Discovering and Relieving Peripheral Neuropathies

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Discovering and Relieving Peripheral Neuropathies

• Jeff Gould, MD
• Neurology and Sleep Medicine, P.C.
• Bethlehem, PA
• neurologychannel.com/nsm

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Peripheral Neuropathy The Presenter

• Training Emory University
• Hahnemann University
• Lehigh Valley Hospital
• Pennsylvania Hospital
• MCP Hahnemann University
• Board Certifications Neurology
• Sleep Medicine

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Peripheral Neuropathies (PN)

• What is PN?
• Finding PN
• How PN happens
• ID PN
• Treating PN pain
• Conclusions

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What is PN?

• Peripheral neuropathy means
• Damage to nerves (neuro-pathy) far from the
  center of the body
• Can be present on one side initially
• Some neuropathies stay on one side
• When due to injury (trauma)
• When due to selective inflammation

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What is PN?

• PN may involve
• Sensation nerves
• Motor nerves
• Both
• Small fibers (smallest nerves)
• Usually a temporary situation

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PN Pattern

• Typically starts with small nerves damaged
• Eventually larger fibers involved
• Nerves nearest to the body are involved last
• Eventually bladder, bowel, and sexual function is
  effected

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PN Symptoms

• What you may feel
• My feet hurt
• My knee pain is worse/unchanged
• Ive had carpal tunnel syndrome
• Ive had both carpal tunnel releases performed
• Ive had (all of the above) and ulnar
  release(s)
• Just give me some Vioxx, doc

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PN Symptoms

• Pain
• Burning
• Aching
• Beginning in lower ext. typically (feet then up
  legs)
• May be mildly asymmetric
• Ascending nature

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PN Symptoms

• You may be experiencing
• YES Bladder (rarely bowel) incontinence
• YES Tingling in the legs / hands
• YES Unsteadiness
• YES Dizziness with positional change
  indicating orthostatic hypotension
• YES Erectile dysfunction

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Peripheral Neuropathies (PN)

• What is PN?
• Finding PN
• How PN happens
• ID PN
• Treating PN pain
• Conclusions

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PN Evaluation

• Tell your doctor
• Be prepared to take off shoes and socks for
  examination
• Be prepared to have an evaluation by a specialist
  (or two)
• Be prepared to need additional testing

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Peripheral Neuropathies (PN)

• What is PN?
• Finding PN
• How PN happens
• ID PN
• Treating PN pain
• Conclusions

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PN Mimics

• Stroke
• Usually involves one side if sensation only
• Seizure
• Usually temporary, intermittent
• Spinal cord narrowing
• Symptoms may involve all extremities
• Physical examination different than for PN

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PN Causes

• Genetic
• Chemical imbalances
• Vitamin deficiencies
• Inflammations in the body
• Infections
• Cancer
• Drugs
• Nerve injury at specific locations

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PN Genetic causes

• Suggested by very long term course
• No treatable reason found despite repetitive
  evaluation
• Strength problem (motor nerves damaged) without
  sensory loss
• Pain
• Family history

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PN Genetic causes

• Charcot-Marie-Tooth disease
• Approximately 9 forms
• HNPP
• Tool-belt pressure causing pain and weakness
  (femoral and brachial)
• Porphyria

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PN Rare Genetic causes

• Fabrys
• Metachromatic leukodystrophy
• Adrenoleukodystrophy
• Refsums disease
• Motor neuron disease(s)

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PN Causes

• Chemical imbalances
• Diabetes
• Thyroid disease
• Abnormal proteins in body
• Vitamin deficiencies
• Vitamin B12 deficiency
• Inflammation of blood vessels (vasculitis)

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PN Causes

• Connective tissue disorders (Lupus)
• Drugs
• Chemotherapy
• Alcohol exposure (heavy)
• Huffing
• Cocaine exposure

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PN Causes

• Infections
• HIV
• Hepatitis
• Lyme disease
• Sarcoid
• Leprosy
• Most common reason in the world

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PN Causes

• Cancer
• Due to any cancer in general
• Lymphoma
• Multiple myeloma
• Result of cancer treatments
• Unknown reasons

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Peripheral Neuropathies (PN)

• What is PN?
• Finding PN
• How PN happens
• ID PN
• Treating PN pain
• Conclusions

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PN Testing for diagnosis

• Blood work
• Nerve conduction study / Electromyogram (EMG)
• Chest X-Ray
• Cancer screening
• Lumbar Puncture
• Nerve and muscle biopsy

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PN Testing for diagnosis

• ? Spinal tap
• MRI of the neck
• Biopsy of nerve and muscle

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PN Testing for diagnosis

• Fasting blood sugar
• 2 Hour after eating blood sugar
• Thyroid test
• Inflammation rate
• Protein in blood and urine
• Infection tests (Lyme)
• Vitamin levels (B12)

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PN Testing for diagnosis

• The EMG test itself
• Nerve Conduction Studies (NCS)
• EMG (Needle portion)

