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Download Article (PDF) CLINICAL PRACTICE Evaluating the Patient with Peripheral Nervous System Complaints Kevin Scott, MD Milind J. Kothari, DO Patients commonly seek care from their family physicians Typically, symptoms of sensory disturbance range along for symptoms that are suggestive of peripheral nervous a continuum from “negative” phenomena (eg, numbness, loss system (PNS) dysfunction. At some point in active practice, of sensation) to “positive” phenomena (eg, tingling, burning, virtually all family physicians will be required to conduct “pins and needles,” bands of tightness, and stabbing or at least an initial evaluation of a patient with PNS. The shooting pain or both). Sensory symptoms may be subtle and authors outline and describe common themes found in are not always present during physical examinations, partic- the symptoms and diagnoses of PNS dysfunctions. These ularly when it is early in the progression of PNS dysfunction. themes may be useful to physicians when performing ini- Dysesthesia refers to unpleasant sensations perceived in tial evaluations of patients with PNS dysfunctions. The response to normally nonnoxious stimuli. Alternatively, pares- authors also discuss diagnostic methods and effective ther- thesia is an unpleasant sensation that is perceived despite the apeutic interventions for this population. absence of external stimuli. Finally, when normal stimuli are perceived as painful, allodynia is the descriptor used.1 he human nervous system is an incredibly complex net- In most cases of injury to the PNS, patients’ sensory symp- Twork of pathways that allows us to interact successfully toms are length-dependent, beginning in the distal portions of with our environment. The nervous system can be divided the lower extremities (toes) and progressing proximally.1 Occa- into two parts: the central nervous system (CNS), which sionally, sensory symptoms may begin in the distal portions includes the brain, brainstem, and spinal cord, and the periph- of the upper extremities (fingers). This common anatomic dis- eral nervous system (PNS) that consists of the individual tribution of symptoms is referred to as a stocking-glove pattern cranial, motor, and sensory nerves. and is virtually pathognomic for a peripheral neuropathy. Although the autonomic nervous system (ie, the sym- Once sensory symptoms have progressed to the midshin, pathetic and parasympathetic nervous system) is often con- patients may report the involvement of the fingers.2 Patients sidered part of the PNS, this review will focus on disorders may also report difficulties with balance and coordination of the motor and sensory nerves within the PNS. This review that may be secondary to a loss of distal sensation. will only briefly address cranial neuropathies and autonomic nervous system dysfunction. Radiculopathy Radiculopathies are not length-dependent, but there is, once Clinical Presentation again, a continuum of sensory symptoms that patients may Disorders of the PNS present in myriad ways that can make describe. Along this continuum, physicians may receive patient clinical diagnosis challenging. The key to efficient diagnosis lies reports of pain levels that range from an “ache” to a “shooting in being able to recognize certain patterns in patients’ per- electric-shock–like pain” that radiates toward the periphery of sonal and family histories and in the results of physical and the limb. Patients may also have spasms of the paraspinal neurologic examinations. If PNS disorder is suspected, family muscles, which are often sore and tender to the touch. physicians can request targeted diagnostic evaluations and Radiculopathies are often exacerbated by certain activities consider giving their patients referrals to neurologists. that increase intra-abdominal pressure, such as coughing or In general, patients with PNS dysfunction complain of sneezing.1 When stationary, patients may naturally favor cer- sensory disturbance, motor weakness, or both. Peripheral tain positions (eg, standing versus sitting) to accommodate nerve pain is often more active at night. and minimize their pain. Motor symptoms may include motor weakness or muscle fatigue or atrophy. Patients typically complain about impaired From the Department of Neurology at the Pennsylvania State University motor abilities after the onset of sensory symptoms, but excep- College of Medicine in Hershey. tions are not uncommon. Address correspondence to Milind J. Kothari, DO, Professor of Neurology, As with sensory symptoms, motor weakness often Pennsylvania State University College of Medicine, 500 University Drive, MC H037, Hershey, PA 17033-2360. involves the distal musculature initially, though it may have E-mail: [email protected] begun with weakness when the toes were in flexion or