KEYWORDS: ..Symptoms depend upon which nerves are affected : Motor nerve - weakness Sensory nerve - numbness, tingling(paresthesias) Autonomic nerve - often the most subtle, postural hypotension, lightheaded arising, abnormal sweating, constipation, urinary retention, impotence ..Peripheral neuropathy의 임상적 분류 - Mononeuropathy - Multifocal neuropathy -드뭄 - Polyneuropathy Mononeuropathy common causes ..직접적 외상, 압박, Entrapment ..감염 : 대상포진 ..독성 : 좌골신경에 페니실린주사 ..혈관성 : 혈관염, 당뇨병 ..종양 : 림프종, 신경섬유종 Peripheral neuropathy Median nerve Ulnar nerve Common Peroneal Site Wrist-carpal tunnel Elbow-cubital tunnel or Knee-fibular head condylar groove Sensory loss Lateral palm ; 1st~3rd Medial palm ; 5th±4th finger Dorsal foot finger±4th finger Lateral calf Motor weakness Thumb abduction Index finger abduction Foot dorsiflexion Thumb opposition 5th finger adbuction Foot eversion Conservative Rx Wrist splint, NSAIDs Avoid elbow trauma Avoid direct compression Surgical Rx Transverse carpal Cubital tunnel release ; ligament section ulnar nerve transposition Conservative Rx indication : sudden onset, no motor deficit, few or no sensory findings (pain or paresthesia may be present), no evidence of axonal loss by EMG Surgical Rx indication : chronic course (lack of response to conservative treatment), motor deficit, electrodiagnostic evidence of axonal loss < Common Mononeuropathies - findings and treatment > Polyneuropathy common causes Usually distal, sensorimotor, symmetrical ..대사성 : 당뇨병, 알코올 중독 비타민 결핍(thiamine-B1, B12), 요독증, 갑상선기능저하증, 포르피린증 ..독성 : 납, 시스플라틴 ..감염성 : 디프테리아, 나병, AIDS ..염증성 : Guillain-Barre syndrome ..결체조직 질환 : SLE, polyarteritis nodosa, 쇼그렌 증후군, rheumatoid arthritis ..종양성 : Plasma cell dyscrasia, Paraproteinemia, Benign monoclonal gammopathy, Cryoglobinemia ..유전성 : Amyloidosis, Hereditary sensorimotor neuropathies ..Diabetic polyneuropathy : insidiously onset and progress slowly, distal, symmetrical sensory loss (often painful) plus mild distal weakness. Compressive mononeuropathies (e.g., unlar neuropathy at the elbow, median neuropathy at the wrist) are frequently superimposed. And the severity of diabetic autonomic neuropathy does not appear to correlate with the severity of diabetic polyneuropathy. Rochester Diabetic Neuropathy Study에 의하면 전체 당뇨환자의 50%에서 Polyneuropathy 소 견을 가지지만, 그 중 1/3에서만 증상을 호소한다고 보고하고 있다. ..Hypothyroidism : A mild polyneuropathy can occur in patients with hypothyroidism ; correction of the hormonal disturbances probably improves these polyneuropathy, although this has not been well studied. ..Vitamin deficiency : Thiamine(B1), B12 결핍이 mild axonal neuropathy를 일으 키지만, 영양상태가 나쁘지 않은 환자에게 Polyneuropathy를 예방하기 위해 Multivitamin제제를 처방하는 것은 근거가 부족하다. ..Guillain-Barre syndrome (Acute inflammatory demyelinating polyneuropathy) : most common nontraumatic cause of acute quadriparesis in the Western World. An antecedent infection triggers the patient’s immune response, which is subsequently misdirected at peripheral nerve.(most common pathogen : Campylobacter jejuni). The clinical course of GBS is characterized by the acute onset of motor and sensory symptoms, most often distally in the limbs. 289 The Root of ambulatory care Key tests Peripheral neuropathy There is progressive worsening over several days, a plateau period lasting days to weeks, and then slow spontaneous improvement. ..Polyneuropathy의 경우 발의 지각 이상(paresthesia)이 가장 흔한 증상이다. 흔히 환자들은 이상 감각을 호소하며, 세게 문지르거나 차게 하면 좋아진다 고 한다. 가끔 사지가 무겁거나 차다고도 한다. Antineoplastics Cisplatin, Suramin, Taxoids(docetaxel, paclitaxel), Vinca alkaloids(vincristine, vinblastine) Antimicrobials Chloramphenicol, Dapsone, Didanosine, Isoniazid, Metronidazole, Nitrofurantoin, Stavudine, Zalcitabine Durgs for Rheumatologic Diseases Chloroquine, Colchicine, Gold, Thalidomide Miscellaneous Amiodarone, Disulfiram, Perhexilene, Phenytoin, Simvastatin ..Electrodiagnostic study : NCV / EMG ▶ EMG : useful for distinguishing between and among myopathic and neuropathic disorders. ▶ NCV : 1)Demyelinative neuropathy ; slowing of nerve conduction velocity, dispersion of evoked compound action potentials, conduction block, marked prolongation of distal latencies. 2)Axonal neuropathy ; reduced amplitude of evoked compound action potentials with relative preservation of NCV. ..CBC, Blood glucose(HbA1c), TFT ..Vitamin B12, BUN/Cr, ESR ..Chest X ray 291 The Root of ambulatory care - Nonpharmacologic 1. Shoes with a spacious fit or open-toed sandal 2. Modifications at work (e.g., Frequent sitting breaks for jobs requiring standing) 3. Soaking the feet in cold tap water for 20~30minutes before bed - Pharmacologic - generally applicable therapy (Diagnosis-independent) 1. Anti-depressants ..Amitriptyline.. 10mg 1T, 1T pohs in dose up to 100mg/day ..Sensival.. 10mg 1T, 1T-2.5T tid-qid in dose up to 100mg/day 2. Anti-convulsants ..Tegretol CR.. 200mg 1T, 1T qd in dose up to 1200mg/day ..Neurontin.. 300mg 1C, 1C qd in dose up to 1800mg/day ± Acetaminophen 300mg bid~qid ..Sensival.. - Nortriptyline ..Tegretol.. -Carbamazepine ..Neurontin.. -Gabapentin ..감각신경병증과 연관된 통증은 일반적으로 만성이며 치료하기 힘들 뿐 아니 라, 적절한 anti-depressants 효과를 보기 위해선 2~3개월의 시간이 필요하다. Key treatments Key treatments 참고 문헌 James P. McKenna, Steven K. Rothschild : Paresthesias, Peripheral neuropathy, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 1323-1325, P 1325-1327 최영호 : 말초성 신경 질환, in 가정의학 임상편. 서울, 계측문화사, 2002, P 471-475 Colin Chalk, M.D., C.M. : Peripheral Neuropathies, in Conn’s Current Therapy 2004, Robert E. Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004, P 996-1004 Eugene Braunwald, M.D., M.A., M.D., ScD. : Peripheral Neuropathies, including Guillain-Barre Syndrome, in Harrison's Manual of Medicine, 16th ed, Dennis L. Kasper, M.D., M.A., Eugene Braunwald, M.D., M.A., M.D., ScD., Anthony S. Fauci, M.D., ScD., Stephen L. Hauser, M.D., Dan L. Longo, M.D., J. Larry Jameson, M.D., PhD.(ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 936-941