Clinical Approach in Suspected

Cases of Neuropathy

dr. Meiti Frida, Sp.S (K)

INTRODUCTION
Peripheral neuropathy describes
damage to the peripheral nervous
system.
More than 100 types of peripheral
neuropathy have been identified,
Impaired function and symptoms depend
on the type of nerves that are damaged:
motor, sensory, or autonomic

INTRODUCTION
Motor nerves

control movements of all muscles under

conscious control, such as those used for
walking, grasping things, or talking.

Sensory nerves

transmit information about sensory experiences,

such as the feeling of a light touch or the pain
resulting from a cut.

Autonomic nerves

regulate biological activities that people do not

control consciously, such as breathing, digesting
food, and heart and gland functions

SARAF PERIFER

Epidemiology
Prevalence of peripheral neuropathy in the
family medicine :
Person older in 55 years old 8%
General population 2,4 % .
Type 2 Diabetes Melitus 26,4 %

Hughes RA Peripheral Neuropathy BMJ 2002

EPIDEMIOLOGY
The incidence of peripheral neuropathy is not
known, but it is a common feature of many
systemic diseases.
Diabetes and alcoholism are the most
common etiologies of peripheral neuropathy
The primary worldwide cause of treatable
neuropathy is leprosy.
Neuropathies associated with human
immunodeficiency virus (HIV) infection
account for an increasing number of cases.

EPIDEMIOLOGY
Peripheral neuropathy has numerous
other causes, including hereditary, toxic,
metabolic, infectious, inflammatory,
ischemic and paraneoplastic disorders.
The number of peripheral neuropathies for
which an etiology cannot be found despite
extensive evaluation ranges from 13 to 22
percent.

Causes of Peripheral Neuropathy Based on Clinical

Presentation

CLASSIFICATION OF PERIPHERAL
NEUROPATHY
1. According to the number of nerves :

Mononeuropathy :eg. carpal tunnel syndrome.

Polyneuropathy : often symmetrically so that both

feet or hands affected

Associations
Systemic diseases
Metabolic disorders
Exogenous toxins

Diabetes is prototype: Chronic, sensory and

motor

CLASSIFICATION OF PERIPHERAL
NEUROPATHY
2. ACCORDING TO THE TYPE OF FIBER
Motor fibers: necessary for all our voluntary or intentional
movements, such as walking, stretching, or making a
fist; motor neuropathies may result in weakness or
spasms.
Sensory fibers: involved with feeling and touching;
sensory neuropathies cause abnormal sensations such
as pain, cold, heat or burning sensations, tingling, or
numbness.
Autonomic fibers: concerned with involuntary functions.
autonomic neuropathies can cause changes in these
functions and include decreased perspiration, bowel and
bladder

CLASSIFICATION OF PERIPHERAL
NEUROPATHY
3. According to the pathology
Axonal Neuropathy
Demyelinating Neuropathy
4. According to the onset
Acute Neuropathy : eg trauma
Subacute Neuropthy : eg: GBS
Chronic Neuropathy

FREQUENTLY OCCURRING NEGATIVE AND

POSITIVE SYMPTOMS DUE TO NERVOUS SYSTEM
DYSFUNCTION
NEGATIVE SYMPTOMS
Motor
Paresis
Paralysis
Sensory
Hypoanesthesi
Hypoalgesia
Anosmia
Amaurosis
Deafness
Autonomic
Vasodilatation
Hypo/anhydrosis
Piloerection deficits

POSITIVE SYMPTOMS
Motor
Myokimia
Fasciculation
Dystonia
Sensory
Paraesthesia
Dysesthesia
Allodynia
Hyperaesthesia
Pain
Photopsia
Tinnitus
Autonomic
Vasoconstriction
Hyperhydrosis
Piloerection

Making an Accurate Diagnosis

The evaluation of a peripheral neuropathy can be timeconsuming and costly.
A systematic approach based on a careful clinical and
electrodiagnostic assessment can help narrow the possibilities
and tailor the laboratory evaluation to a specific differential
diagnosis.

History
Physical Examination
EDX studies
Epidermal skin fiber density
Nerve biopsy

History
Neuropathy may present with variety of sign and
symptom s may be clasified negative or positive
Motor Symptoms
Positive symptoms: Kram,twiching,myokymia .
Negative symptoms: Weakness,fasting,fatigue.
Weakness may not be apreciated until 50%80% nerve lost.
Positive symptoms may present earlier in the
disease

Sensory Symptoms
Positive symptoms:burning or lansinating
pain,buzzing, allodynia, hiperalgesia,
tingling/parestesia.
Negative symptoms:hypestesia,gait
abnormalities ataxia, difficulty
differentiating hot and cold,and worsening
balance.

