1. Diabetic Lumbosacral Radiculoplexopathy DLSRP
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

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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)

13. Arch Neurol 1991;48:

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