POLINEUROPATITUTORIAL KLINIK

SISTEM SARAF

PATOFISIOLOGI

LOKASI NEUROPATI

Mononeuropathy – one nerve Mononeuritis multiplex Radiculopathy – nerve root Plexopathy – brachial or lumbosacral

plexus Cranial neuropathy – Bell’s Palsy, 3rd nerve

palsy Distal symmetric peripheral neuropathy

(DSPN) Small fiber versus large fiber Sensory only Motor only Sensorimotor

Keluhan Umum

1. Numbness, or a feeling of walking on cotton wool or wearing a thick sock

2. Pains that can be dull, constant and boring in type, or more spontaneous sharp, shooting, or stabbing in nature; a sensation as if walking on pebbles

3. Tingling, pins and needles4. Hot or cold sensations (e.g., “burning feet”;

“like walking on hot sand”5. Allodynia (pain caused by an otherwise non-

painful stimulus, such as light touch or stroking); this can be very troublesome at night when the feet and legs rub against the bedclothes

6. Cramps in the calves and foot muscles.

Keluhan Berdasarkan Sistem Sensory symptoms

Gains and/or Losses Motor symptoms

Gains (cramps) and/or Losses (distal predominant)

Autonomic symptoms Orthostasis Impotence Anhidrosis Vascular instability in feet

Diferensial Diagnosis

Painful feet Arthritis, including gout Morton’s Neuroma Tarsal tunnel syndrome Arterial insufficiency

Tingling in the legs Venous stasis/peripheral edema Restless leg syndrome idiopathic

Numbness/Weakness Radiculopathy CNS dysfunction (i.e. spinal cord pathology or stroke)

Diferensial Diagnosis

Diabetes and Pre-Diabetes Alcohol neuropathy Chemotherapy

Platinum-based Paraproteinemia Vasculitis and Connective Tissue Diseases Heavy metals and other toxins HIV Amyloidosis Porphyria

AUTONOMIC NEUROPATHY Closely associated with sensorimotor

neuropathy Signs are common if looked for (40%

subjects have abnormal CVS tests) but symptoms are rare (<1%)

Affects the response to hypos but not awareness

If symptoms: mortality=30-50% over 10 years

DIAGNOSIS

Annual review Enquire annually for:·         Painful neuropathy·         Loss of sensation·         Erectile impotence Note duration of DM, treatment,

complications & weight Ask about other manifestations of

autonomic neuropathy if:·         Other complications are present·         Anaesthesia is contemplated·         Blood glucose control is erratic

PENATALAKSANAAN

Tricyclic antidepressants Anticonvulsants (gabapentin,

lamotrigine) Vitamin E Glutamine Topical treatment

MEDIKASI

Nortriptyline– Modest benefit, small study, lack of effectiveness

Amitriptyline - Failed to improve sensory symptoms, but QOL

improvedGabapentin, duloxetine and pregabalin - Studies failed to demonstrate benefit Lamotrigine

– not effective Glutamine

–Up-regulate nerve growth factor, decrease PN in a few previous trials

Alpha-Lipoic- AcidDiabetic PN, may interfere w/ Bortezomib

NONMEDIKASI

Acupuncture – limited data on PN No data in PN on

Physical activity/exercise TENS (transcutaneous external

nerve stimulation) Meditation/bio-feedback Pulsed infrared light therapy or

anodyne therapy

PENATALAKSANAAN ANS

Postural hypotension Fludrocortisone NSAIDs Compression stockings Elevate the head of the bedBladder Manual SP pressure ISC ? Anticholinesterase Cyclical antibiotics if recurrent infectionsSweating ?clonidineErectile dysfunction

PENATALAKSANAAN ANS

Gastroparesis Improve glycaemic control Prokinetic drugs

Metoclopramide, domperidone, cisapride, erythromycin (250 mg tds)

Octreotide? If severeadmit for IV fluids, IV drugs NG tube

IV/jejunal feedingDiarrhoea Codeine/loperamide/diphenoxylate Clonidine or octreotide Treat bacterial overgrowth (oxytet/erythromycin)

if suspected/present