Diabetic thoracic polyradiculopathy

Focal inflammatory neuropathies

This chapter focuses on neuropathies that present with focal involvement of nerve roots, plexus, and/or peripheral nerves associated with autoimmune and inflammatory mechanisms that present with focal involvement of nerve roots, plexus and/or peripheral nerves. The clinical presentation, diagnosis, and treatment of focal autoimmune demyelinating neuropathies, focal nonsystemic vasculitic disorders (diabetic and nondiabetic radiculoplexus neuropathies, postsurgical inflammatory neuropathy, and neuralgic amyotrophy), and focal neuropathies associated with sarcoidosis and bacterial and viral infections are reviewed.

Electrodiagnostic Assessment of Radiculopathies

This article discusses the electrodiagnostic assessment of radiculopathy. Relevant anatomy initially is reviewed followed by discussion surrounding the approach to nerve conduction studies and needle electrode examination when it comes to radiculopathy evaluation. Pitfalls of the electrodiagnosis versus clinical diagnosis of radiculopathy and the definitions of acute versus chronic, and active versus inactive, are reviewed.

Rare diabetic neuropathies: It is not only distal symmetrical polyneuropathy

The prevalence of diabetes mellitus is increasing at an epidemic level, leading to a consequent increase of its chronic complications, including neuropathy. Diabetic neuropathy constitutes a heterogeneous group of disorders with distinct clinical presentations and pathophysiological mechanisms. These distinct forms may be categorised according to their clinical presentation as symmetrical (distal symmetrical polyneuropathy, autonomic and acute sensory neuropathy) and focal or multifocal (radiculoplexus neuropathies, entrapment syndromes, cranial palsies and other mononeuropathies). Additionally, people with diabetes may have neuropathies due to causes other than diabetes. The commonest forms of diabetic neuropathy are distal symmetrical polyneuropathy and autonomic neuropathy. However, clinicians should be aware that people with diabetes may suffer from less common forms of neuropathy and should be able to recognise their symptoms and signs. The recognition of the rare diabetic neuropathies is crucial, as they often lead to different clinical outcomes and require different management. The aim of the present narrative, non-systematic review is to outline the rare types of diabetic neuropathies.

Diabetic thoracic radiculopathy: a case of a young woman with clinical improvement following immunotherapy

Thoracic radiculopathy is a rare cause of thoracic-abdominal or abdominal pain in subjects with poorly controlled diabetes. We present a case of a young woman with type I diabetes and a severe abdominal pain in both lower quadrants. An extensive diagnostic gastroenterological and gynaecological workup did not disclose abnormalities. Electromyography revealed an initial polyneuropathy and significant neurogenic abnormalities in the T10-T12 paravertebral muscles. Following the hypothesis that the radiculopathy-related abdominal pain might have an immuno-mediated pathogenesis, the patient underwent a complex trial of immunotherapy, which was accompanied by a sustained improvement over months to full recovery. This report would support the hypothesis that immune-mediated mechanisms are still active even months after onset of symptoms.

Chronic Abdominal Wall Pain

BACKGROUND

Chronic abdominal wall pain is a poorly recognized clinical problem despite being an important element in the differential diagnosis of abdominal pain.

METHODS

This review is based on pertinent articles that were retrieved by a selective search in PubMed and EMBASE employing the terms "abdominal wall pain" and "cutaneous nerve entrapment syndrome," as well as on the authors' clinical experience.

RESULTS

In 2% to 3% of patients with chronic abdominal pain, the pain arises from the abdominal wall; in patients with previously diagnosed chronic abdominal pain who have no demonstrable pathological abnormality, this likelihood can rise as high as 30% . There have only been a small number of clinical trials of treatment for this condition. The diagnosis is made on clinical grounds, with the aid of Carnett's test. The characteristic clinical feature is strictly localized pain in the anterior abdominal wall, which is often mischaracterized as a "functional" complaint. In one study, injection of local anesthesia combined with steroids into the painful area was found to relieve pain for 4 weeks in 95% of patients. The injection of lidocaine alone brought about improvement in 83-91% of patients. Long-term pain relief ensued after a single lidocaine injection in 20-30% of patients, after repeated injections in 40-50% , and after combined lidocaine and steroid injections in up to 80% . Pain that persists despite these treatments can be treated with surgery (neurectomy).

CONCLUSION

Chronic abdominal wall pain is easily diagnosed on physical examination and can often be rapidly treated. Any physician treating patients with abdominal pain should be aware of this condition. Further comparative treatment trials will be needed before a validated treatment algorithm can be established.

Sensory manifestations of diabetic neuropathies: anatomical and clinical correlations

BACKGROUND

Diabetes mellitus is among the most common causes of peripheral neuropathy worldwide. Sensory impairment in diabetics is a major risk factor of plantar ulcers and neurogenic arthropathy (Charcot joints) causing severe morbidity and high health-care costs.

OBJECTIVE

To discuss the different patterns of sensory alterations in diabetic neuropathies and their anatomical basis.

STUDY DESIGN

Literature review.

METHODS

Review of the literature discussing different patterns of sensory impairment in diabetic neuropathies.