 Symptom of autonomic nerve involvement

Bloating,early satiety,constipation,
diarrhea, urinary incontinence ,impotence,
hyperhidrosis,anhidrosis,orthostasis.
Vasomotor instability.

History
Impairment in activities of daily living
Detail regarding diseases onset ,duration
and progresion .
Any other patients with similar neurology
disorder.
Impairment of consciousness,visual
disturbances.
Social history :occupation,sexual
history,drug abuse ,alcohol,smoking.

History
Illness associated with neuropathy:
Diabetes Melitus, Hypothyroidism, Renal
insuffisiency, hepatic dysfuntion.
Patient with cancer: nutritional deficiency,
chemotheraphy side effect, paraneoplastic
syndrome.
Surgical: multiple orthopedic procedur .
Medication :HIV,Antibiotic,chemotheraphy.

Differential Diagnosis Of Neuropathies by Clinical

Course

Physical Examination
Gait: Tandem,toe/heel walk,hop,squat
Skeletal deformation :pes cavus,hammertoes, and
kyphoscoliosis are sugestive inherited
polineuropathy.claw hand is ulnar palsies.
Nerve elargemenet: infection (leprtosy),neoplasia
(neurofibromatosis)
Skin lesion: vasculitis rash,hipopigmentasi,
hiperpigmentasi,(poems diseases) oral ulcer (Behcet
disease,HIV)
Gum lesion: lead leines
Nail lesion: arsenic Thalium poisoning
Hair lesion: alopecia( hypothyroidism),curly.(giant
axonal neuropthy)

Physical Examination
Motor sign :
Negative : weakness,atrophy. weakness of flexion
and extension of the small toes and weaknes of
great toe extension may be early sign .
Positive :tremor,faciculation,myokimia,cramps
Cranial nerve assessment should include anosmia
(refsum disease,Vitamin B 12,deficiency),
Imparied ocular motility (botulism,Miller fisher),
Fascial weakness (GBS) .

 The Sensory Examination should be aproached

with knowledge of peripheral nerve anatomy.
Small fiber: pain and temperatur loss
Large fiber: vibration ,joint position and light touch
ataxia and romberg test positif.
Autonomic sign: orthostatis,tachycardia,
hiperhydrosis.
Deep tendon reflexes Ankle jerk hyporeflexia is
common with leng dependent neuropathy,but ankle
reflexes normal with small fiber neuropathy.

Diagnostic Testing
Laboratory and genetic testing
Electrodiagnostic testing
Neurophysiologic testing (Evoked
potensial,TMS)
Quantitative Sensory testing
Autonomic testing
Nerve and skin biopsy
Imaging test.

Laboratory and Genetic

Testing
Blood testing for the etiology of a
neuropathy include fasting blood
glucose,electrolytes, complete blood count
and differensial, Vitamin B12, thiroid test, and
serum immunofixation electrophoresis.
Genetic testing is most effective when
talored to the clinical presentation,
inheritance pattern, and electrodiagnostic
clasification.

Tests

Clinical disorders

Routine

Tests

Clinical disorders

Urinalysis (including 24-hour

urine collection)

Heavy metal toxicity,

porphyrias, multiple myeloma

Urine and serum protein

electrophoresis with
immunofixation

Demyelinating neuropathy

Complete blood count

Comprehensive metabolic
panel

Erythrocyte sedimentation
rate

Angiotensin-converting enzyme
levels

Sarcoidosis

Fasting blood glucose level

Antinuclear antibodies, PANCA, C-ANCA

Vasculitis

Thyroid-stimulating
hormone level

level

Vitamin B12
If indicated by clinical
suspicion
Glucose tolerance test, A1C
level

Diabetes mellitus

HIV antibodies

HIV

Hepatic panel

Liver disorders

Lyme antibodies

Lyme disease

Rapid plasma reagin, VDRL

Syphilis

Tests for uncommon conditions

Paraneoplastic panel

Underlying malignancy

Antimyelin-associated
glycoprotein and
antiganglioside antibodies

Sensorimotor neuropathy

Antisulfatide antibodies

Autoimmune polyneuropathy

Cryoglobulins

Cryoglobulinemia

Salivary flow rate, Schirmer

test, rose bengal test, labial
gland biopsy

Sjgren syndrome

Cerebrospinal fluid analysis

Acute or chronic inflammatory

demyelinating neuropathy

Genetic testing

Hereditary neuropathy

Electrodiagnostic studies
Electrodiagnostic studies are helpful in
determining the locatuion of peripheral
nervous system involment.
Magnetic stimulation and somatosensory
evoked potentials may assist in identifying
root plexus and proximal nerve.

