peripheral neuropathy peripheral neuropathy dr h. n. sarker mbbs,fcps,macp(usa),mrcp(uk) associate...

38
Peripheral Peripheral Neuropathy Neuropathy Dr H. N. SARKER Dr H. N. SARKER MBBS,FCPS, MBBS,FCPS, MACP(USA),MRCP(UK) MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR ASSOCIATE PROFESSOR MEDICINE MEDICINE

Upload: thomasina-cox

Post on 23-Dec-2015

220 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Peripheral Neuropathy Peripheral Neuropathy 

Dr H. N. SARKERDr H. N. SARKER

MBBS,FCPS,MBBS,FCPS,

MACP(USA),MRCP(UK)MACP(USA),MRCP(UK)

ASSOCIATE PROFESSORASSOCIATE PROFESSOR

MEDICINEMEDICINE

Page 2: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

IntroductionIntroduction

Peripheral neuropathy is the term for Peripheral neuropathy is the term for damage to nerves of the peripheral damage to nerves of the peripheral nervous system, which may be nervous system, which may be caused either by diseases of the caused either by diseases of the nerve or from the side-effects of nerve or from the side-effects of systemic illness.systemic illness.

Page 3: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

IntroductionIntroduction

Peripheral neuropathy affects ~2–8% Peripheral neuropathy affects ~2–8% of adults; the incidence increases of adults; the incidence increases with age.with age.

Peripheral nervous system is Peripheral nervous system is composed of 12 pairs of cranial composed of 12 pairs of cranial nerves and 31 pairs of spinal nerves.nerves and 31 pairs of spinal nerves.

Page 4: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

IntroductionIntroduction

Cranial nerves 3-12 share same Cranial nerves 3-12 share same compositions as spinal nerves, any compositions as spinal nerves, any pathology involving peripheral pathology involving peripheral nervous system may affect 3-12 nervous system may affect 3-12 cranial nerves.cranial nerves.

Page 5: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE
Page 6: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Peripheral nervous systemPeripheral nervous system

The peripheral nervous system is The peripheral nervous system is made up of three main types of made up of three main types of nerves, each with its own specific nerves, each with its own specific function:function:

- Automatic nerves help regulate the - Automatic nerves help regulate the automatic functions of the body, automatic functions of the body, such as blood pressure, bladder such as blood pressure, bladder function and sweat levels. function and sweat levels.

--

Page 7: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Peripheral nervous systemPeripheral nervous system

Motor nerves control the muscles of Motor nerves control the muscles of the body. the body.

- Sensory nerves pass sensations, - Sensory nerves pass sensations, such as cold, heat or pain, from the such as cold, heat or pain, from the affected area of the body to the affected area of the body to the brain. brain.

Page 8: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

ClassificationClassification

Peripheral neuropathy may be Peripheral neuropathy may be classified in a varieties of ways-classified in a varieties of ways-

according to the according to the 1.number of nerves affected 1.number of nerves affected • MononeuropathyMononeuropathy• MononeuritisMononeuritis multiplex multiplex• PolyneuropathyPolyneuropathy

Page 9: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

ClassificationClassification

2.the type of nerve cell affected 2.the type of nerve cell affected

motor motor

sensory sensory

autonomic autonomic

Page 10: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

ClassificationClassification

3. the process affecting the nerves 3. the process affecting the nerves Demyelinating Demyelinating

Axonal Axonal

NeuronalNeuronal

Page 11: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Definitions Definitions

Neuropathy Neuropathy simply means a simply means a pathological processpathological process

affecting a peripheral nerve or affecting a peripheral nerve or nerves.nerves.

Mononeuropathy Mononeuropathy means a process means a process affecting a single nerve.affecting a single nerve.

Page 12: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

DefinitionsDefinitions

Mononeuritis multiplex Mononeuritis multiplex (multiple (multiple mononeuropathy and/or multifocal mononeuropathy and/or multifocal neuropathy) affects several or neuropathy) affects several or multiple nerves.multiple nerves.

