Lower Extremity Peripheral Neuropathy Research Articles

The role of high-resolution ultrasound and MRI in the evaluation of peripheral nerves in the lower extremity.

Lower extremity peripheral neuropathy is a commonly encountered neurologic disorder, which can lead to chronic pain, functional disability, and decreased quality of life for a patient. As diagnostic imaging modalities have improved, imaging has started to play an integral role in the detection and characterization of peripheral nerve abnormalities by non-invasively and accurately identifying abnormal nerves as well as potential causes of neuropathy, which ultimately leads to precise and timely treatment. Ultrasound, which has high spatial resolution and can quickly and comfortably characterize peripheral nerves in real time along with associated denervation muscle atrophy, and magnetic resonance neurography, which provides excellent contrast resolution between nerves and other tissues and between pathologic and normal segments of peripheral nerves, in addition to assessing reversible and irreversible muscle denervation changes, are the two mainstay imaging modalities used in peripheral nerve assessment. These two modalities are complimentary, and one may be more useful than the other depending on the nerve and location of pathology. Imaging must be interpreted in the context of available clinical information and other diagnostic studies, such as electrodiagnostic tests. Here, we offer a comprehensive overview of the role of high-resolution ultrasound and magnetic resonance neurography in the evaluation of the peripheral nerves of the lower extremity and their associated neuropathies.

ID:16066 IPG-Free Peripheral Nerve Stimulation for Treatment of Lower Extremity Peripheral Neuropathy in a Diabetic Amputee

A 29-year-old female with type-1 diabetes mellitus complicated by a non-healing right foot wound presented to our clinic with left lower extremity neuropathic pain following a right below knee amputation (BKA). She complained mostly of pain on the lateral and medial aspects of her left lower calf. Treatment with traditional medications (gabapentin, Lyrica) did not provide sufficient pain relief. A diagnostic injection at the distal peroneal and saphenous nerves at the ankle relieved the majority of her pain for ∼36hr. Subsequently, patient was considered a candidate for wireless peripheral nerve stimulation. Patient underwent a PNS trial (Stimwave, Pompano Beach, Florida) in clinic in which temporary leads were placed along the distal aspects of the above-mentioned nerves using fluoroscopic guidance. Intra-op testing confirmed adequate coverage of the painful areas. Patient’s trial lasted 4 days at which point she was scheduled for permanent implantation.

Brachial Plexopathy Following High-Dose Melphalan and Autologous Peripheral Blood Stem Cell Transplantation for AL Amyloidosis

Brachial plexopathy (also known as neuralgic amyotrophy or Parsonage-Turner syndrome) is a rare, self-limited condition characterized by bilateral or unilateral shoulder pain followed by weakness. The pathogenesis is unknown, but is believed to be an immune-mediated disorder that is treated conservatively with analgesics and physical therapy (PT). It has been described following viral infections, surgeries, and immunosuppression. There has never been a reported case following high dose melphalan and stem cell transplantation (HDM/SCT) for immunoglobulin light chain (AL) amyloidosis.Here we report two cases of brachial plexopathy following HDM/SCT for AL amyloidosis. These cases were prospectively identified from a population of 42 patients who underwent HDM/SCT at Boston Medical Center between January 2014 and June 2017.The first patient was a 68-year-old woman with AL amyloidosis with renal involvement with a lambda clonal plasma cell dyscrasia. She was diagnosed with AL amyloidosis three months prior to HDM/SCT. She had no history of peripheral neuropathy or other neurologic disorder. Neutrophil engraftment post-SCT occurred on day +9. On day +12, she developed acute onset bilateral shoulder pain and weakness, left greater than right. Neurologic evaluation at the time was notable for 4/5 strength in the left deltoid, triceps, and biceps muscles. Sensation to pinprick was decreased on the dorsum of the left hand. Deep tendon reflexes were normal. These deficits were consistent with C5-8 motor and sensory dysfunction. Magnetic resonance imaging (MRI) of the cervical spine and brachial plexus and electromyography/nerve conduction study were consistent with bilateral brachial plexopathy. Doppler ultrasounds of the upper extremities were negative for deep venous thrombosis. Lyme disease and West Nile virus testing were negative. She began treatment with PT and her symptoms completely resolved at two years following HDM/SCT.The second patient was a 58-year-old woman with Waldenström's macroglobulinemia (WM) and associated AL amyloidosis with renal involvement with an underlying lambda clonal plasma cell dyscrasia. She was initially diagnosed with WM eight years prior to her diagnosis of AL amyloidosis. She received eight cycles of rituximab, cyclophosphamide, vincristine, and prednisone for treatment of WM, and then four cycles of rituximab, bortezomib, and dexamethasone after diagnosis of AL amyloidosis. She then underwent HDM/SCT. She had a history of lower extremity peripheral neuropathy secondary to prior treatments, but had no other neurologic symptoms. Neutrophil engraftment occurred on day +10 post-SCT. On day +13, she developed acute onset left shoulder pain and weakness. MRI of the cervical spine and left brachial plexus was consistent with brachial plexopathy. Her symptoms completely resolved by one year post-SCT with PT.These two cases of brachial plexopathy following HDM/SCT are, to our knowledge, the first reported cases in association with AL amyloidosis. Previously, a handful of cases of brachial plexopathy with similar time courses have been described after both autologous and allogeneic PBSCT in association with multiple myeloma, non-Hodgkin's lymphoma, myelodysplastic syndrome, diffuse large B-cell lymphoma, and multiple sclerosis.1-3 An autoimmune process has been postulated, especially given the known phenomenon of immune dysregulation following SCT with immune reconstitution. Direct trauma was not a contributing factor in these cases, and both patients had an internal jugular tunneled venous catheter on the right side. We conclude that brachial plexopathy is an uncommon, but potential early complication of HDM/SCT for AL amyloidosis that should be considered in patients with new onset shoulder pain or weakness. PT may be beneficial to patients with this self-limited disorder.

