Sensory DisturbanceSensory Disturbance

Dr Naomi WarrenDr Naomi WarrenConsultant NeurologistConsultant Neurologist

RVIRVIFeb 25Feb 25thth 2016 2016

OutlineOutline Basics of anatomyBasics of anatomy Could it be MS?Could it be MS? Peripheral neuropathyPeripheral neuropathy Entrapment neuropathiesEntrapment neuropathies

Where is the lesion?Where is the lesion?

UMN or LMN?

Upper motor neuroneUpper motor neurone

Spinal cord = sensory level

Lower motor neuroneLower motor neurone

LMNLMN NerveNerve Normal tone/flaccidNormal tone/flaccid Peripheral or Peripheral or

individual nerveindividual nerve Reduced reflexesReduced reflexes Sensory involvementSensory involvement

MuscleMuscle Normal tone/flaccidNormal tone/flaccid Variable pattern often Variable pattern often

proximalproximal Normal reflexesNormal reflexes No sensoryNo sensory

•Anterior horn cell

•Motor only

•Fasiculations

•Neuromuscular junction

•Motor only

•Reflexes usually normal

•Fatigue

Peripheral neuropathyPeripheral neuropathy

MononeuropathyMononeuropathy

Radiculopathies (pain!)Radiculopathies (pain!)

Case 1Case 1 36 yr old woman36 yr old woman Few months intermittent sensory Few months intermittent sensory

symptoms arms and legs – random. symptoms arms and legs – random. Occ drops things – feels clumsyOcc drops things – feels clumsy Feels lethargicFeels lethargic Mild back painMild back pain Nil on examNil on exam Worried has MSWorried has MS

Unlikely MS

Important questionsImportant questions Pattern of sensory disturbancePattern of sensory disturbance

• Evolving v random?Evolving v random?• LocationLocation

Bladder?Bladder? Previous neuro eventsPrevious neuro events

• Eg optic neuritis/vertigo/trigeminal Eg optic neuritis/vertigo/trigeminal neuralgianeuralgia

Case 2Case 2 36 year old woman36 year old woman Sensory disturbance feet 3/52 ago – Sensory disturbance feet 3/52 ago –

spreading up legs onto abdo over spreading up legs onto abdo over 1/52 1/52

Fingers tinglyFingers tingly Bladder urgencyBladder urgency Now starting to improveNow starting to improve Brisk reflexes – nil elseBrisk reflexes – nil else

MS possible

SENSORY SYMPTOMSSENSORY SYMPTOMS

Could it be MS?Could it be MS?

StatisticsStatistics

Commonest cause of Commonest cause of acquired neurological acquired neurological disability in young peopledisability in young people

Prevalence in UK Prevalence in UK (~1990s): (~1990s): NE England ?150/100 000 NE England ?150/100 000

(1:650)(1:650) F:M 3:1F:M 3:1

What is MS?What is MS?

Clinical diagnosisClinical diagnosis

Loosest definition: Loosest definition: 1.1. At least 2 episodes of CNS At least 2 episodes of CNS

dysfunction dysfunction (relapses/attacks/exacerbations) (relapses/attacks/exacerbations)

2.2. ‘‘disseminated in time and space’ disseminated in time and space’ 3.3. not explained by something elsenot explained by something else

MRIMRI

relapsing/ remittingrelapsing/ remitting primary progressive

Patterns of MSPatterns of MS

secondary progressive

85% 15%

( ‘benign’)

5%

Common presentations Common presentations (relapses)(relapses)

transverse myelitistransverse myelitis

brainstem syndromesbrainstem syndromes

optic neuritisoptic neuritis

paroxysmal symptomsparoxysmal symptoms

The duration of the attack should be The duration of the attack should be longer than 24 hourslonger than 24 hours

1 to 2/52 3 to 5/52

What are the typical sensory What are the typical sensory symptoms of MS?symptoms of MS?

