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Multifocal Motor Neuropathies and Diabetic Neuropathy

by Carlo Raj, MD
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    00:01 Cause of metabolic neuropathy.

    00:03 Diabetes is always on top of that list, as is thyroid disease, hepatic failure, your kidney is failing, uremic neuropathy, that’s an important one.

    00:15 At the end of this entire section, I want to walk you through a very, very important, what I call a polyneuropathy Nirvana diagram, as we shall see.

    00:27 Porphyric neuropathy, what does that mean? You know much biochemistry, you should know about your porphyria pathway on your way to produce your heme.

    00:36 And in that porphyria pathway, there are a couple of diseases or biochemical pathologies that you should be familiar with.

    00:44 One of them being acute intermittent porphyria.

    00:47 Vitamin deficiencies, either B1, B6, or B12.

    00:51 Once again, remember, B1, that's a problem.

    00:53 Thiamine.

    00:55 B6 required, for once again, proper myelination.

    00:59 And of course, B12.

    01:01 Critical care neuropathy, these are metabolic neuropathies, important etiologies Let’s quickly walk through diabetic neuropathy.

    01:09 Chronic progressive distal symmetric diabetic polyneuropathy.

    01:13 Every single word there is incredibly important.

    01:17 Diabetes, in the U.S., type 2 diabetes, of course, extremely common.

    01:23 Chronicity, decades have gone by, and now at this point, you’re going to have symmetric distal neuropathy taking place.

    01:32 We call this stocking-glove, don't we? Most common presentation, small and large fiber involvement.

    01:38 There is no discrimination with diabetic neuropathy.

    01:41 It affects you everywhere.

    01:44 Neuropathic pain is usually prominent.

    01:47 For example, what about the nerves in the stomach, would they be lost? Oh, absolutely.

    01:52 So, you have paralysis of the stomach.

    01:54 We call this gastroparesis, or maybe your patient has suffered myocardial infarction, and there was no chest pain.

    02:01 A sound myocardial infarction, nerves have been lost.

    02:05 Or down in the feet, and here once again, the nerves, you’re worried about decubitus ulcers, aren’t you? Diabetic neuropathy, small and large fibers.

    02:16 Neuropathic pain, usually prominent, if you’re actually wondering about what’s happening to your nerves.

    02:24 Clinical features: initial symptoms are severe thigh and back pain with diabetic neuropathy.

    02:31 And with diabetic proximal motor neuropathies, what we’re referring to specifically, our diabetic, what’s known as amyotrophy.

    02:39 Followed by hip and thigh muscle weakness and atrophy.

    02:42 So, you begin initially with thigh and back pain, and then followed by hip and thigh muscle weakness and atrophy.

    02:50 You put all this together and you call it amyotrophy, proximal motor.

    02:57 We have the diabetic proximal motor neuropathy.

    03:00 Continuing with our discussion.

    03:02 Acute axonal diabetic polyneuropathy.

    03:05 And then with diabetes, remember, there’s no discrimination here.

    03:09 By that, I mean, you could have diabetic mononeuropathy.

    03:12 What does that mean? You could have one nerve that is being affected.

    03:16 Maybe radial nerve, maybe the ulnar nerve, maybe the median nerve, maybe the common peroneal nerve.

    03:22 You could have the nerves coming at a spinal cord, radiculopathy, polyradiculopathy, compression neuropathy.

    03:31 All are significantly much more common in patients that are diabetic, every single nerve, just about.

    03:38 In a patient with diabetes, over a long period of time, if not properly managed, is at risk for injury.

    03:46 Plain and simple to pathologists maybe, to a doctor possibly, but for the patient, it’s a lot of education, isn’t it? Management: Well, the most important thing is going to be glycemic control.

    04:01 That’s your best measure of treatment.

    04:03 And by this, we mean what? Lifestyle modification: lose weight, watch your diet.

    04:08 Why do I roll my eyes when I do that? Because you know if you’ve done your rotations or those of you that are practicing, it’s easier said than done.

    04:18 Symptomatic management: Well, now if you’re actually getting into diabetic neuropathy and you need to treat the symptoms, tricyclic antidepressants, antiepileptics, especially carbamazepine, and perhaps, gabapentin.

    04:32 Remember, carbamazepine, that was actually a first line drug for trigeminal neuralgia.

    04:39 So, we know the carbamazepine definitely helps out with people that have neuropathies.

    04:44 Tramadol, opioids, maybe perhaps because of refractory cases that pain is actually intolerable sometimes.

    04:52 This is a deadly road, isn’t it, the opioid? A huge discussion in behavioral science.

    04:57 And NSAIDS for entrapment neuropathies as well.


    About the Lecture

    The lecture Multifocal Motor Neuropathies and Diabetic Neuropathy by Carlo Raj, MD is from the course Polyneuropathy. It contains the following chapters:

    • Multifocal Motor Neuropathies
    • Diabetic Neuropathy

    Included Quiz Questions

    1. Burning sensation in all the fingers up to the wrist
    2. Burning sensation in the right hand from the wrist to fingers only
    3. Burning sensation in the left hand from the wrist to fingers only
    4. Burning sensation in the left hand from wrist to fingers and in right hand up to the biceps
    5. Burning sensation of right-hand 4th and 5th fingers only
    1. Acute intermittent porphyric polyneuropathy
    2. Uremic polyneuropathy
    3. B12 polyneuropathy
    4. Critical care neuropathy
    5. Diabetic neuropathy
    1. Constant control of glucose levels
    2. Use of Gabapentin
    3. Use of Carbamazepine
    4. Use of NSAID's
    5. Use of opioids
    1. Neuromyelitis optica
    2. Compression neuropathy
    3. Decubitus ulcers
    4. Mononeuropathy
    5. Polyradiculopathy

    Author of lecture Multifocal Motor Neuropathies and Diabetic Neuropathy

     Carlo Raj, MD

    Carlo Raj, MD


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