Swallowing impairment in older adults: association with sensorimotor peripheral nerve function from the Health, Aging and Body Composition study.

The purpose of this study was to examine whether impairments in sensorimotor peripheral nerve function are associated with a higher likelihood of swallowing impairment in older adults. Health, Aging and Body Composition participants (n = 607, age = 75.8 ± 2.7years, 55.8% women, 32.3% black) underwent peripheral nerve testing at Year 4 and 11 with swallowing difficulty assessed at Year 4 and 15. Nerve conduction amplitude and velocity were measured at the peroneal motor nerve. Sensory nerve function was assessed with the vibration detection threshold and monofilament (1.4-g/10-g) testing at the big toe. Symptoms of lower extremity peripheral neuropathy and difficulty swallowing were collected by self-report. Data analysis was performed using a hierarchical approach. Odds ratios (ORs) were estimated using non-conditional logistic regression. At Year 15 108 (17.8%) participants had swallowing impairments. In fully adjusted models, the peripheral nerve impairments associated with swallowing impairment were numbness (OR 4.67; 95%CI 2.24-9.75) and poor motor nerve conduction velocity (OR 2.26; 95%CI 1.08-4.70). Other peripheral nerve impairments were not related to swallowing. The association between slow motor nerve conduction velocity and numbness and a higher likelihood of swallowing difficulties a decade later in our prospective study identifies an important area for further investigation in older adults.

(275) - Ultrasound guided posterior tibial nerve block for the management of chronic peripheral neuropathic foot pain secondary to sarcoidosis

Sarcoidosis is a systemic inflammatory disease of unknown etiology involving multiple organ systems. Sarcoidosis affecting the central and/or peripheral nervous system is called neurosarcoidosis. The case presented focuses on the use of a single interventional therapy for the management of sarcoidosis-induced bilateral lower extremity peripheral neuropathy. A 53 year-old Caucasian male with a 14 year history of steroid-dependent, refractory pulmonary sarcoidosis, and neurosarcoidosis with resulting lower extremity pain secondary to peripheral neuropathy was referred for pain management. Prior to presentation, the patient had been tried on various pharmacological therapies, including but not limited to high doses of opioids (methadone/oxycodone), steroids, pregabalin, and duloxetine. Patient's severe bilateral plantar foot pain continued to adversely affect his functionality to the point of placing him on disability. Three sets of bilateral ultrasound guided posterior tibial nerve blocks were performed three months apart. The patient experienced significant pain relief after each block. His daily methadone consumption decreased by over 50% and his functionality improved significantly allowing him to return to work full-time as he was able to tolerate prolonged periods of standing and walking. Ultrasound guided posterior tibial nerve blocks should be considered as a first-line treatment option for peripheral neuropathic pain secondary to sarcoidosis, as it can diminish dependence on opioids, while simultaneously increasing functionality and quality of life of patients.

