Diabetic Lumbosacral Radiculoplexopathy DLSRP

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Presentation transcript:

Diabetic Lumbosacral Radiculoplexopathy DLSRP www.rrnmf.com Richard J. Barohn, MD Chair, Department of Neurology Gertrude and Dewey Ziegler Professor of Neurology University Distinguished Professor Vice Chancellor for Research University of Kansas Medical Center Kansas City, KS

Case History 65 F DM 2 yrs., oral Rx Tingling toes x 1 yr. Now CC – leg pain/weak – ? more tingling 6 mos – pain/wk left leg – pain lumbar to hip/post-thigh 2 mos – similar symptoms right leg MRI – DJD L4/5 laminectomy Post-op – worse/can’t walk 20 lb weight loss over 6 mos Gabapentin/TCA no help

Case PE Quad atrophy, L > R Arm strength – NL DTR – NL arms/0 legs Sens – No vib toes/prop NL Dec touch/pin to ankles R L HF/Abd 3- 2 KE/KF 4 3 AD/E/I

Case Question 1 What pattern of neuropathy does this patient have? Symmetric proximal and distal weakness with sensory loss (NP1) Symmetric distal sensory loss with or without weakness (NP2) Asymmetric distal weakness with sensory loss (NP3) Asymmetric proximal and distal weakness with sensory loss (NP4) Asymmetric distal weakness without sensory loss (NP5) Answer: d – NP4

Case Question 2 What is the diagnosis? Vasculitis neuropathy Lumbar stenosis with radiculopathy Diabetic lumbosacral radiculoplexopathy MADSAM Arachnoiditis Answer: c. Diabetic lumbosacral radiculoplexopathy

Case Labs Random glucose 120 – 200 HgA1C - 6.5 NCS: L PER/TIB – NR R PER – Amp 0.5/LAT 6.6/CV 34 R TIB – Amp 11/LAT 6.7/CV 35 Sural – NR Bilat UE NCS – NL EMG – Fibs/neurogenic MUPS Prox/Distal LE & LS paraspinous

Case Question 3 What is the treatment? IVIg Cyclophosphamide Narcotics for pain and physical therapy Plasmapheresis Oral prednisone Answer: c. Narcotics for pain and physical therapy

Case Course Rx – Fentanyl patch and oxycodone to break pain cycle Pain improved Begin vigorous PT In 2 weeks – beginning to walk Slow improvement over next 6 months

Diabetic Lumbosacral Radiculoplexopathy DLSRP Other Names: Proximal diabetic neuropathy Ischemic mononeuropathy multiplex Femoral or fem-sciatic neurop Diabetic amyotrophy Bruns-Garland Syndrome Patients are usually: > age 50; “NIDDM” 1/3 on oral meds 1/3 on insulin 1/3 new onset DM Glucose often inc, but may be NL

Typical Clinical Presentation DLSRP Typical Clinical Presentation Pain - Back, hip, thigh Initially overshadows weakness Weakness - prox + distal leg within days or weeks after pain Spreads to opposite side At least 25%, perhaps much more Latency - days to months Numb/Tingling c/o - 50% Distal Sens Loss (DSPN) Knee + Ankle Reflex Loss Wt Loss in 1/3

DLSRP Lab NCS - DSPN EMG - Profuse fibs Prox/Distal/Paraspinous CSF - Often  prot 60-100 mg/dl (up to 400) ESR NL or  , usually < 50 Sural Nerve Bx - Asymmetric fiber loss Axonal degen Occas slight perivascular inflammation

DLSRP Course Initially worsens in gradual or step-wise manner Eventually stabilizes, plateaus, and improves Worsening phase lasts weeks to months (up to 18 mo)

Arch Neurol 1991;48:1130-1135.

Diabetic Lumbosacral Radiculoplexopathy DLSRP The Neurologists Pattern Only a neurologist makes Dx Only a neurologist can give best recommendations/prognosis