Neuropathies Flashcards
1
Q
Neuropathy list
A
- Peripheral Neuropathy
- Compressive Neuropathy
- Bell’s Palsy
- Trigeminal Neuralgia
- Herpes Zoster/Post-herpetic neuralgia
- herpes zoster/post - HN
- Motor neuron dz/ AML
2
Q
History
Pain
A
- location
- character
- pain elsewhere? (Back neck)
- pattern / time course of progression
- better/worse ?
- meds?
- ADL changes
- Bothered by touching, sheets
3
Q
History
Causes
A
- DM, HIV, EtOH, Autoimmune, cancer, ?
- Healthy lifestyle
- Med use
- social hx (etoh)
- ‘Do elders in family always complain about feet?”
4
Q
MC etiologies
A
- DM
- HIV/HepC
- Meds = Chemo,HIV,FQ
- vit deficiencies/excess (B)
- inherited neuropathies
- autoimmune dz
- cancer (weight loss?)
- idiopathic
- leprosy
5
Q
Differential Dx
Painful feet
A
- Peripheral Neuro (both legs, whole leg)
- Radiculopathy (dermatomes - strip down leg)
- Claudication/Vascular dz - insuff blood
- Plantar fasciitis
- Gout
- Rheumatoid Arthritis
- Morton’s neuroma
6
Q
Physical exam
A
- CN
- Motor exam
- reflexes
- sensory exam
- gait/romberg
- PSN
7
Q
Strength testing
A
Weakness/symptoms worse distally than proximal
Pain limits strength test
8
Q
Sensory testing
A
Stocking glove sensory loss
Also down mid chest (distal part of spinal offshoots)
9
Q
Sensory testing
Modalities
A
- **Pinprick
- **Temperature
**Vibration
**Proprioception
DIFFERENT NERVE TRACTS, but these often go together
10
Q
Small fibers
A
Unmyelinated fibers innervating skin
11
Q
Large fibers
A
Macroscopic
12
Q
Which impaired in small fiber neuropathy?
A
temperature
Pinprkc
13
Q
Which impaired in large fiber neuropathy?
A
Vibration
Proprioception
14
Q
Labs
A
- help with UNDERLYING CAUSE
- Glucose test/ A1C
- Hepatitis serologies
- Autoimmune
- Testing for B12
15
Q
Labs
Extra tests
A
Serum protein electrophoresis (MM)
B6 levels
HIV testing
16
Q
Electrical Studies
A
Measure speed of conduction / amplitude of transfer - LARGE FIBER, KNOWN PATHWAY
Problem with axon /myelin/both
Acute problem/ chronic
17
Q
Genetic testing
A
- Charcot-Marie-Tooth syndrome
- only helpful if known mutation
- avoid unnecessary back surgery
- genetic non-discrimination concerns
18
Q
PSN Tx
Anticonvulsants
A
1st line
Gabapentin
*NOT PAIN PILLS, PAIN PREVENTERS, need a week or two of regular dosing
19
Q
PCN Tx
Anti-depressants
A
TCA - sleep difficulties
SNRI - depression
20
Q
PSN Tx
Weak mu-opiod ag
A
Tramadol
S.E. - toxic metabolite = seizures
Give 10 for “bad days”
21
Q
PSN Tx
Opiates
A
not effective for neuro pain
*NOT 1st line
22
Q
PSN Tx
Lidocaine
A
for small focal areas
Wear gloves!
23
Q
PSN Tx
Supplements
A
Alpha-lipoic acid
*Buy from german pharmacy (UNREGULATED in USA)
24
Q
Tx
Exercise, Diet, Weight loss
A
- peripheral nerve regeneration
* Painful - try water, bicycle, rowing
25
PSN
Patient Education
* DAILY foot inspection
* Nail cutting at podiatry
* Fall prevention
* Med titration
* Family ed = it's real!
* Risk of chemo/fluoroquinolones
26
Compression Neuropathies vs. radiculopathy
Radiculopathy is compression at nerve root, this is anywhere
27
Compression Neuropathies
Common sites
Carpal tunnel
Thoracic outlet
Ulnar entrapment at elbow
Tarsal tunnel
28
CTS risk factors
```
Genetic
DM
Pregnancy
Age
Repetitive strain
```
29
* Dull aching discomfort
* tingling
* weakness/clumsiness of hand
* sleep provokes
* repetitive actions provoke
* improve by changing posture
S/s
CTS
30
CTS
Tx
* night splints
* NSAID
* PT - muscular imbalance
* Rest/activity mods
* steroid injections
* Surgical decompression = do early
31
+Tinel's test (medial nerve)
+Phelen's Test
*Wasting/atrophy of hand muscles (late sign)
*abnormal nerve conduction tests
Signs
Carpal Tunnel CTS
32
Bell's Palsy
Peripheral CN 7 abnormality
| *entire nerve after foramen = affected
33
* facial weakness over DAYS - WEAKS
* Taste, lacrimation, hyperacusis change
* facial tingling pain near ear
s/s?
Bell's Palsy
34
Bells Palsy
Tx
Early (72 hrs) - steroids +acyclovir
Symptomatic = eye patch, pain control
Late, just Symptomatic tx
35
Bell's Palsy
Prognosis
Worse for older, complete palsy, severe pain
36
* Recurrent severe, lancinating pain - unilateral,
* come from slight stimulus - chewing, yawning, touch
S/s?
