PND 2022

Dr HEEWA A. YOUNIS 2th NOV.
2021
FIBN FEBN MAAN MRCP(S.NEU)
Peripheral Nerve Diseases

USUALLY ARE DISTAL IN DISTRIBUTION & ONSET
The most common forms of peripheral nerve diseases are:
1- Peripheral Neuropathy: common peripheral nerve disorder could be sensory
presenting with paresthesia, numbness and burning sensation in the feet &
fingertips then extend to other regions, or Motor or Mixed.(Glove & Stock
PATTERN)
2- Types of PNS
PATTERNS OF PND:
a-GLOVE & STOCK
b-PERIPHERAL NERVE DISTRIBUTION.
c-RADICULOPATHY (ex cervical root)
d-PLEXOPATHY ( ex BRACHIAL PLEXUS)
examples of diseases:
1- Ideopathic Inflammatory Polyradiculoneuropathy:
Acute AIDP (Guillian Barre Syndrome) GBS-ascending motor PNP
Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP).
2- Metabolic & Endocrine: DM, Thyroid Disorder, Acromegaly, Uremia,
Liver Diseases.GLOVES & STOCKS
3- Neutritional deficiency: B12, B6, B1 (NEUROTROPIC VITAMINS). G&S PATTERN
4- Infective & Granulomatous Neuropathy: AIDS, Leprosy, Diphtheria,
Sarcoid .....etc
5- Drugs: Alcohol, INH, Phenytoin, Pyridoxine, Metronidazole,
Vincristine .......etc
6- Toxic Neuropathy: Organic : Organophosphorus
Non organic; LEAD, Hg
7- Neoplastic Neuropathy: Compression,

Infiltration
or Paraneoplastic reaction.
1
Dr HEEWA A. YOUNIS 2th NOV. 2021
8- Hereditory Neuropathy: as Charcot Marie Tooth Disease, Friedreich

Disease ....etc G&S PATTERN
9- Metabolic : Porphyria, Refsum's Disease, Abetalipoproteinemia ..G&S
10- Entrapment Neuropathy: CTS, Ulnar nerve....
Investigations:
1- Hematology: CBC, ESR, B12, & Folate level.
2- Biochemistry: RFT, LFT, Glucose, Electrolytes.
3- Immunology: Autoantibodies (ANF, Rheumatoid Factor), VDRL.
4- NCS-EMG.
5- THORACOABDOMINAL IMAGING: EX SOL.
6- Cancer Scanning.
7- Lumbar Punture.
8- Nerve & Muscle Bx.
9- Genetic testing
Treatment:
includes CONTROL OF UNDERLYING DISEASE
Treatment of Painful Peripheral Neuropathy:
1- AED.s: Gabapentine, Carbamazepine, Pregabalin, Lamotrigine.
2- Antidepressants:
- TCA: Amitryptilline, nortryptilline, Imipramine.
- SSRI: Less effective as Fluoxetine, Sertraline.
- SNRI: Duloxetine, Venlafaxine.
3- Antiarrhythmic Drugs: Mexilietine, Flecainide.
4- Local Treatment: a- Lidocaine Patch.
b- Capsiacine Ointment.
Guillain Barre Syndrome

Acute syndrome of Inflammatory Demyelinating Polyradiculoneuropathy (AIDP)
with 1-4 weeks, in 70% postinfectious after Compylobacter diarrhoea or RTI. Cell
mediated immune reaction directed at schwan cell due to Molecular Mimicry with
some microorganisms Ag.
2
Clinical Presentation:
 Distal paraesthesia & limb pains (often severe) staring in lower limbs,
preceding rapidly progressing weakness (Ascending Fashion) from
lower to upper limbs symmetrical or mildly assymetrical (more severe
proximally). Girdle
 Unilteral or bilateral LMNL VII is found up to& 70% of cases, there

may be Bulbar and respiratory weakness in about 20% of cases
mandating ICU admission & ventilator support.
 O/E: Afebrile, weakness of LMNS, on sensory examination features

of posterior column dysfunction, there may be evidence of autonomic
dysfunction.
Investigations:
1-
 CSF Albuminocytological dissociation, other parameters are normal.10 less
 2-NCS-EMG shows evidence of demyelination.
 3-Ix to look for the cause, CXR, Serology for Compylobacter, CMV,
Myocoplasma.....
 4-Secondary Infections, DVT, Hyponatremia should be prevented & looked

for & appropriated treated if occurs.
Treatment:
 NEED ICU ADMISSION
 Within first two weeks Plasma Exchange PE or IV IgG shorten the

duration of ventilation & improve prognosis.
 Monitoring respiration with VC & ABG, if VC less than 1L.
3
80% recover completely within 3-6 months, 5% die, others suffer variable
neurological disability.
 BP + HR + SPO2 MONITORING:
 PHYSIOTHERAPY: RESPIRATORY CARE,
 DVT PREVENTION, ATROPHY PREVENTION
 SWALLOWING CARE(NGT FEEDING)
 Miller Fisher Variant
triad of ( Ataxia, Areflexia & External Ophthalmoplegia) unique

antiGQ1b Ab.
- Carpal Tunnel Syndrome:

