Peripheral nerves are composed of sensory, motor, and autonomic elements. Diseases can affect the cell body of a neuron or its peripheral processes, namely the axons or the encasing myelin sheaths. Most peripheral nerves are mixed and contain sensory and motor as well as autonomic fibers. Nerves can be subdivided into three major classes: large myelinated, small myelinated, and small unmyelinated. Motor axons are usually large myelinated fibers that conduct rapidly (approximately 50 m/s). Sensory fibers may be any of the three types. Large-diameter sensory fibers conduct proprioception and vibratory sensation to the brain, while the smaller-diameter myelinated and unmyelinated fibers transmit pain and temperature sensation. Autonomic nerves are also small in diameter. Thus, peripheral neuropathies can impair sensory, motor, or autonomic function, either singly or in combination. Peripheral neuropathies are further classified into those that primarily affect the cell body (e.g., neuronopathy or ganglionopathy), myelin (myelinopathy), and the axon (axonopathy). These different classes of peripheral neuropathies have distinct clinical and electrophysiologic features. This chapter discusses the clinical approach to a patient suspected of having a peripheral neuropathy, as well as specific neuropathies, including hereditary and acquired neuropathies. The inflammatory neuropathies are discussed in Chap. 54.
In approaching a patient with a neuropathy, the clinician has three main goals: (1) identify where the lesion is, (2) identify the cause, and (3) determine the proper treatment. The first goal is accomplished by obtaining a thorough history, neurologic examination, and electrodiagnostic and other laboratory studies (Fig. 53-1). While gathering this information, seven key questions are asked (Table 53-1), the answers to which can usually identify the category of pathology that is present (Table 53-2). Despite an extensive evaluation, in approximately half of patients, no etiology is ever found; these patients typically have a predominately sensory polyneuropathy and have been labeled as having idiopathic or cryptogenic sensory polyneuropathy (CSPN).
Approach to the evaluation of peripheral neuropathies. CIDP, chronic inflammatory demyelinating polyradiculoneuropathy; EDx, electrodiagnostic; GBS, Guillain-Barré syndrome; IVIg, intravenous immunoglobulin.
TABLE 53-1APPROACH TO NEUROPATHIC DISORDERS: SEVEN KEY QUESTIONS ||Download (.pdf) TABLE 53-1APPROACH TO NEUROPATHIC DISORDERS: SEVEN KEY QUESTIONS
|1. What systems are involved? |
|– Motor, sensory, autonomic, or combinations |
|2. What is the distribution of weakness? |
|– Only distal versus proximal and distal |
|– Focal/asymmetric versus symmetric |
|3. What is the nature of the sensory involvement? |
|– Temperature loss or burning or stabbing pain (e.g., small fiber) |
|– Vibratory or proprioceptive loss (e.g., large fiber) |
|4. Is there evidence of upper motor neuron involvement? |
|– Without sensory loss |
|– With sensory loss |
|5. What is the temporal evolution? |
|– Acute (days to 4 weeks) |
|– Subacute (4–8 weeks) |
|– Chronic (>8 weeks) |
|– Monophasic, progressive, or relapsing-remitting |