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Ростовский Государственный Медицинский Университет

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whereashandweakness,atrophy,andclumsinesspredominateinthelatter.

Sensorydistributionoftheulnarnerve.Involvementofthepalmarcutaneousordorsalcutaneousbranches indicatesthatthelesionisproximaltothewrist.

PeronealandTibialNeuropathies

Thesciaticnerveisthelargestnerveinthebody,runningfromthehipallthewaydownintothetoes.Itis derivedfromspinalnervesL4toS3.Thesciaticnerverunsdowntheposteriorthighandthensplitsinto twobranchesatthepoplitealfossa:1)thetibialnerve(L4S3)and2)thecommonperoneal,orfibular, nerve(L4S2).

Thecommonperonealnerverunslaterally,wrappingitselfaroundthelaterallegandfibula.It dorsiflexesandevertsthefootandsuppliessensationtothelateralleganddorsumofthefoot.Fibular neckfractures,laterallegtrauma,andsignificantweightlosscanallcauseperonealneuropathy,which presentswithfootdrop,peronealdistributionnumbness,andasteppage(highstepping)gait.

Thetibialnerverunsmedially.Itinvertsandplantarflexesthefootandsuppliessensationtothesoleof thefoot.Tibialnerveinjuryislesscommonthanperonealnerveinjury.Tibialnerveinjuryismost commonlycausedbycompressioninthepoplitealfossa(oftenduetoahematomaorafluidfilledBaker cyst)orwithinthetarsaltunnelattheankle.

Themosthelpfulmnemonictokeepthesetwoneuropathiesstraightthatwewereabletoturnupisquite clever:

Peronealneuropathy:presentswith“footdropPED”(Peroneal,Everts,Dorsiflexes) Tibialneuropathy:presentswithinabilitytostandonTIPtoes(Tibial,Inverts,Plantarflexes)

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Anatomyofthemajornervesofthelowerextremity.

Box11.8Sciatica

“Sciatica”isacolloquialtermthatreferstoradicularbackpain,i.e.,painthatradiatesfrom thebackintothelegalongthedermatome(sensorydistribution)ofanerve.Itisa nonspecifictermandisoftenusedincorrectlytodescribewhatismoreaccuratelytermed lumbosacralradiculopathy.Furthermore,thetermsciaticaismisleading,becauseradicular backpaincanbetheresultofcompressionofanyofthelumbosacralnerveroots,L1through S4(L5andS1aremostcommonlyaffected),whereassciaticmononeuropathy(remember, thesciaticnerveisformedfromtheL4S3nerveroots)isrelativelyuncommon.

Lumbosacralradiculopathyis,ontheotherhand,extremelycommon.Itismostoftencaused byeitheraherniateddiscorspinalstenosiscompressingpartofthenerverootandcausing inflammation.Painthatshootsfromthelowerbackdownintotheleg,oftenwithassociated numbnessandtingling,istheclassicpresentation.Mostpatientscanbemanaged conservativelywithphysicaltherapyandashortcourseofacetaminophenoranantiinflammatorymedicationsuchasibuprofen.Epiduralsteroidsaregenerallynot recommendedbecauseoftheirlimitedefficacyandnotinconsequentialrisks.Systemic glucocorticoidsalsoappeartohavelittlevalue.Surgicalmanagementisgenerallyreserved forpatientswhodevelopfrankweaknessorwhohavepersistentanddebilitatingpaindespite conservativemeasures.

BellPalsy

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ApatientwithBellpalsy.

WearegoingtoholdoffonafulldiscussionofthiscommonconditionuntilChapter18,whenwefocus ondisordersofthecranialnerves.Fornow,youshouldknowthatfacialpalsiescomeintwotypes:upper motorneuron(UMN)andlowermotorneuron(LMN).LMN(or“peripheral”)facialpalsy,affectingthe nucleusoraxonsoftheseventhcranialnerveitself,iscommon,affectingupto1in60peopleduringtheir lifetime.Whenthecauseisunknown,peripheralfacialnervepalsyisreferredtoasBellpalsy.

Peripheralfacialnervepalsypresentswiththeacuteonsetofweaknessontheipsilateralsideofthe face(i.e.,alesionoftheleftseventhnerveresultsinleftsidedfacialweakness),involvingboththeupper face(resultinginthepatient’sinabilitytoclosetheeyeorfullyelevatetheeyebrow)andthelowerface (resultinginnasolabialfoldflatteninganddroopingofthemouth).Theforeheadissparedinpatientswith UMNfacialnervepalsies;again,allthiswillmakemoresensewhenwelookatitindetailinChapter18.

MeralgiaParesthetica

Thiscommonmononeuropathyistheresultofcompressionofthelateralfemoralcutaneousnerve,a purelysensorybranchofthelumbarplexusthatsuppliessensationtotheanterolateralthigh.Themajority ofcasesresultfromcompressionofthenerveasitpassesbeneaththeinguinalligament,ofteninthe settingofpregnancyorobesity,orevenjustfromwearingtightbeltsorwaistbands.Patientscomplainof numbness,paresthesias,andpainintheanterolateralthigh.Becausethelateralfemoralcutaneousnerveis

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purelysensory,thereshouldbenoassociatedmotordeficits.

Additionaltestingisalmostneverrequired.Thisisadiagnosisyoucanmakebyhistoryand examinationalone.Treatmentinvolvesavoidingprecipitants(anewwardrobemaybeinorder),weight loss,and,forthosepatientswithsignificantpain,thesamemedicationsthatareusefulforthe polyneuropathies.Mostpatientsrecoverwithinafewweekstomonths.