Polyneuropathy Polyneuropathy describes diffuse, describes diffuse, symmetrical disease, usually symmetrical disease, usually commencing peripherally. commencing peripherally.

Page 13: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

PolyneuropathyPolyneuropathy

The course may beThe course may be

- acute, chronic, static, progressive, - acute, chronic, static, progressive, relapsing or towards recovery.relapsing or towards recovery.

Polyneuropathies are motor, sensory, Polyneuropathies are motor, sensory, sensorimotor and autonomic. sensorimotor and autonomic.

Page 14: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

PolyneuropathyPolyneuropathy

They are classified broadly into They are classified broadly into demyelinating and axonal types, demyelinating and axonal types, depending upon which principal depending upon which principal pathological process predominates. pathological process predominates.

Page 15: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

PolyneuropathyPolyneuropathy

Many systemic diseases cause Many systemic diseases cause neuropathies. Widespread loss of neuropathies. Widespread loss of tendon reflexes is typical, with distal tendon reflexes is typical, with distal weakness and distal sensory loss.weakness and distal sensory loss.

Page 16: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

DefinitionsDefinitions

RadiculopathyRadiculopathy means disease means disease affecting nerve roots andaffecting nerve roots and

plexopathy,affecting the brachial or plexopathy,affecting the brachial or lumbosacral plexus.lumbosacral plexus.

Page 17: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

MononeuropathyMononeuropathy

MononeuropathyMononeuropathy is a type of is a type of neuropathy that only affects a single neuropathy that only affects a single nerve. nerve.

The most common cause of The most common cause of mononeuropathy is by physical mononeuropathy is by physical compression of the nerve, known as compression of the nerve, known as compression neuropathy.compression neuropathy.

Page 18: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

MononeuropathyMononeuropathy Nerve compression and entrapmentNerve compression and entrapment NerveNerve Entrapment/compression Entrapment/compression

sitesite Median Median Carpal tunnel Carpal tunnel

(wrist)(wrist) Ulnar Ulnar Cubital tunnel (elbow)Cubital tunnel (elbow) Radial Radial Spiral groove (of Spiral groove (of

humerus)humerus) Posterior interosseous Posterior interosseous Supinator Supinator

muscle (forearm)muscle (forearm) Lateral cutaneous of thigh Lateral cutaneous of thigh Inguinal ligamentInguinal ligament Common peroneal Common peroneal Neck of fibulaNeck of fibula Posterior tibial Posterior tibial Tarsal tunnel Tarsal tunnel

(flexor retinaculum foot)(flexor retinaculum foot)

Page 19: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Mononeuritis multiplexMononeuritis multiplex

Mononeuritis multiplexMononeuritis multiplex is is simultaneous or sequential simultaneous or sequential involvement of individual involvement of individual noncontiguous nerve trunks, either noncontiguous nerve trunks, either partially or completely, evolving over partially or completely, evolving over days to years and typically presents days to years and typically presents with acute or subacute loss of with acute or subacute loss of sensory and motor function of sensory and motor function of individual peripheral nerves.individual peripheral nerves.

Page 20: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Mononeuritis multiplexMononeuritis multiplex

This occurs in:This occurs in: ■ ■ diabetes mellitusdiabetes mellitus ■ ■ leprosyleprosy ■ ■ vasculitisvasculitis ■ ■ sarcoidosissarcoidosis

Page 21: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Mononeuritis multiplexMononeuritis multiplex

■ ■ amyloidosisamyloidosis ■ ■ malignancymalignancy ■ ■ neurofibromatosisneurofibromatosis ■ ■ HIV infectionHIV infection ■ ■ Guillain–Barré syndrome – usually Guillain–Barré syndrome – usually

polyneuropathy.polyneuropathy. ■ ■ idiopathic multifocal motor idiopathic multifocal motor

neuropathy.neuropathy.

