How Effective Is Amitriptyline for Neuropathy?

Peripheral nerves are brain and spinal nerves other than the olfactory and optic nerves, including 10 pairs of brain nerves and 31 pairs of spinal nerves. Peripheral nerve disease refers to a disease that is originally caused by damage to the structure or function of the peripheral nervous system. Peripheral spinal neuropathy can be classified and named in many different ways. According to the classification of the affected nerve distribution, that is, the type of nerve distribution, it is divided into mononeuropathy; multiple mononeuropathy; plexus neuropathy; (distal symmetry) polyneuropathy.

Basic Information

Visiting department

Neurology

Common causes

Caused by trauma, thoracic outlet syndrome, physical injury, etc.

Common symptoms

Weakness of the shoulder strap muscles and proximal muscles of the upper limbs, atrophy, claw-shaped hands, intercostal neuralgia, etc.

Contagious

no

Causes of mononeuropathy and plexus neuropathy

Brachial plexus neuropathy

(1) Violent traction and impact on the upper limbs during car accidents and mechanical injuries are the most common causes of traumatic brachial plexus neuropathy.

(2) Thoracic outlet syndrome

(3) Physical damage such as electric shock and radiation damage.

(4) Acute brachial plexus neuritis is also called neuralgia. Often after acute or subacute onset of flu or after using drugs such as penicillin, it may be related to autoimmunity.

(5) Genetic factors, such as familial recurrent brachial plexus neuropathy or hereditary familial brachial plexus neuropathy, nerve biopsy in some patients can show myelin hypertrophy, which is a sausage-like change, similar to hereditary stress-susceptible peripheral neuropathy.

(6) The most common tumor is brachial plexus schwannomas, followed by brachial plexus neurofibromas.

(7) During the delivery of brachial plexus neuropathy , if the fetal shoulder is difficult to give birth, pulling the fetus's head with force will easily cause brachial plexus injury, which mostly occurs in giant infants larger than 4000g. However, brachial plexus injury can also occur in a considerable number of newborns weighing less than 4000g and having difficulty in delivering the shoulders, indicating that there may be other causes than birth injuries.

(8) Chronic brachial plexus neuropathy refers to a group of slowly progressive idiopathic brachial plexus neuropathy of unknown cause.

Intercostal neuralgia

It is mainly related to the involvement of intercostal nerves in lesions of adjacent tissues and organs. Common causes include pleurisy, pneumonia, and aortic aneurysms; trauma, tumors, and deformities of the thoracic spine and ribs; cavities, inflammation, and tumors of the thoracic spinal cord. Varicella or shingles infections and intercostal neuralgia after infection are common in the elderly, HIV patients, patients with malignancies and chemotherapy.

3.lumbosacral plexus neuropathy

(1) Diabetic proximal muscle atrophy is considered to be caused by bilateral lumbosacral plexus involvement, and the immune mechanism plays an important role in nerve injury.

(2) Traumatic and hemorrhagic diseases Traumatic pelvic fractures, psoas or intrapelvic hematomas, hip dislocations, and fractures can all cause lumbosacral plexus injury. Patients with hematological diseases or anticoagulant treatment may have psoas or iliopsoas hematomas that directly invade the lumbosacral plexus.

(3) Iatrogenic intraperitoneal and pelvic surgery such as hysterectomy, kidney transplantation, prostate and bladder surgery, etc. Due to the use of self-limiting retractors, its sharp blades can easily compress the lumbosacral plexus nerve and cause damage. During kidney transplantation, the donor renal artery anastomosis with the recipient's inferior vena cava artery can easily lead to arterial blood stealing and cause lumbosacral plexus ischemia. During hip arthroplasty, the adhesive is squeezed out of the pelvis to compress the plexus.

(4) Aortic and pelvic arterial malformations and deformed blood vessels rupture and bleed to form pelvic hematomas that compress the lumbosacral nerve plexus.

(5) In the process of childbirth , the primiparous or huge fetus has a long labor process, and the long lithotomy position will cause excessive abduction of the hip joint, which may cause lumbosacral plexus injury.

(6) Tumor Tumors of the lumbosacral plexus are common and difficult to diagnose. CT, MRI, and lumbar puncture are often not found abnormally. Tumors of the prostate, rectum, bladder, and kidney can invade the lumbosacral plexus and surrounding lymph nodes through local spread. Large fibroids in the posterior wall of the uterus and endometriosis can directly compress the lumbosacral plexus. In addition, aneurysms formed by aortic atherosclerosis can also affect the plexus.

(7) Infection of psoas muscle tuberculous abscess, lumbar osteomyelitis, and appendicitis, inflammation can invade the lumbosacral plexus through the diaphragm. Sometimes chickenpox or shingles infections can also cause lumbosacral neuralgia and herpes in the corresponding cortex. Systemic vasculitis can involve lumbosacral plexus and cause vasculitis peripheral neuropathy.