Damagetothelateralfemoralcutaneousnervecanleadtonumbnessoftheanterolateralthigh.

https://t.me/med1917

Box11.9ThePeripheralNeurologicManifestationsofDiabetesMellitus

Asyouhavesurelynoticedbynow,diabetescanwreakhavocontheperipheralnervous systeminanumberofways.Heretheyallare,inoneplace,tohelpyoukeepthemall straight:

 Distal symmetric predominantly sensory peripheral neuropathy, by far the most common  Autonomic neuropathy can result in gastrointestinal symptoms, erectile dysfunction, andorthostatichypotension.Also,andhere’sasmallpearl,patientscanlosethenormal sinusarrhythmiaof the heart, that is, the normal variation in heart rate withinspiration (faster) and expiration (slower); this can sometimes be the very first manifestation of diabeticneuropathy  Polyradiculopathy—these include diabetic amyotrophy (just a fancy term for lumbosacral radiculopathy, with prominent pain, muscle weakness, and atrophy in the proximal lower extremity) and thoracic polyradiculopathy (which characteristically presentswithabdominalpaininabandlikepatternaroundthetrunk)  Mononeuropathy—almost any nerve can be affected, but the most common are the cranial nerves (usually the oculomotor, trochlear, and abducens nerves, resulting in diplopia and ophthalmoplegia) and the median nerve (resulting in carpal tunnel syndrome)  Small fiber neuropathy—characterizedby distalburning pain anda normalneurologic examination;remember,skinbiopsyisrequiredfordiagnosisbecauseelectrophysiologic testingwillbenormal

Box11.10MultipleCranialNervePalsies

Thereareonlyahandfulofthingsthatcancausemultiplecranialneuropathiessimultaneously orwithinashorttimeframeofeachother.Itisworthgoingthroughthedifferential,because noneofthesearediagnosesyouwanttomiss.

Infections:Lyme,listeria,syphilis,andcryptococcusaremostoftenimplicated. Autoimmunediseases:GuillainBarresyndromeandneurosarcoidosisarethetwomost commonlyencountered.  Neoplastic disease: Leptomeningeal carcinomatosis occurswhen cancer cellsspread into the leptomeninges (the pia and arachnoid) and cerebrospinal fluid and are thus disseminated throughout the neuraxis. This can present with severe headache (remember,themeningesarepainsensitive),polyradiculopathies(duetoinvolvementof thespinal nerve roots as theyexit the cord), and multiplecranialneuropathies (due to malignant invasion of the cranial nerves within the subarachnoid space). For more details,seeChapter16.  Cavernous sinus syndrome: The two cavernous sinuses sit on either side of the pituitary gland and drain blood and CSF from the eye and superficial cortex into the internal jugular vein. Each sinus contains an internal carotid artery, thirdorder

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sympatheticneurons(thatrunonthesurfaceofthecarotidartery),andcranialnerves3, 4, 5 (only the ophthalmic, V1, and maxillary, V2, branches), and 6. Thus, pathology withinthe cavernoussinus(often thrombosis,amass,orfistula)presentswithreduced facialsensationandophthalmoplegiaduetomultiplecranialnerveinvolvement.

Thecavernoussinus,whichcontainstheinternalcarotidartery(ICA)andsympatheticnervesthatrun onitssurface,aswellascranialnerves3,4,5(V1andV2branchesonly),and6.

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YourPatient’sFollowup:Allen,whopresentedwithnumbnessandtinglinginhisfeet,

appearstohaveatypicaldistalsensorypolyneuropathy.Hisfastingglucoseandhemoglobin A1cwerenormal,soyouorderadditionallaboratoryworkincludingavitamin B12/methylmalonicacid,SPEPandIEP(serumproteinelectrophoresisand immunoelectrophoresis,respectively;thesewillhelpruleoutaparaproteinemia)and, becausehelivesinNewEngland,Lymeantibodytiters.Allarenormal.Despitehisnormal fastingglucoseandhemoglobinA1cyoustillsuspectimpairedglucosetolerancebecausehe isoverweight,andaglucosetolerancetestconfirmsyoursuspicion.Nofurtherworkupis neededforthepresentmoment.Youencouragehimtoloseweightandtogetheragreeto considerstartingmetformintoimprovehisinsulinsensitivity,delaythedevelopmentoffrank diabetes,andhelphimloseweightiflifestylechangesaloneareinsufficient.Hereturnsto seeyouin3monthshavinglost8pounds,andhisneuropathicsymptomshaveimproved.

Younowknow:

1. Amyotrophiclateralsclerosis(ALS)involvesbothupperandlowermotorneuronsandcarriesagrimprognosis.

2. Therearevariouskindsofperipheralneuropathies,withvariedetiologiesandpresentations(whichyoucannowrecognize).

3. Lengthdependent sensorimotor neuropathies are most often caused by diabetes, but a long list of other potential causes must be considered in the absence of hyperglycemia, including hereditary conditions (such as CharcotMarieTooth), and metabolic disorders (suchasB12deficiency).

4. Theinflammatoryneuropathiespresentwithprofoundmotordeficits;alwaysthinkofGuillainBarresyndromeand itsmanyvariants,as thesearedonotmissdiagnoses.

5. Mononeuropathies canoccur inmultiples(mononeuritis multiplex) or as singlenerve involvement(carpaltunnelsyndrome, Bell palsy, andmeralgiaparestheticaprominentamongthem).

6. Diabetes can do almost anything to the peripheral nervous system;a stockingglove distribution sensory polyneuropathy is the most commonmanifestationandcanoccurwithoutoverthyperglycemiaorothermanifestationsofdiabetes.

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