Peripheral Neuropathy - NeuroX

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Overview: Peripheral Neuropathy

A peripheral neuropathy is a dysfunction of the peripheral nervous system. The central nervous system consists of the brain, brain stem, and spinal cord. The peripheral nerve system is the portion of the nervous system after the spinal cord. This includes neuronal cell bodies, axons, and myelin sheath. As an analogy to electrical wiring, the axon would be the central metal core to the wire that transmits signal, and the myelin sheath would be the outside rubber or plastic coating that protects and insulates the wiring. When the peripheral nervous system is damaged, it can result in problems with sensation (sensory), strength (motor), or with control over glands, blood flow, and heart rate (autonomic).

Patterns of Peripheral Neuropathy

There are several different patterns of symptoms in peripheral neuropathy, often based on the part of the peripheral nervous system that is affected. Starting closest to the spinal cord and moving peripherally out to the end of the extremities, the potential sites of damage include:
  • Neuronopathy:when the nerve cell body is damaged.
  • Radiculopathy:when the nerve root is damaged, most commonly by degenerative changes in the spine such as a herniated disc or arthritic changes.
  • Polyradiculopathy:when nerve roots at multiple spinal levels are damaged, most commonly by inflammation, infection, or cancer. This also can occur when there are degenerative or arthritic changes of the spine at multiple levels.
  • Plexopathy: when the brachial or lumbosacral plexus – a networking of the nerve roots that split and combine in the armpit and pelvis respectively – are damaged, commonly due to inflammation.
  • Polyradiculoneuropathy:when both the nerve roots and peripheral nerve trunks are damaged, with a common example being the inflammatory condition called Guillain-Barre syndrome.
  • Polyneuropathy:when multiple peripheral nerve trunks are damaged, this results in a length-dependent (symptoms prominent furthest away from the core) symmetrical pattern. A common example of this is the peripheral neuropathy due to diabetes.
  • Axonal neuropathy:when the primary problem is the center axons or “inside wire,” leading to a lack of conduction of signal.
  • Demyelinating Neuropathy:when the primary problem is the myelin sheath that “insulates the wire,” this leads to a dramatic slowing of signals being conducted.
  • Mononeuropathy:when a single peripheral nerve is damaged, most commonly due to compression of the nerve or local trauma. Examples of this include carpal tunnel syndrome at the wrist or the sensation of “hitting the funny bone” with pins and needles sensation after trauma to the elbow area.
  • Mononeuritis Multiplex:a rare problem with multiple individual nerve trunks, associated with autoimmune inflammation of the blood vessels to the nerve trunks.

Symptoms

The symptoms of peripheral neuropathy vary based on where the nervous system is affected and how it is affected. These symptoms are considered “neuropathic” symptoms, as they are due to dysfunction in the nerve cells. On a general level, they can vary from being due to a complete loss of the signal (as if a wire is broken), abnormal additional signal due to irritation (as if there is static on a line), or from erroneous messages being transmitted (like a TV with the wrong colors being shown). The symptoms of peripheral neuropathy are rarely life threatening, but they can be very bothersome and disabling.

Weakness

When the motor component to the peripheral nerves is affected, this can cause significant weakness. People with a polyneuropathy tend to have symmetrical weakness in the extremities at the portions furthest from the core, but other types of damage in peripheral neuropathy can cause other patterns including weakness on only one side of the body or one extremity.

Anesthesia

Complete sensory loss to where the affected area does not have any feeling at all. This causes a complete numbness. Anesthesia from peripheral neuropathy can put people at risk for injuries without the person perceiving it, which can lead to foot injuries, ulcers, or infections.
  • Pain: a very common symptom is pain, which can be severe and disabling. It has several different patterns.
    • Burning pain– the part of the body may feel like it is on fire or hot.
    • Cold pain – part of the body may feel profoundly cold or like it has frost-bite.
    • Short electric-like jabs– brief jabs of sharp pain lasting 1-2 seconds may happen in the fingers, hands, toes, or feet. These sensations are brief but severe.
    • Tight pressure– part of the body may feel like it has a tight band around it.
    • Allodynia – the term allodynia refers to when a person feels pain from a stimulus that should not typically be expected to cause pain. Even light touch or light socks can cause a person with peripheral neuropathy to feel pain.

