www.rrnmf.com Diabetic Lumbosacral Radiculoplexopathy DLSRP Richard J. Barohn, MD Chair, Department of Neurology Gertrude and Dewey Ziegler Professor of Neurology University Distinguished Professor Vice Chancellor for Research University of Kansas Medical Center Kansas City, KS Case History
65 F DM 2 yrs., oral Rx Tingling toes x 1 yr. Now CC leg pain/weak ? more tingling 6 mos pain/wk left leg pain lumbar to hip/post-thigh 2 mos similar symptoms right leg MRI DJD L4/5 laminectomy Post-op worse/cant walk 20 lb weight loss over 6 mos Gabapentin/TCA no help Case PE
Quad atrophy, L > R Arm strength NL R L HF/Abd 3- 2 KE/KF
4 3 AD/E/I 3- 0 DTR NL arms/0 legs Sens No vib toes/prop NL Dec touch/pin to ankles
Case Question 1 What pattern of neuropathy does this patient have? a. Symmetric proximal and distal weakness with sensory loss (NP1) b. Symmetric distal sensory loss with or without weakness (NP2) c. Asymmetric distal weakness with sensory loss (NP3) d. Asymmetric proximal and distal weakness with sensory loss (NP4) e. Asymmetric distal weakness without sensory loss (NP5) Case
Question 2 What is the diagnosis? a) Vasculitis neuropathy b) Lumbar stenosis with radiculopathy c) Diabetic lumbosacral radiculoplexopathy d) MADSAM e) Arachnoiditis Answer: c. Diabetic lumbosacral radiculoplexopathy Case Labs Random glucose 120 200 HgA1C - 6.5 NCS: L PER/TIB NR
R PER Amp 0.5/LAT 6.6/CV 34 R TIB Amp 11/LAT 6.7/CV 35 Sural NR Bilat UE NCS NL EMG Fibs/neurogenic MUPS Prox/Distal LE & LS paraspinous Case Question 3 What is the treatment? a) IVIg b) Cyclophosphamide c) Narcotics for pain and physical therapy
d) Plasmapheresis e) Oral prednisone Answer: c. Narcotics for pain and physical therapy Case Course Rx Fentanyl patch and oxycodone to break pain cycle Pain improved Begin vigorous PT In 2 weeks beginning to walk Slow improvement over next 6 months Diabetic Lumbosacral Radiculoplexopathy DLSRP Other Names:
Proximal diabetic neuropathy Ischemic mononeuropathy multiplex Femoral or fem-sciatic neurop Diabetic amyotrophy Bruns-Garland Syndrome Patients are usually:
> age 50; NIDDM 1/3 on oral meds 1/3 on insulin 1/3 new onset DM Glucose often inc, but may be NL DLSRP Typical Clinical Presentation
Pain - Back, hip, thigh Initially overshadows weakness Weakness - prox + distal leg after pain Spreads to opposite side within days or weeks At least 25%, perhaps much more Latency - days to months Numb/Tingling c/o - 50%
Distal Sens Loss (DSPN) Knee + Ankle Reflex Loss Wt Loss in 1/3 DLSRP Lab NCS - DSPN EMG - Profuse fibs Prox/Distal/Paraspinous CSF - Often prot 60-100 mg/dl (up to 400) ESR NL or , usually < 50 Sural Nerve Bx - Asymmetric fiber loss Axonal degen Occas slight perivascular inflammation
DLSRP Course Initially worsens in gradual or step-wise manner Eventually stabilizes, plateaus, and improves Worsening phase lasts weeks to months (up to 18 mo) Arch Neurol 1991;48:1130-1135. Diabetic Lumbosacral Radiculoplexopathy DLSRP The Neurologists Pattern Only a neurologist makes Dx
Only a neurologist can give best recommendations/prognosis
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