 - Entrapment of Median nerve at wrist under the flexor retinaculum.
 - Numbness, tingling, burning sensation in hands & 1st 2 & half fingers.
 - Pain in anterior wrist may radiate to anterior forearm, prominently at
night, relieved by shaking & wrist extension.
 - Weakness in thenar muscles while atrophy is late sign.
 - TINEL'S TEST: tapping the wrist elicit pain.
 - PHALEN TEST: forced flexion of the wrist produces the symptoms.
 - Bilateral in 40%, may be associated with:
 - overuse of the wrist. – Pregnancy - Myxedema - Rheumatoid
-cole fracture
 - Diagnosis: - Clinical - NCS Nerve conduction study(DX,IC &

PROGNOSTIC
 - Treatment: 1- underlying cause

 2- SUGERY OR
4
 3- SUPPORTIVE - Wrist Splint - NSAID - Local Steroid Injection -
 AUTONOMIC NEUROPATHY
 Is disease of non sensorimotor nervous system mainly affecting internal
organs that regulate pulse rate, blood pressure, bowel & bladder
functions, could be primary, or associated with Diabetes mellitus,
alcohol, certain drugs.
Trigeminal Neuralgia
 Reccurent attacks of lancinating pain in V2, V3 territory distribution, in
patients over 50 years.
 ETIOLOGY aberrant loop of cerebellar artery compresing the nerve or
other compressive lesion ex MS plaque.
 CLINICALLY
 CONSTANT PAIN OR
 severe repetitive very brief pain causing the patient to flinch as if
motor tic (Tic Douloureux), SPONTANEOUS OR may be precipitated
by touch, cold wind, eating.
 It may show Relapsing Remitting Course over years.
 Sensory signs are negative their presence should point toward structural
lesion as MS, Tumor…etc
 TREATMENT:
 1-Carbamazepine or Gabapentine or Pregabalin.
 2-BACLOFEN TAB
 2-Phenol or Alcohol injection into the branch of the nerve.
 3-Radiofrequency Ablasion near the Gasserian Ganglion.
 4-Vascular Decompression Surgery with substantial success.
5
 Bell's Palsy
 - LMNL VII, preceding viral illness in 60%, possible association with
herpes simplex VIRUS.
 - Progression to plateau within hours to a day, the weakness is variable.
 - Weakness of muscles of facial expression(5),
 25% with Taste impairment,
 10% ear ( Hyperacusis),
 eye (Bell's Sign) & (CROCODILE tearing).
 - Untreated 85% untreated recover completely.
 Nerve Conduction Study: to document & assess severity.
 - Treatment: - Prednisolone tab 1mg/kg/d for 5-10 days.
 - VALAciclovir tab 500MG BID. ()
-Electric Nerve stimulation

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Dr HEEWA A. YOUNIS 2th NOV.

Peripheral Nerve Diseases

7- Neoplastic Neuropathy: Compression,

8- Hereditory Neuropathy: as Charcot Marie Tooth Disease, Friedreich

Guillain Barre Syndrome

 Unilteral or bilateral LMNL VII is found up to& 70% of cases, there

 O/E: Afebrile, weakness of LMNS, on sensory examination features

 CSF Albuminocytological dissociation, other parameters are normal.10 less

 2-NCS-EMG shows evidence of demyelination.

 4-Secondary Infections, DVT, Hyponatremia should be prevented & looked

 NEED ICU ADMISSION

 Within first two weeks Plasma Exchange PE or IV IgG shorten the

 Monitoring respiration with VC & ABG, if VC less than 1L.

 Miller Fisher Variant

triad of ( Ataxia, Areflexia & External Ophthalmoplegia) unique

- Carpal Tunnel Syndrome:

 - Diagnosis: - Clinical - NCS Nerve conduction study(DX,IC &

 - Treatment: 1- underlying cause

 3- SUPPORTIVE - Wrist Splint - NSAID - Local Steroid Injection -

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