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Editors

EsaMervaala
MariAuranen

Peripheral Neuropathies: Examination of the Patient

Essentials

  • Determine the level of the disorder: is there
    • specifically a disorder of the peripheral nerve system
    • only one damaged nerve, i.e., mononeuropathy
    • a more extensive peripheral nerve disorder, i.e., polyneuropathy.
  • The symptoms can be motor, sensory, autonomic or all these together.
  • Many neuropathies are caused by a systemic disease, the most common causes being diabetes and excessive consumption of alcohol.

Symptoms

  • Motor symptoms:
    • Weakness, fatigue, cramps, fasciculations (muscle twitches i.e. myokymia Eyelid Myokymia).
  • Sensory symptoms:
    • Sensory deficits, dysaesthesia, pain, burning sensation, ataxia.
  • Autonomic nerve system symptoms:
    • Postural hypotension
    • Disturbances in the gastrointestinal tract, urinary tract, or perspiratory function
    • Erectile dysfunction

History

Clinical examination

  • Quick diagnostics of peripheral nerve disorders: see table T1
  • Muscle weakness or atrophy
  • Sensory deficits and dysaesthesia for all sensory modalities
    • Touch
    • Pain
    • Vibration
    • Joint position
  • Weak or absent tendon reflexes, weakened muscle tone
  • Skin ulcerations due to nerve damage
    • Caused by insufficient provision of nutrients and oxygen in the tissues
  • Clinical findings indicating abnormalities in the autonomic nerve system
    • Pupillary size abnormalities and/or reduced response to light
    • Dry socks (anhidrosis)
    • Palpitations
    • Postural hypotension

Typical symptoms and clinical findings in the most common peripheral nerve disorders

NerveImpairmentAtrophySensory impairment
MedianusOpposition of the thumbThenarPalmar side of fingers I-III (IV)
RadialisExtension of wrist and fingersRadial side of forearmDorsal side of the hand, base of thumb
UlnarisAdduction and abduction of fingersInterosseal, hypothenar musclesLittle finger and ulnar side of ring finger (IV)
FemoralisExtension of knee, straight leg liftingQuadriceps femoris muscleFront thigh
PeronealExtension of toes and foot (weakness when standing on heels)Anterior tibial muscle (tibial bone "sharp")Lateral side of leg, base of toes l-ll
TibialExtension of ankle (weakness when rising on toes)Small plantar musclesCalf, sole of foot, toes III-V
Lateral cutaneous femoral--Lateral anterior surface of thigh
Note: Exaggerated reflexes, spasticity, clumsiness and pareses and sensory impairment not consistent with peripheral nerve or root territories indicate a disorder of the central nervous system.
Types of neuropathy

Polyneuropathy

  • See Polyneuropathies
  • Most common presentation: sensorimotor, characterised by ascending and symmetrical distal dysaesthia ("sock-and-glove" type), muscle weakness, muscle fatigue, and diminished tendon reflexes.
  • Exclusively sensory or motor polyneuropathies are rare.
  • Aetiology: see Polyneuropathies

Multiple mononeuropathy

  • Two or more nerves in several extremities are damaged (e.g. n. ulnaris and n. peroneus)
  • The classic manifestation is associated with periarteritis nodosa and collagen diseases as well as diabetes. Has also been described in association with Sjögren's syndrome and as a paraneoplastic phenomenon.

Mononeuropathy

  • Certain mononeuropathies are typical of certain aetiologies.
    • Paresis of the femoral nerve and the oculomotor nerve: diabetes
    • Paresis of the facial nerve: sarcoidosis, borreliosis
  • See also Nerve entrapment and compression disorders Nerve Entrapment and Compression Disorders.

Differential diagnostics