Relationship between sensorimotor peripheral nerve function and indicators of cardiovascular autonomic function in older adults from the Health, Aging and Body Composition Study

BackgroundAge-related peripheral nervous system (PNS) impairments are highly prevalent in older adults. Although sensorimotor and cardiovascular autonomic function have been shown to be related in persons with diabetes, the nature of the relationship in general community-dwelling older adult populations is unknown. MethodsHealth, Aging and Body Composition participants (n=2399, age=76.5±2.9years, 52% women, 38% black) underwent peripheral nerve testing at the 2000/01 clinic visit. Nerve conduction amplitude and velocity were measured at the peroneal motor nerve. Sensory nerve function was assessed with vibration detection threshold and monofilament (1.4-g/10-g) testing at the big toe. Symptoms of lower-extremity peripheral neuropathy were collected by self-report. Cardiovascular autonomic function indicators included postural hypotension, resting heart rate (HR), as well as HR response to and recovery from submaximal exercise testing (400m walk). Multivariable modeling adjusted for demographic/lifestyle factors, medication use and comorbid conditions. ResultsIn fully adjusted models, poor motor nerve conduction velocity (<40m/s) was associated with greater odds of postural hypotension, (OR=1.6, 95% CI: 1.0–2.5), while poor motor amplitude (<1mV) was associated with 2.3beats/min (p=0.003) higher resting HR. No associations were observed between sensory nerve function or symptoms of peripheral neuropathy and indicators of cardiovascular autonomic function. ConclusionsMotor nerve function and indicators of cardiovascular autonomic function remained significantly related even after considering many potentially shared risk factors. Future studies should investigate common underlying processes for developing multiple PNS impairments in older adults.

Sensorimotor Peripheral Nerve Function and the Longitudinal Relationship With Endurance Walking in the Health, Aging and Body Composition Study

ObjectivesTo determine whether lower extremity sensorimotor peripheral nerve deficits are associated with reduced walking endurance in older adults. DesignProspective cohort study with 6 years of follow-up. SettingTwo university research clinics. ParticipantsCommunity-dwelling older adults enrolled in the Health, Aging and Body Composition Study from the 2000–2001 annual clinical examination (N=2393; mean age ± SD, 76.5±2.9y; 48.2% men; 38.2% black) and a subset with longitudinal data (n=1178). InterventionsNot applicable. Main Outcome MeasuresParticipants underwent peripheral nerve function examination in 2000–2001, including peroneal motor nerve conduction amplitude and velocity, vibration perception threshold, and monofilament testing. Symptoms of lower extremity peripheral neuropathy included numbness or tingling and sudden stabbing, burning, pain, or aches in the feet or legs. The Long Distance Corridor Walk (LDCW) (400m) was administered in 2000–2001 and every 2 years afterward for 6 years to assess endurance walking performance over time. ResultsIn separate, fully adjusted linear mixed models, poor vibration threshold (>130μm), 10-g and 1.4-g monofilament insensitivity were each associated with a slower 400-m walk completion time (16.0s, 14.4s, and 6.9s slower, respectively; P<.05 for each). Poor motor amplitude (<1mV), poor vibration perception threshold, and 10-g monofilament insensitivity were related to greater slowing per year (4.7, 4.2, and 3.8 additional seconds per year, respectively; P<.05), although poor motor amplitude was not associated with initial completion time. ConclusionsPoorer sensorimotor peripheral nerve function is related to slower endurance walking and greater slowing longitudinally. Interventions to reduce the burden of sensorimotor peripheral nerve function impairments should be considered to help older adults maintain walking endurance—a critical component for remaining independent in the community.

Sharpening the Tandem Walking Test for Screening Peripheral Neuropathy

Few tests of functional motor behavior are useful for rapidly screening people for lower extremity peripheral neuropathy. The goal of this study was to improve the widely used tandem walking (TW) test. We tested "normal" (control) adult and ambulatory patients with peripheral neuropathy (PN) with their eyes open and eyes closed while they performed TW on industrial carpeting in sock-covered feet. Each subject wore a torso-mounted inertial motion unit to measure kinematic data. The data of subjects with PN also were compared with historical data on patients with vestibular impairments. The normal and PN groups differed significantly on TW and on the number of steps completed. PN and vestibular impairments data also differed significantly on both visual conditions. Kinematic data showed that patients with PN were more unstable than normal patients in the group. For the number of steps taken during the eyes open condition, receiver operating characteristic (ROC) values were only 0.81 and for the number of steps taken during the eyes closed condition, ROC values were 0.88. Although not optimal, this ROC value is better. Sensitivity and specificity at a cutoff of two steps were 0.81 and 0.92, respectively, and at a cutoff of three steps were 0.86 and 0.75, respectively. ROC values for kinematic data were <0.8, and when combined with the ROC value for the number of steps, the total ROC value did not improve appreciably. Although not ideal for screening patients who may have PN, counting the number of steps during TW is a quick and useful clinical test. TW is most sensitive to patients with PN when they are tested with eyes closed.

