1. Peripheral Neuropathy Clinical Management Course February 12, 2007
Peter D. Donofrio, M.D.
Professor of Neurology

2. What is Peripheral Neuropathy?

3. Common Mononeuropathies
Median at the Wrist (CTS)
Ulnar at the Elbow (Tardy Ulnar Palsy)
Peroneal Palsy at the Fibular Head

4. Median Nerve Innervation of the Hand and Sensory Loss
Kopell, Thompson, 1963

5. Carpal Tunnel Syndrome Atrophy of APB Muscle
Dawson,Hallett, Millender, 1990

6. Carpal Tunnel Syndrome X-Section View of Wrist
Kopell, Thompson, 1963

7. Ulnar Neuropathy Sensory Loss, Nerve Innervation
Kopell, Thompson, 1963

8. Ulnar Neuropathy Claw Hand
Haymaker, Woodhall, 1953

9. Common Peroneal Injury Right Foot Drop and Sensory Loss
Haymaker, Woodhall, 1953

10. Length Dependent Motor and Sensory Polyneuropathy
Schaumburg 1983

11. Peripheral Neuropathy Etiologies
Diabetes mellitus
Alcohol Abuse
Nutritional: Deficiency of B1, B6, B6, B12, malabsorption syndromes
Uremia
Vasculitis
Genetic/Inherited
Inflammatory
Toxic
Industrial agents
Therapeutic agents

12. Diabetes Compelling Facts
7-8 % of U.S. population (23.6 million)
8.9 million unaware of diagnosis
Total annual economic cost (1997) $98 billion
$44 billion direct medical and treatment
$54 billion indirect costs (disability and mortality)
7th leading cause of death
High prevalence in Afro-Americans, Hispanics, Native Americans

13. Diabetic Neuropathy Prevalence
>60% of diabetics-signs/electrodiagnostic evidence of polyneuropathy (depressed ankle reflexes, absent or diminished distal nerve amplitudes)
25%- neuropathic pain which can be severely disabling
Majority of Type II diabetics are symptomatic or have signs of neuropathy at diagnosis

14. Diabetic Neuropathy Insensate Foot

15. Charcot-Marie-Tooth Disease

16. Charcot-Marie-Tooth Disease

17. Polyneuropathy B12 (Cobalamin) deficiency
Neurologic manifestations:
Large-fiber sensory loss
Corticospinal tract involvement
EMG reveals a polyneuropathy
Serum levels of B12 below 100 pg/ml diagnostic, between 100 and 200 pg/ml suggestive
Elevated methylmalonic acid level more sensitive than B12 level.
Shilling’s test rarely done anymore
Treatment may not reverse all symptoms

18. Guillain-Barre(-Strohl) Syndrome Clinical Features
Ascending, symmetric, subacute (days) polyneuropathy-weakness/paresthesias
About 1/3 require mechanical ventilation
Parainfectious: C. jejuni, M. pneumoniae, CMV, EBV, HIV, Hep A, others
Loss of DTRs
CSF: albumino-cytologic dissociation
Treatment: supportive, PEx, IVIG

19. Diagnostic Criteria Typical Guillain-Barré Syndrome
Clinical features:
Weakness that is approximately symmetric in all the limbs
Paresthesias in the feet and hands
Areflexia or hyporeflexia in all limbs by 1 week
Progression of the these three features over several days to 1 month
Laboratory abnormalities that confirm the diagnosis:
Elevated CSF protein concentration (more than 45 mg/dL) within 3 weeks from onset
Abnormalities on electrophysiologic studies

20. Polyneuropathy Initial Evaluation
CBC
Comprehensive Metabolic Profile
Fasting blood sugar
Glucose tolerance test (if needed)
Vitamin B12
ESR
SPEP
Nerve Conduction Studies and EMG

21. Motor Nerve Conductions
Nerve Conduction Velocity = Distance (mm)/ time difference (ms)

22. Summary Definition of Peripheral Neuropathy Common Mononeuropathies
Polyneuropathy-emphasis on diabetes
Evaluation of polyneuropathy
Nerve conduction studies.