Page 22: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

PolyneuropathyPolyneuropathy

Polyneuropathy-Polyneuropathy- The term The term "peripheral neuropathy" is "peripheral neuropathy" is sometimes used loosely to refer to sometimes used loosely to refer to polyneuropathy. Most cases of polyneuropathy. Most cases of peripheral neuropathy affect the peripheral neuropathy affect the sensory and motor nerves..  sensory and motor nerves.. 

Page 23: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

PolyneuropathyPolyneuropathy

Longest fibres are affected first so Longest fibres are affected first so symptoms usually first develop in the symptoms usually first develop in the extremities of your body, such as extremities of your body, such as your feet, legs and hands and arms. your feet, legs and hands and arms. This type of neuropathy is called This type of neuropathy is called generalised sensorimotor generalised sensorimotor polyneuropathypolyneuropathy

Page 24: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

TYPES AND CAUSES OF TYPES AND CAUSES OF PERIPHERAL NEUROPATHY PERIPHERAL NEUROPATHY

AcuteAcute ChronicChronic

Guillain-BarréGuillain-BarréAlcoholAlcoholGuillain-Barré variantsGuillain-Barré variantsToxinsToxinsPorphyriaPorphyriaParaneoplasticParaneoplastic

HereditaryHereditaryCIDPCIDPLymphomaLymphomaOsteoclastic myelomaOsteoclastic myelomaIgM paraproteinaemiaIgM paraproteinaemiaArsenic toxicityArsenic toxicityAmiodarone toxicityAmiodarone toxicityDiphtheria/AlcoholDiphtheria/AlcoholMetabolic/endocrine diseases Metabolic/endocrine diseases (including diabetes)(including diabetes)Drugs and toxins Drugs and toxins Vitamin deficiencyVitamin deficiencyHereditaryHereditaryIgG paraproteinaemiaIgG paraproteinaemiaParaneoplasticParaneoplasticPrimary amyloidosisPrimary amyloidosis

Page 25: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Common causesCommon causes

A - Alcohol,Arsenic toxicityA - Alcohol,Arsenic toxicity B - Vit.deficiency-B1,6,12 def.B - Vit.deficiency-B1,6,12 def. C - CRF,Carcenomatous –C - CRF,Carcenomatous –

lymphoma,myeioma, connective tissue lymphoma,myeioma, connective tissue disease-RAdisease-RA

D - Diabetes, Drugs-INH, MetronidazoleD - Diabetes, Drugs-INH, Metronidazole H-HereditaryH-Hereditary I-Infection-leprosy, GBSI-Infection-leprosy, GBS

Page 26: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Clinical featuresClinical features

Sensorimotor polyneuropathySensorimotor polyneuropathy Symptoms of generalised Symptoms of generalised

sensorimotor polyneuropathy can sensorimotor polyneuropathy can include:include:

prickling and tingling sensation in the prickling and tingling sensation in the affected body part (pins and needles) affected body part (pins and needles)

numbness and a reduced ability to numbness and a reduced ability to feel pain or changes in temperature, feel pain or changes in temperature, particularly in your feet particularly in your feet

Page 27: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Clinical featuresClinical features

a burning pain, usually in the feet a burning pain, usually in the feet and legs, followed by the hands and and legs, followed by the hands and arms as the neuropathy progresses arms as the neuropathy progresses

sharp stabbing pain, which is often sharp stabbing pain, which is often worse at night (again, the feet and worse at night (again, the feet and legs are affected first, followed by legs are affected first, followed by the hands and arms) the hands and arms)

Page 28: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Clinical featuresClinical features

muscle weakness muscle weakness loss of co-ordination loss of co-ordination muscle paralysis muscle paralysis increased risk of developing increased risk of developing

problems that affect the feet, such as problems that affect the feet, such as skin infections and foot ulcers skin infections and foot ulcers

Page 29: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Clinical featuresClinical features

SignsSigns-It depends on the types, -It depends on the types, severity and nerve cells involved.severity and nerve cells involved.