Paresthesia

Similar to the “static” on a phone or radio line when there is interference, this is an additional signal being transmitted. It can feel like a “pins and needles” prickling sensation that is consistently present.

Balance instability

Balance can be affected in more severe peripheral neuropathy, due to both weakness and impairment in the brain to sense where the body is in space. This function is called proprioception, and it is impaired often with peripheral neuropathy.

Cramping

A spasm or cramping sensation in muscles, especially in the feet or leg muscles can occur. Staying adequately hydrated with good electrolyte levels can help some with this.

Causes of Peripheral Neuropathy

Metabolic Neuropathies

  • Diabetic Neuropathy:while multiple peripheral neuropathies can occur in people with diabetes, it is a very common cause of a polyneuropathy which leads to tingling or numbness in the feet and sometimes hands. This is called a “stocking-glove” distribution because the areas furthest from the spinal cord are the feet and ankles (which would be covered by stockings) and hands (which would be covered by gloves). Diabetic neuropathies can be an early sign of developing diabetes. Often the neuropathy symptoms occur before a person is aware they have diabetes, so any new symptoms of neuropathy should warrant testing for diabetes. The treatment includes using medications to treat any discomfort, optimizing control of diabetes, and watching for any complications due to loss of sensation. This will be discussed further below.
  • Alcoholic Neuropathy:occurring due to deficiencies in nutrients in people who consume too much alcohol, alcoholic neuropathy can affect the sensation in the lower legs. Treatment includes stopping consuming alcohol and supplementing vitamins and nutrients, including thiamine.
  • Infectious Neuropathies
    • Lyme’s Disease:this infection is caused by a bacteria passed to people from ticks and can cause various peripheral neruopathies, including facial weakness or a radiculitis (inflammation of a radicular nerve root) that can cause severe pain, loss of sensation, or weakness. The treatment for lyme’s disease related neuropathies involves appropriate antibiotics.
    • HIV:Human Immunodeficiency Virus can be associated with multiple types of peripheral neuropathies. The treatment involves symptom-based management and using antiretroviral medications.
    • Guillain-Barre Syndrome (GBS):GBS can be a post-infectious neuropathy syndrome where following an infection the immune system becomes overactive and this results in a syndrome that involves weakness, numbness or tingling, and occasionally significant problems breathing. This is diagnosed by doing a spinal tap (lumbar puncture) to evaluate for high protein levels in the cerebrospinal fluid with relatively low white blood cell counts. This is treated with immunotherapies such as IVIG or Plasma Exchange, as well as supporting breathing.