((Nb around 35% of presenting symptoms are sensoryNb around 35% of presenting symptoms are sensory))

• Ascending numbness starting in feet• Facial sensory disturbance & typical TN• Lhermitte’s phenomena• Bilateral hand numbness• Hemiparesthesia (rare thalamic presentation)• Dysaesthesia in the whole of one limb (or non

dermatomal)• “sunburn” or “itch” in a non-dermatomal patch

(rare)

Whole body numbness or parasthesiaWhole body numbness or parasthesia Transient flitting sensory disturbances lasting Transient flitting sensory disturbances lasting

minutes to hoursminutes to hours Uncomplicated BellUncomplicated Bell’’s palsys palsy Fatigue as isolated or predominant symptomFatigue as isolated or predominant symptom Chronic dizziness/ light-headednessChronic dizziness/ light-headedness ““WeaknessWeakness”” in setting of musculoskeletal in setting of musculoskeletal

pain/tendernesspain/tenderness Atypical facial painAtypical facial pain

What is not MS….What is not MS….

MS DiagnosisMS Diagnosis ClinicalClinical Bloods – autoabBloods – autoab MRI MRI Sometimes:Sometimes:

• Evoked potentialsEvoked potentials• Lumbar punctureLumbar puncture

If MRI normal and history not typical – very unlikely MS

MS TreatmentMS Treatment Acute relapseAcute relapse

• Treat infectionsTreat infections• Steroids – oral (Steroids – oral (500mg methylpred 5/7500mg methylpred 5/7) v IV) v IV

For RRMSFor RRMS• InjectableInjectable• InfusionsInfusions• OralOral

If problems contact MS team – Drs or nurses

Peripheral NervePeripheral Nerve

Peripheral Nerve TypesPeripheral Nerve Types SensorySensory

• Large fibres – light touch, vibration, Large fibres – light touch, vibration, proprioceptionproprioception

• Small fibres – pain and tempSmall fibres – pain and temp MotorMotor

• NerveNerve• Anterior horn cellAnterior horn cell

AutonomicAutonomic

Mechanisms of InjuryMechanisms of Injury Axonal degenerationAxonal degeneration

• Longest axons affected firstLongest axons affected first• ““dying back”dying back”• Recovery slow - regenerationRecovery slow - regeneration

DemyelinationDemyelination• Slowing of conductionSlowing of conduction• Can be patchyCan be patchy• Repair can be quick unless axonal damageRepair can be quick unless axonal damage

Vascular nerve damageVascular nerve damage• Isolated axonal degen usually with vasculitisIsolated axonal degen usually with vasculitis

Peripheral Nerve DisordersPeripheral Nerve Disorders Spectrum of peripheral nerve disorders includes:Spectrum of peripheral nerve disorders includes:

• Mononeuropathies (entrapment, trauma, etc)Mononeuropathies (entrapment, trauma, etc)

• Mononeuritis multiplex (DM, vasculitis)Mononeuritis multiplex (DM, vasculitis)

• Radiculopathies (discs, immune)Radiculopathies (discs, immune)

• Plexopathies (immune, neoplastic)Plexopathies (immune, neoplastic)

• Peripheral NeuropathiesPeripheral Neuropathies

Peripheral neuropathy - historyPeripheral neuropathy - history Time courseTime course Pattern (starts in legs)Pattern (starts in legs) Diabetes?Diabetes? Alcohol?Alcohol? Other toxins/drugs?Other toxins/drugs?

• Amiodarone, metronidazole, phenytion, Amiodarone, metronidazole, phenytion, chemotx, HIV drugs etcchemotx, HIV drugs etc

Sensory +/or motorSensory +/or motor

Peripheral neuropathy – Peripheral neuropathy – examinationexamination

Glove and stocking sensory Glove and stocking sensory disturbancedisturbance• Test PP, JPS, VibTest PP, JPS, Vib

Distal wastingDistal wasting Tone normal or reducedTone normal or reduced Weakness – distal > proximalWeakness – distal > proximal Reduced/absent reflexesReduced/absent reflexes

