1. Neuropathies
Dr. RS Mehta, BPKIHS
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2. What is Neuropathy
• Neuropathy is a disorder resulting from injury
to the peripheral nerves – the motor, sensory
and autonomic nerves.
• The main function of the peripheral
nervous system is to connect the central
nervous system (CNS) to the limbs and
organs.
• Unlike the CNS, the PNS is not protected by
the bone of spine and skull, or by the blood
brain barrier, leaving it exposed to toxins and
mechanical injuries.
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3. Review Basic Concept of Nerves
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4. Synapses
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Figure 11.17

5. Reflex Arc
Spinal cord
(in cross-section)
Stimulus
2 Sensory neuron
3 Integration
center
1 Receptor
4 Motor neuron
Skin
Interneuron
5 Effector
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Figure 13.14
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6. Structure of a Nerve
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Figure 13.3b
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7. Regeneration of Nerve Fibers
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Figure 13.4

8. Cranial Nerve X: Vagus
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Figure X from Table 13.2

9. Spinal Nerves
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Figure 9
13.6

10. Brachial Plexus
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Figure 13.9a
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11. After the PNS is damaged!
• The deterioration of the peripheral nerves disrupts
the body’s ability to communicate with its muscles,
organs and tissues.
• Neuropathy is like the body’s wiring system going
haywire, causing unusual or unpleasant irritations
including tingling, burning, itchiness, dizziness and
many many more!
• If ignored, as this is done often these symptoms can
lead to numbness at one extreme to unremitting
pain at the other.
• It can come and go, slowly progress over many
years or become severe and debilitating.
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12. Neuropathy – a rare illness ???
• Often it is misdiagnosed or thought of merely
as a side effect of another disease such as
diabetes or cancer or even kidney failure.
• It can occur at any age however it is more
common among older adults.
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Dr. RS Mehta, BPKIHS

13. Neuropathy= pathological processes
damaging a nerve or nerves.
The mechanisms of damage may be:1. Demyelination e.g. GB Syndrome
2. Axonal degeneration: e.g. Toxic neuropathies
3. Compression: Causes segmental demyelination
e.g. Entrapment N.
4. Vasculopathy (infarction): e.g. DM
5. Infiltration: e.g. leprosy, sarcoidosis.
Dr. RS Mehta, BPKIHS
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14. Neuropathies may affect just one nerve,- a
condition called mononeuropathy, or several
nerves – called polyneuropathy.
The “peripheral nervous system” is part of the
nervous system that includes nerves in the face,
arms, legs, torso, and some nerves in the skull. In
fact, all the nerves which are not located in the
central nervous system (which includes the brain
and the spinal cord) are peripheral nerves.
Dr. RS Mehta, BPKIHS
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15. There are four types of neuropathy:
1. Autonomic Neuropathy
damage to the nerves that regulate the body functions that a person
doesn’t control, including the nerves that regulate heart rate, blood
pressure, perspiration and digestion.
2. Peripheral Neuropathy
damage to the peripheral nervous system, which transmits information
from the brain and spinal cord to every other part of the body.
3. Mononeuritis
damage to a single nerve or nerve group, which results in loss of
movement, sensation, or other function of that nerve.
4. Mononeuritis Multiplex
damage to at least two separate nerve areas.
Dr. RS Mehta, BPKIHS
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16. A number of conditions can lead to damage of the
autonomic nerves and these possible causes are similar to
those for peripheral neuropathies. The most common
cause is diabetes.
Other causes include:
–
–
–
–
–
–
–
Alcoholism
Amyloidosis- abnormal protein buildup in organs
Autoimmune diseases
Tumors
Multiple system atrophy
Surgical or traumatic injury to nerves
Certain medications, (including chemotherapy drugs and
anticholinergics)
– Parkinson’s disease and HIV/AIDS
Dr. RS Mehta, BPKIHS
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17. More than 100 types of peripheral
neuropathy have been identified, each with
its own characteristic set of symptoms,
pattern of development, and prognosis.
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18. Peripheral
Neuropathies
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19. Peripheral nerve diseases:
1- Mononeuropathies
2- Multiple mononeuropathies
(mononeuritis multiplex)
3- Polyneuropathies
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20. Mononeuropathies
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21. Mononeuropathies
1- Acute : sustained pressure e.g. tourniquet
2- Chronic: entrapment
Causes according to site of compression
1- Carpal tunnel
2- Cubital tunnel
Median N
Ulnar N
Radial N
4- Inguinal ligament Lateral cutaneous of thigh
5- Neck of fibula Common peroneal N
6- Flexor retinaculum (tarsal tunnel) Post tibial
3- Spiral groove of humerus
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22. Brachial Plexus: Distribution of
Nerves
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Figure 22
13.9c