Trigeminal Neuralgia (CN 5)
*Trigem distribution
37
Trigeminal Neuralgia
Tx
* before tx - high suicide rate
* Anti-convulsant meds
* Glycerol injections
if refractory, remove nerve insult to allow regeneration
* Gamma knife radiosurgery
* microvascular decompression (most invasive, sometimes no effect)
38
Shingles (herpes zoster)
Who
* those primary varicella zoster
| * immunocompromised
39
Where does VZV live?
Sensory dorsal root ganglia
40
Grouped vesicles on an erythematous base
Herpes
41
Zoster distribution on body
Can't cross midline
| Always on dermatome
42
* Shingles in V1 distribuition
| * Vesicles on tip of nose
Herpes Ophthalmicus
URGENT REFER OPTHALMALOGIST TODAY
43
Herpes Zoster
Tx
W/In 72 hours - Antivirals
* Acyclovir
* Valacyclovir
* Famciclovir
Pain Control
* Opiates
* Anti-convulsants
44
Persistence of electric shock pain and severe itching >3 months after rash
Post-herpetic neuralgia
45
Post-Herpetic Neuralgia development risks
* Old (>50s)
* Female >
* w/ prodrome
* PAIN w/ rash
46
Post-Herpetic Neuralgia
Tx
*Anti-convulsants
GABAPENTIN
```
*ADD
TCA / SNRI
*Weak mu-Opioid
(TRAMADOL / ZYDOL)
*Opiates, Lidocaine patch (GOOD = LOCAL) cream
```
47
ALS
Name
Amyotrophic Lateral Sclerosis
48
ALS
Causes
* Excess glutamate in brain
| * Muscle weakness + atrophy
49
UMN vs. LMN Lesion
Weakness
BOTH
50
UMN vs. LMN Lesion
Atrophy
LMN Lesion = YES
51
UMN vs. LMN Lesion
Fasciculations
LMN Lesion = YES
52
UMN vs. LMN Lesion
Reflexes
LMN Lesion = DOWN
UMN Lesion = UP
53
UMN vs. LMN Lesion
Tone
LMN Lesion = DOWN
UMN Lesion = UP
54
* progressive arm/weak weakness, asymmetrick
* fasciculations/twitching
* Stiffness
* Weight loss/ muscle atrophy
* Drool
* NO PAIN, NO SENSORY, NO BOWEL CONTROL, OCULAR CONTROL
S/S
ALS
55
ALS
Tx
***RIluzole
* Ventilatory Support - (a serious decision)
* Symptomatic Speech Therapy
* Psyc
56
ALS
Assessment
PE:
| Weakness, Hyperflexia, fasiculations
57
ALS
Prognosis
* 3 years after Dx (median)
* come in w/ facial s/s = 1 yr left
* Respiratory failure
58
* Pins + Needles
* Numbness
* Hypersensitiive/burning
* Bunched sock feeling
General Presentation?
Peripheral Neuropathy
59
Peripheral Neuropathy (PSN)
General Tx
* Anti-convulsants
* Antidepressants (TCA/SNRI)
* Weak u-opioid ags (tramadol)
* Opiates
* Lidocaine patches/creams
* Healthy lifestyle
60
```
Peripheral Neuropathy (PSN)
Tx
```
Anti-convulsants
1st LINE
| Gabapentin
61
```
Peripheral Neuropathy (PSN)
Tx
```
Anti-Depressants
*TCA/SNRI
* TCA = sleep
* SNRI = depression
62
```
Peripheral Neuropathy (PSN)
Tx
```
u-opioid ags
Tramadol
* breakthrough pain
* NOT daily med
63
```
Peripheral Neuropathy (PSN)
Tx
```
LIdocaine patch/cream
focal neuropathies
NO 24 hr
64
```
Peripheral Neuropathy (PSN)
Tx
```
Supplements
Alpha-lipoic acid
65
```
Peripheral Neuropathy (PSN)
Tx
```
Pt needs to be alert and driving?
Anti-convulsants
| Gabapentin
66
```
Peripheral Neuropathy (PSN)
Tx
```
Pt w/ concurrent depression?
anti-depressants
67
```
Peripheral Neuropathy (PSN)
Tx
```
Pt w/ very focal pain?
Lidocaine patches/topical cream
68
```
Peripheral Neuropathy (PSN)
Tx
```
Pt w/ insomnia?
TCAs - bedtime
69
```
Peripheral Neuropathy (PSN)
Tx
```
Pt w/ chronic constipation?
***NO*** TCAs, Tramadol, Opiates
70
```
Peripheral Neuropathy (PSN)
Tx
```
Pt w/ orthostasis/older pt?
***NO*** TCAs
71
Compression Neuropathy vs. Radiculopathy
Radiculopathy = compression neuropathy at nerve root
72
Compression Neuropathies
MC sites
* Carpal Tunnel
* Thoracic Outlet
* Ulnar Entrapment at the Elbow (Cubital Tunnel)
* Tarsal Tunnel
73
What is MC compression Neuropathy?
Carpal Tunnel
| Median N.
74
Carpal Tunnel
Risk Factors
* Genetic
* DM
* pregnancy
* fat
* Age
* Repetitive strain
75
Facial muscle weakness:
Can raise both sides of forehead
CNS problem
76
Facial muscle weakness:
One side of forehead completely paralyzed
Peripheral problem
| Bell's Palsy (CN 7)
77
Trigeminal Neuralgia vs Bell's Palsy
*Trigeminal Neuralgia = Facial PAIN
Bell's Palsy = Facial WEAKNESS
78
Trigeminal Neuralgia
Cause?
UNCLEAR
- compression
- demyelination
- inflammation
- trauma