Peripheral NeuropathiesPeripheral NeuropathiesClassificationClassification

Peripheral neuropathy

Axonal Demyelinating

<4 weeks

AIDP (GBS)Diphtheria

CIDPParaproteinsHereditaryHIV

Weeks

AlcoholDrug inducedToxinsNutritional eg B12Subst abuse

DiabetesAlcoholParaproteinsConnective tissue diseaseAmyloidMetabolicHereditary

Months - years Months -

years

AIDP -Refer A+E or Neuro emergency clinic

Case 3Case 3 76 yr old man76 yr old man 5 months progressive numbness/tingling 5 months progressive numbness/tingling

feetfeet Worse at nightWorse at night Feels unsteadyFeels unsteady No meds, DMNo meds, DM Alcohol – 30 units/weekAlcohol – 30 units/week Nil on exam, except reduced AJ and Nil on exam, except reduced AJ and

sensation feetsensation feet

Check bloods then if no answer refer to neuro

InvestigationsInvestigations Bloods – Bloods – FBC, U+E, LFT, Gluc/HBA1C, Ca, FBC, U+E, LFT, Gluc/HBA1C, Ca,

TSH, ESRTSH, ESR, Autoab, Igs and Electro, , Autoab, Igs and Electro, B12, B12, folate folate +/- ANCA, ENA, genetics, +/- ANCA, ENA, genetics, HIV HIV

CXRCXR Nerve conduction studiesNerve conduction studies

• Help distinguish axonal/demyelinating, Help distinguish axonal/demyelinating, and sens/motorand sens/motor

Rarely: nerve biopsyRarely: nerve biopsy

DiabetesDiabetes Peripheral neuropathyPeripheral neuropathy

• In 30% but only 10% symptomaticIn 30% but only 10% symptomatic• Often only PP, tempOften only PP, temp• Can occur in prediabetesCan occur in prediabetes

Diabetic AmyotrophyDiabetic Amyotrophy• Rapid pain + weakness, ant thigh, abs KJRapid pain + weakness, ant thigh, abs KJ

Autonomic neuropathyAutonomic neuropathy• Pupil abn, sweating, post BP, GI, bladder, impotencePupil abn, sweating, post BP, GI, bladder, impotence

Cranial Nerve palsyCranial Nerve palsy• Pupil sparing III, VI, VIIPupil sparing III, VI, VII

Median nerveMedian nerve All thumb muscles All thumb muscles

except adductorexcept adductor Lat 2 long finger Lat 2 long finger

flexors flexors (if above (if above wrist)wrist)

SensorySensory Most commonly Most commonly

carpal tunnelcarpal tunnel• Night, carryingNight, carrying• Check TFTCheck TFT

NCS (open access north of tyne)

Treatment – conservative v injection v surgery

Ulnar NerveUlnar Nerve Small muscles Small muscles

handhand• Add/abductorsAdd/abductors

Med 2 long finger Med 2 long finger flexors flexors

SensorySensory Most commonly at Most commonly at

elbowelbow

Refer neuro for NCS Treatment – conservative v surgery

Radial NerveRadial Nerve Extensors wrist and Extensors wrist and

fingersfingers +/- triceps+/- triceps SupinatorSupinator Little sensoryLittle sensory Most commonly Most commonly

around humerusaround humerusIf not improving – refer neuro Treatment - conservative

Common Peroneal NerveCommon Peroneal Nerve Dorsiflexion Dorsiflexion Eversion footEversion foot Sensory dorsum Sensory dorsum

and lat footand lat foot Most commonly Most commonly

head fibulahead fibula Trauma, fractures, Trauma, fractures,

pressure, castpressure, cast DD L5 root DD L5 root

(eversion spared)(eversion spared)

If not improving – refer neuro

Treatment - conservative

Meralgia ParastheticaMeralgia Parasthetica

Sensory disturbance Sensory disturbance lateral thighlateral thigh

Obesity, pregnancyObesity, pregnancy No associated featuresNo associated features Do not need referral if Do not need referral if

no other symptomsno other symptoms Treatment – weight Treatment – weight

loss, rarely loss, rarely neuropathic pain neuropathic pain killerskillers

ConclusionConclusion Sensory Sensory

disturbance disturbance commoncommon

Mostly benignMostly benign Think anatomyThink anatomy Learn patternsLearn patterns If peripheral nerve If peripheral nerve

check bloodscheck bloods