(8) Radiation of radiation from pelvic tumors can cause radiation lumbosacral plexus neuropathy.

(9) Idiopathic corresponds to acute brachial plexus neuritis in the upper limbs, and idiopathic lumbosacral plexus neuritis in the lower limbs. The pathological mechanisms of both may be related to autoimmune abnormalities.

4. Sciatica

(1) Radical sciatica is more common, mainly in spinal and spinal lesions, and lumbar disc herniation is the most common. Others include lumbar hypertrophic spondylitis, lumbosacral spinal radiculitis, spinal tuberculosis, spinal stenosis, and vascular malformations. Lumbosacral spinal tumors or arachnoiditis.

(2) Dry sciatica is mostly lumbosacral plexus and adjacent diseases of the neural trunk, such as sacroiliitis, tuberculosis or subluxation, and psoas muscle abscess, pelvic tumor, uterine appendicitis, pregnancy uterine compression, improper gluteal injection , Hip injuries and infections.

Clinical manifestations of mononeuropathy and plexus neuropathy

Brachial plexus neuropathy

Brachial plexus damage caused by various reasons is collectively referred to as brachial plexus neuropathy, which is one of the most common plexus plexus diseases. The main clinical manifestations of brachial plexus neuropathy include muscle weakness and muscle atrophy of the shoulder muscles, upper limbs, and chest and back muscles, and numbness, pain, and decreased sensation in the sensory area of the skin corresponding to the affected brachial plexus branches. Depending on the affected area and the degree of damage, there may be different forms of symptom combinations in the clinic.

(1) Damage of the upper brachial plexus (upper trunk of brachial plexus), also known as Duchenne-Erb paralysis, is clinically characterized by the involvement of the shoulder muscles and the proximal muscles of the upper limbs, which are manifested as the subscapularis, great round muscle, superior ganglia, subganglia, The deltoid muscle, pectoralis major clavicle head, radial wrist flexor muscle, pronator round muscle, radial brachii muscle and supinator muscle weakness, atrophy, shoulder abduction, lifting, elbow flexion and wrist flexion and extension cannot. The sensory disturbance is not obvious, and sometimes there is a sensory loss in the upper limb and the radial side of the hand.

(2) Injury of the lower brachial plexus (under brachial plexus), also known as Klumpke-Dejerine paralysis, is clinically characterized by the involvement of various motor functions of the hand, ulnar carpi flexor muscle, vermiform muscle, large and small flexor muscles, and all digital flexors Paralysis, hand muscle atrophy is obvious, forming claw-shaped hands. Fingers and wrist joints cannot flex. The movements of the extensors and shoulder and elbow joints are not affected.

(3) Injury of the brachial plexus alone is rare. The main symptom is weakness of the upper limb extensors. The clinical features of total brachial plexus damage are paralysis of the joints of the shoulders, elbows, wrists, and hands, muscle atrophy, and all tendon reflexes in the upper limbs disappear. Except for the part of the medial arm innervated near the axilla, the rest of the upper limb feels completely lost.

Intercostal neuralgia

It refers to the pain in the intercostal nerve innervation zone, which is usually located in one or several intercostal areas. It is usually a burning pain. Breathing, coughing and sneezing can cause the pain to increase. Physical examination sometimes shows corresponding hyperalgesia of the intercostal area.

3.lumbosacral plexus disease

Radical pain can occur when the lumbosacral nerve root is damaged, and pain can be aggravated when bending over, sneezing, coughing, and flexing the neck. Straight leg elevation test was positive, lumbar spine movement was restricted, anterior spine mutation was straight, local palpitation, and erector spinae muscle spasm. Simple nerve root damage generally does not affect autonomic function.

Straight leg elevation tests are often negative for nerve plexus damage, and increased spinal cord pressure often does not cause increased pain. Hip flexion and abduction and weakness of knee extension when the upper lumbar plexus is damaged, sensory disorders are distributed in the front of the thighs and calves. Inferior plexus damage causes weakness in the posterior femoral muscles, calves, and feet, and loss of sensation in the spinal nerve segments 1, 2 and 2. All lumbosacral plexus lesions are rare, showing paralysis, weakness, and atrophy of the entire lower limb muscles, tendon reflexes disappearing, and the feeling from the tip of the toes to the periphery of the anus is diminished or missing. Autonomic nerve involvement is characterized by dry skin and fever in the lower extremities, often with leg edema. Neural stem damage is mainly manifested as motor and sensory functions related to the nerve.

