Diseases of the Peripheral Nervous System

Diseases of the Peripheral Nervous System Differences between upper and lower motor neuron paralysis

PERIPHERAL NERVOUS SYSTEM UPPER MOTOR NEURON, OR SUPRANUCLEAR LOWER MOTOR NEURON, OR NUCLEAR-
Structures outside of the pial membrane of the spinal cord and brainstem PARALYSIS INFRANUCLEAR PARALYSIS
Muscles affected in groups; never individual muscles Individual muscles may be affected
Spinal nerve roots, spinal nerve, plexus, peripheral nerve, neuromuscular junction, muscle
Atrophy slight and due to disuse Atrophy pronounced; up to 70% of total bulk
Peripheral Nerve Disease
Sensory, motor or mixed function Spasticity with hyperactivity of the tendon reflexes and Flaccidity and hypotonia of affected muscles with loss
Sensory loss of all modalities over autonomous zone extensor plantar reflex (Babinski sign) of tendon reflexes
Area of light touch sensory loss greater than area of pin prick sensory loss Plantar reflex, if present, is of normal flexor type
Lower motor neuron type of paralysis
Decreased muscle stretch reflex Fascicular twitches absent Fasciculations may be present
Skin (thin & scaly), no hair, sweating, ulcers
Normal nerve conduction studies; no denervation Abnormal nerve conduction studies; denervation
potentials in EMG potentials (fibrillations, fasciculations, positive sharp
waves) in EMG

Classification and function of sensory peripheral nerve fiber types and symptoms associated with intrinsic
dysfunction of each type

Fiber type Alternative Fiber Conduction velocity Function and symptoms of

designation diameter (M/S) dysfunction
A-alpha and beta II 5-20 30-70 Touch, pressure
Large, heavily myelinated

A-gamma Ia 3-6 15-30 Spindle afferents

A-delta III 2-5 12-30 Pain and temperature,
soma touch
(Sharp, lancinating, prickly
Small, thinly myelinated pain)
B 1-3 3-15
C IV 0.3-1.1 0.5-2 Slow pain and temperature

Small, unmyelinated; (Dull, burning, poorly

polymodal localized pain)

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 Diseases of the Peripheral Nervous System

Mononeuropathy- one nerve

Mononeuropathy multiplex- several isolated nerves
Nerves widely separated
Polyneuropathy- many peripheral nerves simultaneously impaired
Symmetric, distal loss of function
Axonal length principle

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 Diseases of the Peripheral Nervous System

DISEASES OF SPINAL NERVE AND ROOT

Dorsal and anterior rootmixed spinal nerveanterior Rami (limbs,non axial skeletal muscle, skin of
the lateral and anterior trunk and neck) also communicate with the sympathetic ganglia
Posterior Rami (skin on dorsal aspect of trunk-sensory;motor-long. Muscle of axial skeleton)
Dermatome, myotome
Radicular pain- abrupt, well localized

DISC REFLEX ROOT MOTOR SENSORY PAIN

C4-C5 Biceps C5 Deltoid, external rotators Lateral arm Neck, shoulder, anterior
Brachioradialis of arms, forearm flexors arm

C5-C6 Same C6 Forearm(F); arm Lateral forearm, Lateral arm and dorsal
pronation, finger and Arm, 1 & 2 digits forearm
wrist (e)

C6-C7 Triceps C7 Arm extension, finger (e & 3 & 4 digits Dorsal forearm
f), wrist (e & f)

C7-T1 Finger flexor C8 Intrinsic hand muscle Medial forearm and Dorsal forearm
hand fifth digit

L3-L4 Patellar L4 Knee extension Knee and medial leg Low back, buttock,
anterior lateral anterior
ENTRAPMENT SITES IN THE UPPER EXTREMITIES leg
Nerve Main site of compression
Dorsal scapular Scalenus Medius Muscle L4-L5 Same L5 Thigh, adduction knee, Lateral leg, large Law back buttock, lateral
Suprascapular Suprascapular Foramen plantar dorsiflexion toe, dorso medial thigh, anterior lateral calf
Axillary Quadrilateral Space leg
Median Ligament Of Struthers, Pronator Teres Carpal
L5- S1 None S1 Hip extension, plantar Lateral foot, sole, Low back, buttocks,
Tunnel flexion of foot and toes small toe lateral thigh, calf
Ulnar Cubital Tunnel, Guyons Canal
Radial Spiral Groove, Elbow
Ilioingual Abdominal Wall, Inguinal Canal GBS
Genitofemoral Abdomen, Femoral Canal, Inguinal Canal Worldwide, no sex, age predilection
Femoral Psoas Muscle, Inguinal Ligament Preceded by GI or respiratory infection 1 to 3 weeks in 60% of cases, post vaccinal
Obturator Pelvic Wall, Obturator Wall Campylobacter jejuni- most frequent identifiable
Lateral femoral cutaneous Inguinal Ligament 1.7 cases per 100,000 per year
Sciatic Pelvis, Gluteal Region, Piriformis Muscle Autoimmune
Tibial Popliteal Fossa, Tarsal Tunnel, Foot Anti-GQ1b (ophthalmoplegia)
Peroneal Fibular Head, Anterior Tarsal Tunnel Anti-GM1

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 Diseases of the Peripheral Nervous System

Clinical features Probable cellular events in GBS

Cardiovascular autonomic instability
Dysautonomia
Respiratory depression Attachment of lymphocyte to endoneurial vessels
Immobility With transformation
Facial diplegia

demyelination with axonal sparing

lymphocyte and PMN; Axonal death

Intense root or nerve lesion

dissolution

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Diseases of the Peripheral Nervous System

Modified Ossermans Classification

Class 1 Patients with ocular involvement alone
Class 2 Mild weakness, not incapacitating without oropharyngeal or respiratory muscle involvement
Class 3 Moderate weakness, not incapacitating including oropharyngeal and respiratory muscle weakness
Class 4 Incapacitating weakness of any muscle system incl. oropharyngeal& respiratory muscle weakness
Class 5 Life-threatening respiratory insuffiency requiringventilatory assistance

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JOLLY TESTING Consensus Statement PNA

Benefit from Thymectomy Level 2B
HYPOTHENAR MUSCLES Generalized myasthenia gravis
Age bet. Puberty and 60 years
DECREMENT Female gender
Duration of disease within 2 years from onset
INCREMENT POSITIVE anti-chr Ab

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Diseases of the Peripheral Nervous System

TRIGEMINAL NEURALGIA
UNILATERAL, PAROXYSMAL
rd
Second and 3 division of CN 5
Presence of an initiating or trigger point
No sensory or motor dysfunction
Usually idiopathic
Disorder of middle age and later life

Bells Palsy
23/100,000
?2 weeks preceding delivery and 2 weeks postpartum
HSV type 1
Acute onset of paralysis maximum in 48 hours and all within 5 days
Pain behind the ear 2 days before
Hypesthesia, impairment of taste

Sign Neuropathy Myopathy

Weakness, wasting, Yes Yes
decreased reflexes
Distribution Distal Proximal
Twitching Yes No
Hyperreflexia No No
Sensory loss Yes No
Nerve conduction Slow Normal
EMG Fibrillations, decreased Decreased amplitude and
no of potentials duration of potentials
Elevated CSF protein Yes No
Elevated muscle enzyme No Yes
Muscle biopsy Group atrophy degeneration

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tabs

FIBRILLATION
POSITIVE SHARP WAVE

FASCICULATION

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