knee joint
Often unilateral

Question 18

Meralgia Paresthetica

PE and Dx

Answer 18

Same as signs and symptoms
No loss of motor function

No Dx necessary

Question 19

Polyneuropathies & Mononeuritis Multiplex

Answer 19

Weakness, sensory disturbances (often including pain), or both in arms/ legs; diminished or absent DTRs; sometimes has family link; sometimes has a link to toxic exposure or systemic illness

Question 20

Diabetic Neuropathy- Peripheral

general

Answer 20

Due to late-stage diabetes mellitus (types I and II)
Damage to axons, worse with long nerves (why legs/ feet are worse)
Causes motor and sensory problems
Eventually develop vascular problems

Question 21

Diabetic neuropathy - peripheral

Early S/Sx

Answer 21

Early- sensory: diminished sensation to pain, vibration and temperature
Stocking glove pattern (starts distally and progresses proximally)

Question 22

diabetic neuropathy - peripheral

PE

Answer 22

Perform Semmes-Weinstein filament test- if cannot feel 5.07 size, they are at significant risk for injury
May have toe clawing
Calluses and ulcerations on plantar skin over MT heads

Question 23

Diabetic neuropathy - peripheral

Dx

Answer 23

X-rays will eventually show joint subluxation (shifting), subtle fractures and then bone destruction
Obviously need to monitor blood glucose levels
Might consider EMG/NCV early to determine tarsal tunnel syndrome vs diabetic neuropathy

Question 24

Diabetic Neuropathy- Peripheral

Charcot arthropathy

Answer 24

Prolonged neuropathy in addition to trauma can lead to collapse of arch and destabilization of midfoot joints
Patient ends up with rocker bottom foot deformity
Leads to ulcers on bottom of foot

Question 25

# diabetic neuropathy - peripheral Tx

Answer 25

Improve glucose control Shoe adjustments (diabetic shoes reduce injuries that cause calluses and ulcers) Ulcers must be treated by wound care specialists Prevention!! See podiatrist regularly for exams and paring of calluses Medications: Low dose **nortriptyline and amitriptyline (tricyclic antidepressants)** treat the pain and cause drowsiness which helps with sleep **Gabapentin and pregabalin** help with pain but have abuse potential SSRIs give some relief but not as much as tricyclics Sometimes topicals give some relief (capsaicin and lidocaine creams)

Question 26

# Diabetic Neuropathy- Autonomic general

Answer 26

Just like peripheral, damage to autonomic nerves by long term high blood glucose Can change BP, pulse, GI activity, bladder fxn, ED

Question 27

# Diabetic neuropathy - autonomic S/Sx

Answer 27

GI- N&V, feeling of fullness, reflux, constipation or diarrhea, gastroparesis (more in type I) GU- incomplete emptying of bladder, erectile dysfunction Circulatory- orthostatic hypotension

Question 28

# Diabetic neuropathy - autonomic Tx

Answer 28

Treatments: treat each issue individually as you normally would treat it, nothing special specifically for cases related to neuropathy

Question 29

# Charcot-Marie Tooth Disease general

Answer 29

NOT THE SAME AS CHARCOT FOOT Inherited, motor and sensory Type 1- mutations in myelin protein genes Type 2- axonal loss, also genetic

Question 30

# Charcot-Marie Tooth Disease S/Sx

Answer 30

Foot deformities, abnormal gait as a child or early adult Progresses slowly and eventually leads to muscle wasting that starts in the legs Distal sensory loss Sometimes will have slight tremor

Question 31

# CHarcot-Marie Tooth disease PE

Answer 31

Same as signs and symptoms Will have diminished or absent DTRs Claw foot and high arch Claw fingers

Question 32

# Charcot-Marie Tooth Disease Dx and Tx

Answer 32

EMG/NCV No cure NSAIDs and acetaminophen for pain Surgeries for deformities

Question 33

# Friederich Ataxia general

Answer 33

Autosomal recessive trinucleotide repeat disease Obvious cerebellar dysfunction (gait and hand coordination) Weakness in legs Sensory disturbance and diminished DTRs

Question 34

Question 35

# Guillain-Barre Syndrome general

Answer 35

Acute, idiopathic polyneuropathy Often follows infection, vaccine, or surgery Probably immune-based but no real known cause

Question 36

# Guillain-barre Syndrome S/Sx

Answer 36

**Weakness** is more of a problem than sensory issues, but they **do NOT have loss of sensation or neuropathic pain** Tends to be **symmetric Begins in proximal legs, spreads to arms and sometimes the face**

Question 37

# Guilain-barre syndrome PE

Answer 37

See signs and symptoms Can develop autonomic nerve problems like cardiac irregularities, hypo or hypertension, pulmonary dysfunction, impaired sphincter control

Question 38

# Guillain-barre syndrome LP and EMG

Answer 38

Lumbar puncture: CSF has high protein count with normal cell ct EMG/NCV- very odd changes, neurologist will interpret

Question 39

# Guillain-barre syndrome Tx

Answer 39

Not much for mild cases **Plasmapheresis-** need to do this early and especially with severe cases Need to be in ICU if trouble breathing Clot prevention