23. Lumbar Plexus
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Figure 13.10

24. Sacral Plexus
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Figure 24
13.11

25. Mononeuritis multiplex
Causes
123456789-
leprosy (commonest)
DM
vasculitis
sarcoidosis
amyloidosis
malignancy
neurofibromatosis
HIV infection
Idiopathic multifocal motor neuropathy
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26. Poly neuropathies
Causes:
1-
Metab & endocrine:
DM
Uraemia
Chronic liver failure
Hypothyroidism
Acromegaly
Amyloidosis
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27. 2- Toxic neuropathies:
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Alcohol
Drugs ( INH, phenytoin, vincristine)
Heavy metals (lead, arsenic, Hg)
Organic solvents (acryl amide, organophos)
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28. 3- Infective:
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Leprosy
Diphtheria
HIV
H. zoster
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32. Dr. RS Mehta, BPKIHS

33. 4.Inflammatory:
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Guillian – Barre’ syndrome.
Chronic demyelinating polyneuropathy
Idiopathic chronic sensorimotor neuropathy
Connective tissue diseases
Sarcoidosis
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34. 5- Vitamin deficiency:
- B12
- B1
- B6
- Folate
- Nicotinic acid
- Vit E
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35. 6- Neuropathy associated with malignant
disease
7- Neuropathy associated with critically ill
pts
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36. Modalities of polyneuropathies:
- Sensory
- Motor
- Mixed
- Autonomic
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37. C/F of Polyneuropathies
1- Sensory dysfn: numbness, paraesthesiae,
hyperaesthesia & pain starting distally and
ascending proximally in gloves & stockings
with impaired perception of pain, touch, temp
vibration & position sense.
2- Motor dysfn: flaccid weakness most marked
distally.
3- tendon reflexes: depressed or absent.
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38. 4- Autonomic neuropathy: gastro paresis,
gustatory sweating, noct. diarrhoea, over flow
incontinence, failure of erection, resting
tachycardia
Causes: - DM
- GB
- Acute intermittent porphyria
- Amyloidosis
- Drugs
Dr. RS Mehta, BPKIHS
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39. Investigations:
guided by sympt & signs
The cause of polyneuropathy is suggested by
the history including the onset, FH, PMH, DH,
and predominant clinical manifestations.
- CBC & ESR
- Renal profile & liver biochemistry
- Blood glucose & thyroid fns.
- Plasma electrophoresis
- Urinary levels of heavy metals.
- CSF
- CXR
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40. - Serum lipids, lipo proteins, cry proteins
- Vitamins assay
- Genetics
- Search for cause e.g. radiology, immaging,
stools for occult blood, endoscopy,
mamography
- Nerve conduction studies
- EMG
- Nerve biopsy.
Dr. RS Mehta, BPKIHS
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41. Tests to evaluate neuropathy
• Electrodiagnositic Tests
1. Nerve Conduction Studies - evaluates how the
nerves transmit electrical stimuli.
2. Electromyography – (EMG) measures the
electrical activity of muscles in response to
nerve stimulation.
• Skin Biopsy – Small Fiber Neuropathy cannot be
diagnosed with EMG and nerve conduction
studies that only measure the large fibers.
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Dr. RS Mehta, BPKIHS

42. Other Investigations:
 Diabetes
 Autoimmunity
 Infections
 Nutritional Deficiencies
 Toxins
 Hereditary Conditions
 Certain Cancer and Cancer Treatments
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Dr. RS Mehta, BPKIHS