exten- Scott and Kothari • Clinical Practice JAOA • Vol 105 • No 2 • February 2005 • 71 CLINICAL PRACTICE sion. Motor weakness is usually more prominent in extensor Peripheral neuropathies have a characteristic pattern of muscles than in the flexor muscles (ie, walking on one’s heels findings on physical examination. In mononeuropathy, sen- is affected earlier than walking on ones toes). Motor weak- sation should be decreased only in that nerve’s distribution. ness may progress proximally. Sensory findings owing to a median neuropathy with com- A loss of muscle mass (atrophy), abnormally frequent pression at the wrist (ie, carpal tunnel syndrome), for example, and painful cramps, or fasciculations are strongly suggestive classically involve nocturnal paresthesias with decreased sen- of lower motor neuron involvement. Patients with these symp- sation over the palmar surface of the first three fingers—but toms may have difficulty in ambulating, problems with manual sparing the thenar eminence.3 dexterity, or both.2 With mononeuritis multiplex (MNM) or multifocal When taking notes on personal and family medical his- mononeuropathy, sensory deficits localized to multiple indi- tory, it is important to document the age of symptom onset, the vidual peripheral nerves will be found simultaneously. In progression of symptoms over time, any similarities to other cases of mononeuropathy or MNM, typically all sensory family members, comorbidities, and the anatomic pattern of modalities are affected (ie, pinprick, temperature, vibration, symptom involvement. and touch). Identification of exacerbating and alleviating factors can Polyneuropathies can imply systemic illness. Sensation help physicians localize patient complaints. Symptoms usually is decreased in a stocking-glove pattern, but some- involving a specific dermatome suggest a nerve root problem. times there is a disproportionate loss of certain sensory modal- Conversely, sensory involvement limited to one limb, in a ter- ities. Patients with small-fiber sensory (unmyelinated) neu- ritory not conforming to a particular dermatome, may suggest ropathy (SFSN) may have decreased sensitivity to pinprick the involvement of a particular peripheral nerve. and temperature sensory modalities, but their response to vibration remains relatively normal. Conversely, patients with Polyneuropathy large-fiber neuropathies may first have vibration or proprio- Polyneuropathies usually present with a symmetric stocking- ception preferentially affected.1 glove pattern of symptoms that do not respect individual Deep-tendon reflexes (DTRs) are often decreased or absent peripheral nerve or dermatomic areas. in PNS dysfunction. Hyporeflexia implies dysfunction of large Symptoms in children and young adults—particularly if myelinated fibers representing the afferent limb of muscle there is a family history suggestive of this dysfunction—may spindle–initiated reflexes. If the pathologic process is limited indicate a hereditary neuropathy. strictly to small sensory fibers, DTRs may not be affected.2 As A chronic or slowly progressive course may also suggest with the sensory examination, documenting DTR abnormal- a hereditary, metabolic, or pathologic cause. Acute onset of ities can help physicians localize the site of PNS dysfunction. symptoms—particularly involving the territory of a specific Orthopedic findings such as pes cavus (talipes), “ham- peripheral nerve or root—may suggest spinal compression mertoe,” and high arches are seen in many cases of neuropathy or trauma, or an ischemic injury. that are known to be of hereditary origin. Motor findings on examination imply motor weakness. Physical Examination Affected muscles may be within the myotome of an individual All patients presenting with the complaints detailed in the nerve (eg, “foot drop” with a peroneal nerve injury) or they previous section should receive a complete physical exami- may involve distal muscles in a symmetric fashion. Thus, nation to identify comorbid conditions that may be causative motor findings suggest a more diffuse dysfunctional pro- of sensory or motor symptoms. gression. Classically, disease of the PNS causes motor weak- In particular, findings that suggest the source of dys- ness, muscle atrophy, and fasciculations to varying degrees function might be an underlying metabolic disease (eg, thyroid of severity. condition, diabetes mellitus), nutritional deficiency (alco- Motor symptoms are usually found in combination with holism), malignant disease, or inflammatory disorder (eg, sensory deficits. Isolated motor findings do occur, however, and lupus, sarcoidosis, Sjögren’s syndrome) can quickly narrow the suggest that the disease process may be limited to the ventral focus of the differential diagnosis. horn or roots. Such
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