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<b>So, when we think about matching the patient presentation to</b>
<b> the type of nerve that's involved,</b>
<b>we can look at the symptoms and map that to our </b>
<b>understanding of peripheral nerve anatomy.</b>
<b>When patients present with reduced vibration and </b>
<b>proprioception,</b>
<b>we think about large fiber involvement and disorders that </b>
<b>affect the large fiber nerves.</b>
<b>When patients report pain, temperature, paresthesias, and </b>
<b>neuropathic pain,</b>
<b>we think about small fiber neuropathies in small fiber </b>
<b>involvement.</b>
<b>And weakness points us squarely to motor involvement.</b>
<b>And so, this is how we use both the history</b>
<b>and our physical exam to narrow our differential diagnosis</b>
<b>to the type of neuropathy that we need to investigate.</b>
<b>So, how do we localize a neuropathy?</b>
<b>Well, neuropathy is a peripheral nervous system disorder.</b>
<b>So, we're going to use all those things we know about </b>
<b>peripheral nervous system</b>
<b>localization to help with these patients.</b>
<b>We think about distribution, sensory changes in reflex </b>
<b>findings,</b>
<b>particularly to help localize a neuropathy.</b>
<b>In terms of distribution, we don't see a level.</b>
<b>We can see a distribution that affects multiple nerves or a </b>
<b>single nerve,</b>
<b>but importantly, symptoms should follow the course of the </b>
<b>nerve.</b>
<b>A myotome should be affected if motor involvement is </b>
<b>present,</b>
<b>or a dermatome should be affected if sensory nerves are </b>
<b>affected.</b>
<b>Motor weakness follows the peripheral nerve pattern.</b>
<b>Again, a myotomal pattern. Sensory dysfunction is common</b>
<b>and may range from numbness to tingling paresthesias, to </b>
<b>frank neuropathic pain.</b>
<b>And very, very importantly, reflexes are often reduced or </b>
<b>can be absent.</b>
<b>Absence of reflexes should point strongly to a peripheral </b>
<b>nerve neuropathic disorder.</b>
<b>We use sensory testing to evaluate the nerve involvement.</b>
<b>Sensory testing of vibration and proprioception interrogates</b>
<b> function of the large fiber nerves</b>
<b>and the dorsal column medial meniscus system in the central </b>
<b>nervous system.</b>
<b>So, problems with vibration and proprioception</b>
<b>should point us to large fiber neuropathies or problems </b>
<b>affecting the dorsal column.</b>
<b>Similarly, sensory testing of pain and temperature </b>
<b>interrogates function of the small fiber nerves</b>
<b>and the anterolateral system of the spinal cord.</b>
<b>And so, patients reporting significant pain, neuropathic </b>
<b>pain, paresthesias,</b>
<b>or small fiber symptoms, those symptoms may be arising</b>
<b>from a small fiber neuropathy or pathology affecting the </b>
<b>anterolateral system.</b>
<b>When we think about strength testing,</b>
<b>strength testing assesses motor function in addition to </b>
<b>other areas of the nervous system,</b>
<b>and deep tendon reflex testing assesses both the sensory </b>
<b>nerve, afferent,</b>
<b>and the motor nerve efferent part of that arc.</b>
<b>And so, reduced areflexia can be seen with our sensory </b>
<b>neuropathies,</b>
<b>motor neuropathies, or polyneuropathies.</b>
<b>The distribution of deep tendon reflex reduction or loss is </b>
<b>very important.</b>
<b>Diffuse deep tendon reflex loss, particularly early in the </b>
<b>course of a disease,</b>
<b>suggests proximal nerve pathology like a polyradiculopathy,</b>
<b>and distal deep tendon reflex loss suggest a distal disorder</b>
<b> like a diabetic polyneuropathy,</b>
<b>which is a distal symmetric length-dependent neuropathy </b>
<b>affecting the distal deep tendon reflexes first,</b>
<b>and approximately deep tendon reflexes over time.</b>
<b>So, let's look one more time at reflex testing and </b>
<b>understand the type -</b>
<b>the distribution of reflex abnormalities and how this can </b>
<b>help us to narrow a differential.</b>
<b>When we tap on a reflex, that input is felt and sensed by </b>
<b>peripheral sensory afferents.</b>
<b>The information is propagated up the sensory afferents and </b>
<b>relays</b>
<b>and terminates with a motor nerve in the ventral horn.</b>
<b>That motor information is carried out the interior rootlet </b>
<b>to the peripheral motor nerve</b>
<b>innervating the muscle and resulting in contraction.</b>
<b>So, there's two patterns of deep tendon reflex </b>
<b>abnormalities.</b>
<b>The first we see with the distal symmetric polyneuropathy is</b>
<b> like diabetes.</b>
<b>Their distal deep tendon reflexes are reduced</b>
<b>and the proximal deep tendon reflexes are preserved.</b>
<b>That distal dying back that we see in the vast majority of </b>
<b>distal symmetric links</b>
<b>dependent polyneuropathies like diabetes, we find this </b>
<b>pattern of reflex exam.</b>
<b>The other pattern is early proximal involvement or diffuse </b>
<b>hypo or areflexia.</b>