43. Neuropathies associated with metab
and endocrine disorders
Diabetes mellitus (occur singly or in combin)
- Symmetric sensory or mixed polyn
- Asymmetric motor radiculopathy
( diabetic amyotrophy)
- Mononeuritis or mononeuritis multiplex
- Autonomic
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44. Toxic neuropathies
- Alcoholic polyn
- Distal sensorimotor polyn frequently accomp
by painful cramps, muscle tenderness and
painful paraesthesia in legs
- Autonomic
- May respond to B1
- Recurs or progress with alcohol intake
- Similar distal sensorimotor polyn occurs in
beri beri (thiamine def)
Dr. RS Mehta, BPKIHS
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45. Vitamin deficiency
- Def states occur in malnutrition
- preventable
- potentially reversible if treated early
1- B12 def
-
Distal sensory polyn
Absent ankle jerk
Extensor planter
Optic neuropathy
Intellectual dysfn
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46. 2- Thiamine def ( beri beri)
- polyn
- cardiac failure
- nystagmus, ophthalmoplegia, ataxia,
amnesia, confusion, coma
- Parental B1 for Rx
3- Pyridoxine def (B6)
- Mainly sensory
- More common in slow acetylaters on INH.
- 10mg per day
Dr. RS Mehta, BPKIHS
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47. Infective neuropathies
1- Leprosy
- peripheral nerves are thickened
- In LL leads to gloves & stockings sensory
loss
- Multiple mononeuropathy
2- Diphtheric neuropathy (demyelinating)
- Loss of accomodation in 2-4 W
- polyn in 4-6 W
Dr. RS Mehta, BPKIHS
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48. 3- AIDS neuropathy
- Chronic symmetric sensorimotor polyn
- progressive polyradiculopathy or
radiculomyelopathy ? CMV
- Seropositive Pts may also develop
demyeelinating polyradiculopathy and
mononeuritis multiplex
Dr. RS Mehta, BPKIHS
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49. Inflammatory polyneuropathies
1- Acute post infective polyn
- 1-4/52 following resp tract infection,
( in 25% of cases, more severe & residual
deficit), surgery & immunization
- Demyelination of the spinal roots & periph N
has probably immunological basis.
- Patient presents with distal weakness and
numbness ascending over days to involve
the face, resp muscles & bulbar muscles.
- Patient may C/O back pain.
Dr. RS Mehta, BPKIHS
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50. - Treatment:
- supportive ( ABC, nursing, physioth)
- mechanical ventilation if resp paralysis
occur.
- Monitor resp with vital capacity.
- Plasmapheresis & IV Ig if given early
- Use of steriod is controversial.
- complete recovery occur in 80% in 3-6 M
- mortality 4% & 3% relapse.
- remainder left with disability.
Dr. RS Mehta, BPKIHS
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51. Predominantly motor neuropathy
1- GB
2- Ca neuropath
3- Charcot Marie tooth disease (peroneal
muscular atrophy
4- lead poisoning
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52. Management of neuropathies
1- In 1/3 treatable cause:
- toxins & offending drugs removed
- Deficiencies & metab abn corrected
- inflammatory causes by
immunosuppression
2- In 1/3 there is identifiable cause but no
TR as in hereditary
3- In 1/3 no specific cause
-- Physiotherapy & occupational therapy
Dr. RS Mehta, BPKIHS
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53. • Rx……………
• Drugs: Gabapentin, Amitriptyline etc.
• In addition to these medications there are
ointments and creams used by patients.
• Oxycodone, Hydrocodone and as well as
other opiates are often prescribed for
neuropathy pain.
• Patients have described getting relief from
acupuncture, reflexology and others.
Dr. RS Mehta, BPKIHS
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54. Types of Neuropathy: Summary
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Autonomic Neuropathy
Cancer-Related Neuropathies
Compressive Neuropathies
Diabetic Neuropathy
Drug-Induced and Toxic Neuropathy
G.I. and Nutrition-Related Neuropathies
Hereditary Neuropathies
Immune-Mediated Neuropathie
Infectious Diseases and Neuropathy
Neuropathic Pain
Chemotherapy Induced Neuropathy
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Dr. RS Mehta, BPKIHS

55. • TENS is delivering tiny
electrical impulses to
specific nerve pathways
through small electrodes
placed on skin.
TENS
• This method is based on
teaching a patient to
control certain body
responses that reduce
pain.
BIOFEEDBACK
• During hypnosis a patient receives
suggestions intended to decrease
perception of pain.
• It is proven that
acupuncture can be an
effective treatment for
chronic pain, including
the pain of neuropathy.
ACUPUNCTURE
• Designed to help reduce the muscle
tension. They range from deepbreathing exercises to visualization,
yoga and meditation.
HYPNOSIS
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RELAXATION
TECHNIQUES
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56. Thank you
Dr. RS Mehta, BPKIHS
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57. Dr. RS Mehta, BPKIHS
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58. Simplified diagram of lumbosacral plexus. Contribution of L1
root is not shown. Lumbosacral trunk or cord is shown.
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59. Dr. RS Mehta, BPKIHS
Origin, course, and distribution of sciatic nerve
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60. Components
•
•
•
•
•
12 pair of Cranial nerves
31 pair of Spinal nerves
Sympathetic trunks
Ganglia
Splanchnic nerves
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61. What exactly is the deficit – Sensory
•
•
•
•
•
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Pain
Touch
Pressure
Temperature
Vibration
Position
•Spinothalamic
•Posterior Column
Dr. RS Mehta, BPKIHS
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62. What exactly is the deficit – Motor
Test:
Abd D Minimi
Ulnar nerve supplies:
Claw Hand
Hypothenar muscles
Card Test
3,4 Lumbricals
All interossi
Book Test
Adductor Pollicus
Anatomy Based Tests
Dr. RS Mehta, BPKIHS
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63. What is the effect of the loss – wasting, residual paralysis,
deformity,
contractures,
sores
Dr. RS Mehta, BPKIHS
Restoring:
Dorsi-flexion of
wrist in Erbs
Palsy.
Wrist
extensors have
been
isolated
and tested will
now
be
powered
by
suturing
Pronator Teres
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insertion
to