Microscopic polyangiitis with renal mass-like lesion : A case report

A 63-year-old man was admitted to our hospital because of persistent fever, weight loss, painful foot, and purpura on his extremities. He had lower extremity peripheral neuropathy, and skin biopsy of the purpura revealed vasculitis. Serum tests for myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA), proteinase 3-ANCA, and ANCA (indirect fluorescent antibody method) were all negative. Computed tomography revealed a 6-cm large, irregularly shaped lesion in the right kidney, while the nasal sinuses and lungs were intact. Based on these findings, a diagnosis of suspected systemic vasculitis associated with renal cell carcinoma was made. Thus, right nephrectomy was performed. However, the pathological findings showed a large infarct with necrotizing vasculitis of the arcuate, interlobular, and perinephric small arteries and a crescent formation in the glomerulus. Based on these findings, he was diagnosed with microscopic polyangiitis. Due to rapidly worsening symptoms of purpura and neuropathy, treatment with a high dose of corticosteroid was initiated on postoperative day 2, which led to improvement of his symptoms. Vasculitis accompanied with a mass-like lesion is occasionally confused with malignancy. The lesion in our patient was considered to have originated by asymptomatic renal infarction. This case suggests that a renal mass-like lesion with vasculitis should be diagnosed with care.

Age Differences in Hopelessness and Toe Pain in Persons with Insulin-Dependent and Non-Insulin-Dependent Diabetes Mellitus

Several studies have established an association between diabetic neuropathy and depressive symptoms. There is a link between depression and peripheral neuropathy in diabetic patients, suggesting an increased likelihood that diabetic patients will experience depressive symptoms related to lower-extremity peripheral neuropathy and arthritis during middle age and later life. The goal of this investigation was to determine whether there are age differences between insulin-dependent and non-insulin-dependent diabetic patients regarding their feelings of hopelessness and toe pain. A large population-based sample of 32,006 adults from the 1998 National Health Interview Survey was analyzed with multivariate statistical procedures. We performed χ² and correlation procedures to test the null hypothesis that there are no age or sex differences between insulin-dependent and non-insulin-dependent diabetic patients in their reporting of feelings of hopelessness and toe pain symptoms in the previous 12 months. There were significant differences between age and sex groups of insulin-dependent and non-insulin-dependent diabetic patients in reporting feelings of hopelessness and toe pain symptoms, rejecting the null hypothesis. Correlational analysis conducted between the variables of hopelessness and toe pain yielded significant correlations in insulin-dependent (r = .28; P = .0009; α = .05), and non-insulin-dependent (r = 0.19; P = .001; α = .05) women older than 61 years, concluding that diabetic women are more likely to experience hopelessness and toe pain in that age group regardless of insulin status. Clinicians should incorporate depression and toe pain symptoms into their assessment and treatment, especially in diabetic women older than 61 years.

Clinical Outcome of Peripheral Nerve Decompression in Diabetic and Nondiabetic Peripheral Neuropathy

Surgical decompression of peripheral nerves in patients with diabetes was reported to restore sensation and improve function. In this study, a retrospective review of 12 diabetic and 20 nondiabetic patients with lower-extremity peripheral neuropathy who underwent surgical decompression was performed. Clinical evaluation by Tinel test, muscle power examination, and 2-point discrimination were performed preoperatively, at 6 months, and between 9 and 15 months postdecompression. Clinical outcomes were classified into excellent, good, or fair based on improvement in symptoms and return of function. Thirty-two patients underwent 36 surgeries, in which 99 lower-extremity nerves were decompressed. There was a statistically significant improvement in muscle function (P < 0.001) and 2-point discrimination for the small toe (P = 0.008) and big toe (P = 0.038). At a mean of 7.7 months, 90% of patients showed significant improvement in pain and function. It is concluded that surgical decompression was associated with significant improvement in clinical outcome in patients with diabetic and idiopathic neuropathy with evidence of superimposed compression.

Surgical Decompression in Lower-Extremity Diabetic Peripheral Neuropathy

Peripheral neuropathy can be a devastating complication of diabetes mellitus. This article describes surgical decompression as a means of restoring sensation and relieving painful neuropathy symptoms. A prospective study was performed involving patients diagnosed as having type 1 or type 2 diabetes with lower-extremity peripheral neuropathy. The neuropathy diagnosis was confirmed using quantitative sensory testing. Visual analog scales were used for subjective assessment before and after surgery. Treatment consisted of external and as-needed internal neurolysis of the common peroneal, deep peroneal, tibial, medial plantar, lateral plantar, and calcaneal nerves. Subjective pain perception and objective sensibility were significantly improved in most patients who underwent the described decompression. Surgical decompression of multiple peripheral nerves in the lower extremities is a valid and effective method of providing symptomatic relief of neuropathy pain and restoring sensation.