<b>And a good example of a disorder where we see this is </b>
<b>Guillain-Barre</b>
<b>or acute inflammatory demyelinating polyneuropathy.</b>
<b>Here, diffuse areflexia is a sign of proximal involvement or</b>
<b> a polyradiculopathy.</b>
<b>The immune system can affect any part of the nerve.</b>
<b>It can attack the distal nerve or the proximal nerve,</b>
<b>and there's equal probability of affecting any aspect of the</b>
<b> nerve.</b>
<b>So, we see early involvement, early loss of that sensory </b>
<b>afferent distal efferent arc</b>
<b>of the reflex exam, and early diffuse areflexia in those </b>
<b>disorders.</b>
<b>So, now, let's put it all together. Let's talk about how we </b>
<b>approach peripheral nerve pathology.</b>
<b>We're going to walk through the different localizations in </b>
<b>the peripheral nervous system</b>
<b>and talk about the motor, sensory, and reflex exams at each </b>
<b>level.</b>
<b>Let's start with anterior horn cell disorders.</b>
<b>These are our motor neuron disorders.</b>
<b>On motor exam, patients have weakness and atrophy in the </b>
<b>segment that is affected</b>
<b>or in a focal pattern. And we commonly see fasciculations. </b>
<b>Fasciculations</b>
<b>are signs of peripheral motor nerve dysfunction.</b>
<b>Our sensory exam is intact, there's no sensory </b>
<b>abnormalities, and reflexes are reduced to absent.</b>
<b>And examples of motor neuron diseases affecting the anterior</b>
<b> horn cells</b>
<b>are amyotrophic lateral sclerosis, or ALS, and </b>
<b>poliomyelitis.</b>
<b>Moving out from the spinal cord, spinal nerve root disorders</b>
<b> present differently.</b>
<b>Again, on our motor exam, we do see weakness and atrophy in </b>
<b>a root innervated pattern.</b>
<b>A specific myotome is affected, or for the sensory exam, a </b>
<b>specific dermatome.</b>
<b>Sometimes, we will see fasciculations in the area innervated</b>
<b> by that nerve root,</b>
<b>but that's uncommon. Our sensory exam corresponds to the </b>
<b>nerve root that's involved.</b>
<b>So, we see a dermatomal pattern of sensory deficits.</b>
<b>And our reflexes may be reduced or absent in the pattern of </b>
<b>the nerve root that's affected.</b>
<b>Examples include a herniated disc in the cervical or lumbar </b>
<b>region.</b>
<b>Moving out even more distally, pathology at the peripheral </b>
<b>nerve,</b>
<b>and specifically the motor nerve or a motor neuronopathy.</b>
<b>This looks a lot like motor neuron diseases.</b>
<b>Motor neuronopathy is present with weakness and atrophy that</b>
<b> fit a peripheral nerve distribution,</b>
<b>and often or sometimes with fasciculations.</b>
<b>Sensory nerve loss is minimal in motor neuronopathies.</b>
<b>We should not see sensory findings and reflexes may be </b>
<b>reduced or absent,</b>
<b>and an example may be trauma.</b>
<b>Moving out more distally, we can talk about peripheral nerve</b>
<b> disorders affecting a single nerve,</b>
<b>the mononeuropathies. A motor exam shows weakness and </b>
<b>atrophy,</b>
<b>and a peripheral nerve distribution following the course of </b>
<b>that single nerve.</b>
<b>We can see fasciculations, but that's not common.</b>
<b>Sensory loss may be seen but should be in the pattern of </b>
<b>that nerve.</b>
<b>Reflexes may be reduced if there is a reflex innervated by </b>
<b>that nerve,</b>
<b>and examples include trauma, carpal tunnel syndrome, or </b>
<b>fibular neuropathy.</b>
<b>Moving out more distally, pathology affecting the peripheral</b>
<b> nerve,</b>
<b>but multiple nerves, a polyneuropathy, present with weakness</b>
<b> and atrophy,</b>
<b>and that may be more distal than proximal, and sometimes </b>
<b>cause fasciculations in that distribution.</b>
<b>Sensory deficits are common and may appear in a stocking </b>
<b>glove distribution</b>
<b>and deep tendon reflexes may be reduced or even absent,</b>
<b>but they'll start distally and move their way proximally</b>
<b>Some of the peripheral polyneuropathies, diabetic </b>
<b>polyneuropathy,</b>
<b>alcoholism-related polyneuropathy are common examples.</b>
<b>And this differs from pathology affecting the neuromuscular </b>
<b>junction.</b>
<b>Junctional disorders can present with weakness.</b>
<b>This may be proximal, it may be with - be distal, but we </b>
<b>commonly see bulbar dysfunction,</b>
<b>and fatigability should raise suspicion for a junctional </b>
<b>disorder.</b>
<b>Our sensory exam should be intact.</b>
<b>Reflexes are often normal, but may be reduced, and the </b>
<b>classic disease is myasthenia gravis.</b>
<b>And then, finally, muscle disorders can present with a </b>
<b>common chief complaint,</b>
<b>but different distribution.</b>
<b>Here, a weakness is usually more proximal than distal.</b>
<b>Most of our neuropathies will present with distal neuro - </b>
<b>distal weakness.</b>
<b>For muscle disorders, sensation exam should be intact.</b>
<b>Reflexes are normal to reduce, and the classic example</b>
<b>are the inflammatory muscle diseases or inherited muscle </b>
<b>disorders like muscular dystrophies.</b>