 Autonomic testing may complement

evaluation of polyneuropathy
Symphathetic and parasymphatetic funtion
are assesed using cardiovagal,
adrenergic, and sudomotor
Cardiovascular evaluation includes heart
deep breathing ,valsava manuver and
blood pressure response

 Nerve biopsy evaluation should not be

perfomed before adequat clinical,
electroneurofisiology, and laboratory
assesment.

Diagnosis of the Patient with Suspected

Peripheral Neuropathy

Algorithm showing a stepwise approach to the

assessment and investigation of a possible neuropathy.

Willison H J , and Winer J B J Neurol Neurosurg

Psychiatry 2003;74:ii3-ii8
2003 by BMJ Publishing Group Ltd

Treatment
Treatment of peripheral neuropathy has two
goal :
Controling the underlying disease process
Treating trouble some symptom

Summary
History and physical examination remain
the most useful for tools for diagnostic
perpheral neuropathy
Characteristic of a neuropathy aids in
limiting the differential diagnoses and
includes temporal profile,hereditery,and
anatomic clasification
Determining wich diagnostic test evaluate
neuropathy is challenging

CARPAL TUNNEL SYNDROME

Adalah neuropati akibat jebakan (entrapment)
N.Medianus sepanjang carpal tunnel ( terowongan
carpal ).

ETIOLOGI
Gerakan berulang-ulang pada pergelangan tangan
Gangguan endokrin
Idiopatik

GEJALA
Perasaan baal dan semutan pada tiga jari tangan
dimana keluhan ini meningkat di malam hari
sehingga pasien terbangun. keluhan berkurang
dengan mengibaskan tangan.
Nyeri dan baal bila menyetir, mengangkat tangan,
membaca koran.
Otot thenar menjadi lembek dan atrofi
Kelemahan terutama pada tangan kanan.

DIAGNOSTIC TEST

Tinels sign
Phalens sign

PEMERIKSAAN PENUNJANG :
1. Pemeriksaan KHS motorik dan sensorik
N. medianus
2. EMG
abductor pelicis brevis, flexor pollicis longus,
pronator teres, biceps dan triceps.

PENGOBATAN :
1. Kortiko steroid injeksi pada ligamentum di daerah
volar
2. Hindari gerakan berulang pada tangan,
Immobilisasi, splint
3. Operasi

DEMENSIA
DEFINISI
Sindroma penurunan kemampuan intektual progresif
yang menyebabkan kemunduran fungsi kognisi dan
fungsional, sehingga mengakibatkan gangguan
fungsi sosial, pekerjaan dan aktifitas sehari-hari.

JENIS DEMENSIA
1. Demensia vaskuler

2. Alzheimer

DEMENSIA VASKULER
DEFINISI :
Demensia yang disebabkan oleh gangguan
serebrovaskuler dengan penurunan kognisi mulai dari
ringan sampai berat.

JENIS DEMENSIA VASKULER

Demensia vaskuler pasca stroke
- Multiple infark serebri
- Infark
- P.I.S
II. Demensia vaskuler sub kortikal
III.Campuran
I.

GEJALA KLINIS
Gangguan perilaku dan psikis : depresi,
perubahan kepribadian, emosi labil, retardasi
psikomotor
disartria, disfagi, gejala ekstrapyramidal
gangguan keseimbangan, sering jatuh
gangguan berjalan
gangguan miksi

PEMERIKSAAN PENUNJANG
Darah : hematologi, faktor risiko stroke
CT Scan kepala
MRI
Tes Neuropsikologi : MMSE, CDT, ADL,
Skala depresi geriatrik

PENGOBATAN FARMAKOLOGI
a. Untuk gangguan kognisi
- Donepezil HCL 5 mg 1 x 1 tab
- Rivastigmin
- Galantamin
b. Untuk gangguan perilaku
Untuk depresi : antidepresan
Untuk halusinasi :
- Haldol 1 x 0,5-2 mg/hari
- Risperidon tablet 1 x 0,5-2 mg/hari

PENGOBATAN NON FARMAKOLOGI

- Olah raga gerak latih otak
- Stimulasi kognisi
- Terapi cahaya, musik