Consult Our Peripheral Neuropathy Specilists

Dr. Sheikh Faheem, MD

Neuro-ophthalmology

Dr. Saqib Chaudhry, MD

Stroke and Neurocritical care

Dr. M Umer Farooq, MD

Stroke and Vascular disorders

Dr. Sana Syed, MD

Neuroimmunology/multiple Sclerosis and Dementia

Dr. Muhammad T Khan, MD

Stroke and Vascular disorders

Dr. Adriana Tanner, MD

Epilepsy/Seizure disorders

Dr. Amir Azadi, MD

Neuro Oncology

Dr. Barbara Pickut, MD

Movement Disorders/ Parkinon's Disease

Dr. Basel Assaad, MD

Epilepsy/Seizure disorders

Dr. David Epstein, MD

Epilepsy/Seizure disorders

Dr. Ekokobe Fonkem, DO

Neuro Oncology

Dr. Geetha K, MD

Neuromuscular Disorders

Autoimmune Neuropathies

  • Guillain-Barre Syndrome (GBS):As it was discussed above, GBS can also be considered to be an autoimmune condition. It can happen in the absence of any infection. Occasionally there will be other identifiable body stressors such as surgery, but it can simply happen randomly as an autoimmune process as well.
  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP):often thought of as the more chronic or long-lasting version of GBS, CIDP involves the peripheral nervous system being compromised due to an overactive immune system. There are various antibodies that can be tested to help with this diagnosis, in addition to EMG. This is treated with short-acting immunotherapies such as IVIG or Plasma Exchange, but typically more chronic immunosuppressant medications are used such as azathioprine, mycophenolate, cyclophosphamide, or steroids.
  • Vasculitic Neuropathy: when the immune system attacks the blood vessels to the nerves, it results in peripheral nerve dysfunction due to the inflammation of the blood vessels (vasculitis). This vasculitic neuropathy tends to affect somewhat random or patchy parts of the body and worsens over days to weeks. This can occur on its own or be part of a broader vasculitic condition such as polyarteritis nodosa, rheumatoid arthritis, lupus, or Wegener’s granulomatosis. Biopsy of the nerve is typically used to provide this diagnosis. This is treated with immunotherapies.
  • Brachial Plexitis, or Parsonage-Turner syndrome:a process that can occur on its own or a few weeks after a stressor such as an infection or surgery, this causes significant pain in the shoulder, upper arm, and neck on one side of the body. Over days or weeks, weakness can also occur in the same arm. These symptoms then slowly improve over months. EMG or MRI imaging of the brachial plexus can help establish this diagnosis. Clinical studies have not shown any benefit from the use of steroids or other treatments.

Other Causes of Sensory Changes or Weakness

Not all sensory changes or weakness are due to peripheral neuropathies. The Neurologist can do a detailed evaluation to find evidence to point towards a peripheral neuropathy or a “central” cause such as with a problem affecting the spinal cord, brain stem, or brain. Examples of central nervous system conditions include spinal cord trauma, multiple sclerosis, stroke, or tumor.

Diagnostics for Peripheral Neuropathy

Depending on the clinical presentation, the Neurologist may want to send blood work to look for causes of peripheral neuropathy that were discussed above, such as checking HgbA1c (to check for diabetes), lyme antibodies, HIV antigens, inflammatory markers (ESR, CRP), lupus labs, rheumatoid factor, SPEP, immunofixation, or other tests. When Guillain-Barre, CIDP, or other autoimmune conditions are considered, a lumbar puncture for cerebrospinal fluid analysis may be considered. Lastly, an Electromyography (EMG) can often be profoundly helpful to investigate a peripheral neuropathy.
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Precautions to Take with Peripheral Neuropathy

When someone has significant peripheral neuropathy, it is important to take certain precautions to avoid other complications. As the peripheral nervous system is responsible for the sensation of proprioception (the sensation of where a part of the body is in space), it can affect balance significantly when there is no way to visually see where the legs and feet are. Therefore, people who have peripheral neuropathy may have significant balance problems and falls in the dark. For this reason, it is important to make sure that lights are on when someone gets up during the night, such as to use the restroom. A loss of sensation in the feet can also result in people stepping on sharp objects or getting injuries and not feeling it. This can lead to significant wounds and infections. For this reason, it is important to ensure that people with peripheral neuropathy visually inspect their feet multiple times per day and wear well-fitting shoes. Peripheral neuropathy is a common condition with many causes. A NeuroX expert can partner with you to care for your needs and help you live a full life.

Treatment of Peripheral Neuropathy Pain

Regardless of the cause, medications can be used to control any uncomfortable painful sensations that occur due to neuropathy. Medication options include antiepileptic medications such as gabapentin (Neurontin) or pregabalin (Lyrica). They also can include certain antidepressants such as nortriptyline (Pamelor), amitriptyline (Elavil), or venlafaxine (Effexor). Occasionally, creams containing numbing medicine lidocaine, gabapentin (Neurontin), clonidine, capsaicin, and/or ketamine may be used. These medications do not restore sensation that is completely lacking, but they can significantly ease any pain from the neuropathy, therefore improving quality of life and function. Opiate medications are not effective and should not be prescribed for peripheral neuropathy pain.

Electromyography (EMG)

EMG is a neurodiagnostic test that can be used to test the health of aspects of the peripheral nervous system. This uses electrical current, electrodes, and small needles to test the conduction and function of the nervous system. In addition to testing the peripheral nerves, the EMG can also test the function of muscles.

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