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PN Testing for diagnosis

• Nerve Conduction Studies (NCS)
• Described by
• Motor or sensation nerve
• Nerve impulse size
• Time to onset of nerve impulse
• Speed of nerve impulse

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PN Testing for diagnosis

• NCS
• Involves stimulation of the nerves by electricity
• Stimulation increases in intensity
• Stimulation often performed on affected and
  normal parts of the body for comparison

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Workup- Electromyogram

• EMG
• Needle portion of the test
• Needle is smaller than IV needle
• Multiple muscles may be evaluated to obtain a
  complete understanding
• Normal arms or legs may also be tested for
  comparison
• Back muscles may also be tested

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Workup- Electromyogram

• EMG (Needle portion)
• Insert needle
• Move the muscle as directed
• Observe changes
• Relax the muscle
• Remove needle
• Repeat if necessary

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Workup- Electromyogram

• EMG can be a near definitive test for PN
• (Nerve biopsy is the ultimate way of telling if
  there is nerve damage)
• EMG can decide if pain is due to other reason
  such as nerve pinching at spine (radiculopathy)

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Workup- Electromyogram

• PITFALLS
• Nerves pinched in the back may resemble PN
  symptoms
• Early PN may have minimal findings on EMG
• Small fiber PN may look normal
• Muscle problems may have similar symptoms as PN

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PN Testing for diagnosis

• Cancer screening
• Mammogram
• Pap smear
• Prostate
• Colonoscopy

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PN Testing for diagnosis

• Spinal tap
• To look for inflammation
• To look for cancer
• To look for infection
• Biopsy of nerve and muscle
• Saved for when absolutely necessary

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Guillain-Barre Syndrome

• Caused by damage to external portion of the nerve
  (Myelin)
• Usually rapid and sudden in progression
• May start in one limb and spread to other side
  (and upward)
• Requires immediate evaluation and treatment

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Guillain-Barre Syndrome

• Reasons
• Unknown
• Infection, Inflammation, etc.
• Evaluation
• Must include physical examination, blood work,
  lumbar puncture, MRI of the entire spine

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Guillain-Barre Syndrome

• Treatment
• Plasmapheresis
• Washes out inflammatory particles
• Risks include significant heart strain
• IVIgG (immunoglobulin)
• Blocks inflammatory particles
• Risks include increased clotting risk
• Fixing the underlying problem
• Infection, etc.

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Guillain-Barre Syndrome

• Initial problem can become chronic
• Acute Inflammatory Demyelinating Polyneuropathy
  (AIDP)
• Chronic Inflammatory Demyelinating Polyneuropathy
  (CIDP)
• Chronic problem (after 4 weeks)
• Treated the same way
• Steroids and immune suppressants

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PN Testing for diagnosis

• Congratulations! The reason was found
• Treat if possible
• Supportive measures if not
• Reason unknown
• Keep looking
• Consider brain and neck imaging, recheck studies
  again in 6 months

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Peripheral Neuropathies (PN)

• What is PN?
• Finding PN
• How PN happens
• ID PN
• Treating PN pain
• Conclusions

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PN Treatment

• Treat the problem causing the PN
• If not possible, treat the pain

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PN Treatment

• Treatment of pain
• Anti-epileptics
• Gabapentin (Neurontin)
• Dont be afraid of 3000mg
• Side-effects sleepiness, mental slowing, leg
  swelling
• Topiramate (Topamax)
• Dosing 15 or 25 mg increments up to 200 per day
• Side-effects mental slowing, tingling in arms
  and legs, weight loss
• Carbamazepine (Carbatrol, Tegretol XR)
• Dosing 200 or 300 mg twice a day
• Side-effects mental slowing, dizziness

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PN Treatment

• Treatment of pain
• Anti-depressants
• Elavil and others
• Prozac and others
• Other
• Lidoderm cream
• Morphine containing medications
• Nerve blocks
• Accupuncture

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PN Pain

• Must watch for Restless Legs Syndrome and
  Periodic Limb Movement Disorder

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Restless Legs Syndrome

• Aching, creeping, crawling
• Worsening immediately before sleep
• Requires moving the extremity to reduce the
  sensation
• Associated with periodic limb movement disorder

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Periodic Limb Movement Disorder (PLMD)

• Involves movements of the legs (and arms) while
  asleep
• Not while falling asleep
• Can cause awakenings from sleep
• People usually dont know why they awoke
• After an awakening, people may have RLS symptoms
  and have trouble falling asleep
• Need to have sleep study to discover

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RLS and PLMD Treatment

• Treatment involves
• Fixing the reason (if discoverable)
• Medications
• Parkinsons disease medications
• Anti-seizure medications

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Peripheral Neuropathies (PN)

• What is PN?
• Finding PN
• How PN happens
• ID PN
• Treating PN pain
• Conclusions

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PN Conclusions

• Neuropathies can be divided by type of nerves
  damaged, duration, and reason
• Reason must be sought with treatment geared
  directly to the problem
• Restudy of labs and tests for neuropathies may
  later be rewarding
• Associated pain can and must be controlled