Motor signs- lower motor neuron Motor signs- lower motor neuron lesion-wasting ,fasciculation and loss lesion-wasting ,fasciculation and loss of reflexsof reflexs

Sensory signs-diminished or loss of Sensory signs-diminished or loss of sensation of all modalities of sensation of all modalities of sensation sensation

Page 30: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

DiagnosisDiagnosis

Diagnosis-Diagnosis- is largely clinical, is largely clinical, supported by electrical studies.supported by electrical studies.

A number of tests can be used to A number of tests can be used to confirm peripheral neuropathy . confirm peripheral neuropathy . These include:These include:

nerve conduction test and nerve conduction test and electromyography (EMG) electromyography (EMG)

nerve biopsy nerve biopsy

Page 31: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

DiagnosisDiagnosis

Other investigations to detect underlying Other investigations to detect underlying causes-causes-

Blood tests Blood tests • Blood sugar,HbA1cBlood sugar,HbA1c• Urea and electrolytes, Urea and electrolytes, • Thyroid function tests Thyroid function tests • Vitamin B12 Vitamin B12 • Venereal Diseases Reasearch Laboratory Venereal Diseases Reasearch Laboratory

(VDRL) test (VDRL) test • ANA, anti-dsDNA ANA, anti-dsDNA

Chest X-ray Chest X-ray

Page 32: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

TreatmentTreatment

Treatment for peripheral Treatment for peripheral neuropathy will first address the neuropathy will first address the condition’s underlying causes. condition’s underlying causes.

For example, in cases of diabetic For example, in cases of diabetic polyneuropathy, a number of lifestyle polyneuropathy, a number of lifestyle changes and treatment are taken to changes and treatment are taken to prevent further nerve damage. This prevent further nerve damage. This may be:may be:

giving up smoking giving up smoking

Page 33: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

TreatmentTreatment

cutting down on your alcohol cutting down on your alcohol consumption, or ideally not drinking consumption, or ideally not drinking alcohol at all alcohol at all

maintaining a healthy weight, if you maintaining a healthy weight, if you are overweight or obese are overweight or obese

taking plenty of exercise taking plenty of exercise tight glycaemic controltight glycaemic control

Page 34: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Neuropathic painNeuropathic pain

As well as addressing the underlying As well as addressing the underlying causes of peripheral neuropathy, causes of peripheral neuropathy, give additional medication to treat give additional medication to treat the symptoms of nerve pain. The the symptoms of nerve pain. The medical term for nerve pain is medical term for nerve pain is neuropathic pain.neuropathic pain.

Page 35: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Neuropathic painNeuropathic pain

Unlike most other types of pain, Unlike most other types of pain, neuropathic pain does not usually neuropathic pain does not usually respond well to treatment with respond well to treatment with widely used painkillers, such as widely used painkillers, such as paracetamol and ibuprofen. paracetamol and ibuprofen. Therefore, alternative medications Therefore, alternative medications are usually required. are usually required.

Page 36: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

Neuropathic painNeuropathic pain

Initial treatments Initial treatments Medications called amitriptyline and Medications called amitriptyline and

pregabalin are the initial treatments pregabalin are the initial treatments for people with neuropathic pain. for people with neuropathic pain.

Page 37: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE

PROGNOSISPROGNOSIS

In 1/3In 1/3rdrd cases cause is identified and cases cause is identified and treatabletreatable

In 1/3In 1/3rdrd cases cause is identified but cases cause is identified but not amenable to treatment.not amenable to treatment.

In another 1/3In another 1/3rdrd cause is not cause is not identifiedidentified

Page 38: Peripheral Neuropathy Peripheral Neuropathy Dr H. N. SARKER MBBS,FCPS,MACP(USA),MRCP(UK) ASSOCIATE PROFESSOR MEDICINE