RESULTS

The different varieties of diabetic neuropathies include typical sensorimotor polyneuropathy (lower extremity predominant, length-dependent, symmetric, sensorimotor polyneuropathy presumably related to chronic hyperglycemic exposure, and related metabolic events), entrapment mononeuropathies, radiculoplexus neuropathies related to immune inflammatory ischemic events, cranial neuropathies, and treatment-related neuropathies (e.g. insulin neuritis). None of these patterns are unique for diabetes, and they can occur in nondiabetics. Sensory alterations are different among these prototypic varieties and are vital in diagnosis, following course, treatment options, and follow-up of treatment effects.

CONCLUSIONS

Diabetic neuropathies can involve any segment of peripheral nerves from nerve roots to the nerve endings giving different patterns of abnormal sensation. It is the involvement of small fibers that causes positive sensory symptoms like pain early during the course of disease, bringing subjects to physician's care.

CLINICAL RELEVANCE

This article emphasizes on the fact that diabetic neuropathies are not a single entity. They are rather different varieties of conditions with more or less separate pathophysiological mechanisms and anatomical localization. Clinicians should keep this in mind when assessing patients with diabetes on the first visit or follow-up.

Thoracic disk herniation, a not infrequent cause of chronic abdominal pain

This study assesses the proportion of patients presenting with nonvisceral chronic abdominal pain who have thoracic disk herniation as a possible cause. We designed a descriptive transversal study of patients attending our offices between February 2009 and October 2010, with a complaint of chronic abdominal pain of suspected abdominal wall source (positive Carnett sign). Nuclear magnetic resonance (NMR) of the spinal column was performed on all patients. When the NMR showed thoracic disk herniation the patients were treated according to their etiology. We also evaluated the symptoms in patients with thoracic disk herniation and their response to the applied treatment. Twenty-seven patients with chronic abdominal pain were evaluated. The NMR results in 18 of these 27 patients (66.66%) showed evidence of disk herniation. We report on the results of these 18 patients, emphasizing that the symptoms are florid and varied. Many patients had been previously diagnosed with irritable bowel syndrome. Thoracic disk herniation may account for chronic abdominal pain in many patients who remain undiagnosed or are diagnosed with irritable bowel syndrome. Thus, this possibility needs to be taken into account to achieve a correct diagnosis and a suitable mode of treatment.

Referred pain in right arm from abdominal wall pseudoaneurysm

Pseudoaneurysm of the abdominal wall is a possible but very rare clinical entity. It is a known complication of surgery, trauma, or arterial puncture, but it is rarely spontaneous. Even though it can usually present with a wide range of local symptoms, it can cause referred pain via spinal cord, which is cross-excited with afferent sympathetic nervous system. We report a case of right arm pain which was referred from a small abdominal pseudoaneurysm like a referred pain from gall bladder. This rare entity should be considered in the differential for pain management in case that the pain does not resolve with medication or interventional pain management.

Sympathetic blocks provided sustained pain relief in a patient with refractory painful diabetic neuropathy

The sympathetic nervous system has been implicated in pain associated with painful diabetic neuropathy. However, therapeutic intervention targeted at the sympathetic nervous system has not been established. We thus tested the hypothesis that sympathetic nerve blocks significantly reduce pain in a patient with painful diabetic neuropathy who has failed multiple pharmacological treatments. The diagnosis of small fiber sensory neuropathy was based on clinical presentations and confirmed by skin biopsies. A series of 9 lumbar sympathetic blocks over a 26-month period provided sustained pain relief in his legs. Additional thoracic paravertebral blocks further provided control of the pain in the trunk which can occasionally be seen in severe diabetic neuropathy cases, consequent to extensive involvement of the intercostal nerves. These blocks provided sustained and significant pain relief and improvement of quality of life over a period of more than two years. We thus provided the first clinical evidence supporting the notion that sympathetic nervous system plays a critical role in painful diabetic neuropathy and sympathetic blocks can be an effective management modality of painful diabetic neuropathy. We concluded that the sympathetic nervous system is a valuable therapeutic target of pharmacological and interventional modalities of treatments in painful diabetic neuropathy patients.

Chronic abdominal wall pain--a diagnostic challenge for the surgeon

BACKGROUND

Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain.

METHODS

The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain.

RESULTS

CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnett's test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology.

CONCLUSION

The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.

Dolor originado en la pared abdominal: una alternativa diagnóstica olvidada

Chronic abdominal pain is a common clinical problem in primary care, and is usually referred to gastroenterologists or general surgeons. Although up to 20% of cases of idiopathic abdominal pain arise in structures of the abdominal wall, this is frequently overlooked as a possible cause. It includes pain arising from structures of the abdominal wall including skin, parietal peritoneum, cellular subcutaneous tissue, aponeuroses, abdominal muscles and somatosensorial innervation from lower dorsal roots. The diagnosis is based on anamnesis and physical examination. Carnett's sign is a simple maneuver that discriminates between parietal and visceral pain. Management with topical anesthesia is effective in a majority of patients and can help to confirm the diagnosis.