Neuropathy
Pathophysiology
Epidemiology
Diagnosis
Peripheral Neuropathies
Large Fiber (LFN)
Small Fiber (SFN)
Most common painful neuropathy
Distal painful peripheral neuropathy
Painful Feet and later may hands
Burning pain, pins and needles: + symptoms
Numbness: -symptoms
Mixed Fiber Neuropathies (MFN)
Gorson KC, Ropper AH. Idiopathic distal small fiber neuropathy. Acta Neurologica
Scandinavica. 1995;92(5):376-382
Nerve Fiber Types
Aβ C, Aδ
Peripheral Neuropathy
15 to 20 million people in the United
States over age 40 have some type of
peripheral neuropathy
Non-Painful
Painful: Small Fiber Neuropathy (SFN)
pain, burning, tingling, and numbness in a
length-dependent or stocking-glove
distribution
Often normal
Neurologic exam
EMG Aα fibers
NCS Aβ fibers
Erroneous diagnoses:
Plantar fasciitis
Vascular insufficiency
Degenerative lumbosacral spine disease
Tavee J & Zhou L, Cleve Clin J Med. 2009 May;76(5):297-305
SFN Prevalence
Sjogren’s: 45% have pure SFN with
burning pain
Diabetes: neuropathy in 50-70%, not all
with burning pain
Inferred prevalence:
Diabetes is at approx 6% of population (CDC)
Distal burning pain occurs in 15-20% of
diabetics, or ~1% of entire population
Of patients referred for the evaluation of
SFN, about 1/3 have diabetes 3-5%
Italian study found prevalence of 3% (Beghi,
1995)
Lopate G et al., Muscle Nerve. 2006 May;33(5):672-6
Low PA et al., Diabetes Care. 2004 Dec;27(12):2942-7.
SFN Pathophysiology
Degeneration of small
Unmyelinated C-Fibers
Thinly myelinated A-δ Fibers
~Autonomic fibers
When progression from small fiber to large
fiber neuropathy occurs, a symptomatic
change from "positive" to "negative"
neuropathic symptoms is observed clinically
Gorson KC, Ropper AH. Idiopathic distal small fiber neuropathy. Acta Neurologica
Scandinavica. 1995;92(5):376-382
Distal Symmetric Polyneuropathy:
Small Fiber
• First: pain and hyperalgesia
• Later: loss of sensitivity
oHeat/Cold Aδ & C fibers
oLight touch/pinprick Aβ fibers
• Predisposes to diabetic foot
disease
• Electrophysiology may not
detect nerve damage
• Autonomic symptoms