(1) Femoral nerve damage The weakness of the iliopsoas, sartorius and quadriceps muscles dominated by motor fibers, manifested as weakness of knee extension and flexion of the hip, and thigh abduction is not affected (dominated by the obturator nerve). There are sensory disturbances in the femoral nerve sensory distribution area of the thigh and anterior medial of the calf.

(2) Obturator nerve damage is manifested as thigh external rotation and difficulty in flexion. The adductor muscle group is dominated by the sciatic nerve, so it is incompletely paralyzed.

(3) The nerve damage of the lateral femoral cutaneous nerve is mainly seen in middle-aged men. The clinical manifestations are skin numbness and tingling in the 2/3 area below the lateral thigh after standing and walking for a long time. Local examination has hypoesthesia and hypersensitivity.

(4) Sciatic nerve damage is mainly manifested as sciatica, a pain syndrome along the sciatic nerve pathway and its distribution area. Acute lumbar disc herniation usually causes pain in the back and leg nerve roots (lumbar 5 or diaphragm 1), often with numbness and paresthesia; motor deficits depend on the affected nerve roots, and the lumbar 5 spinal nerve roots cause weakness in the dorsiflexion of the feet and toes Involvement of the spinal nerve roots in the iliac crest 1 produces plantar flexion weakness and reduced ankle reflexes. May have restricted spine movement, limited back tenderness, palpation of paraspinal muscle spasm, and Lasgue sign. Central lumbar disc herniation results in bilateral symptoms, signs, and sphincter involvement.

4. Sciatica

According to the lesion site, it is divided into root and dry sciatica.

(1) Radical sciatica is more common, mainly in spinal and spinal lesions, and lumbar disc herniation is the most common. Others include lumbar hypertrophic spondylitis, lumbosacral spinal radiculitis, spinal tuberculosis, spinal stenosis, and vascular malformations. Lumbosacral spinal tumors or arachnoiditis.

(2) Dry sciatica is mostly lumbosacral plexus and adjacent diseases of the neural trunk, such as sacroiliitis, tuberculosis or subluxation, and psoas muscle abscess, pelvic tumor, uterine appendicitis, pregnancy uterine compression, improper gluteal injection , Hip injuries and infections.

Sciatica is common in young adults. It is characterized by radiation pain along the sciatic nerve path, which is mostly unilateral. It radiates from the lower back or buttocks to the back of the thigh, the back of the calf, and the outside of the foot. It shows persistent dull pain or burning pain. Paroxysmal aggravated, often aggravated at night. Walking, movement, or traction can induce or aggravate. The patient adopts a pain-reducing posture. The affected limb is slightly flexed and lying to the healthy side. The knee of the sick side is bent when standing upright. The hip of the healthy side is stressed when sitting. The spine is facing the patient when standing. Scoliosis, etc.

Mononeuropathy and Plexus Neuropathy

Blood test

Including routine serology tests of blood glucose, liver function, kidney function, ESR, hepatitis B and C; serum thyroid hormone and growth hormone levels; serum vitamin B ₁ , B ₆ , B ₁₂ and vitamin E concentrations; rheumatism series, ANCA ( Anti-neutrophil cytoplasmic antibody), immunoglobulin electrophoresis, cryoglobulin, M protein, anti-GM-1 antibody, anti-GD1a antibody, anti-MAG antibody, tumor-related antibody (anti-Hu, Yo, Ri antibody), etc. Serological tests related to autoimmunity; Serum antibodies to varicella-zoster virus, cytomegalovirus, HIV-1 and Borrelia Burgdorferi; detection of serum heavy metals (lead, mercury, arsenic, thallium, etc.).

2. Urine test

Including urine routine, periprotein, uroporphyrin, and urine heavy metal excretion.

3. Cerebrospinal fluid

In addition to routine cerebrospinal fluid, anti-GM-1 and GD1b antibodies should also be checked.

4. X-ray and bone marrow cytology

Chest and bone X-rays and bone marrow cytology should be performed when paraneoplastic peripheral neuropathy, paraprotein peripheral neuropathy, or POEMS syndrome is suspected.

5. Genetic defect analysis

For example, the TIR mutation test is used for the diagnosis of amyloid peripheral neuropathy, the PMP22 gene deletion is used for the diagnosis of hereditary stress-susceptible peripheral neuropathy, and the PMP22 repeat, Po mutation, and ligandin-32 gene analysis are used for CMT1A, 1B, and X-linked genotypes, respectively. CMT diagnosis.

6. Muscle and nerve electrophysiological examination

It is of great significance to identify the location of neurogenic and myogenic damage, the location of peripheral nerve damage, and to distinguish between axonal mutation and demyelinating damage.

7. Peripheral nerve biopsy

It is an important laboratory test for differential diagnosis of peripheral neuropathy.

Mononeuropathy and Plexus Neuropathy

Acute brachial plexus neuritis

Patients can take prednisone orally with physical therapy. For severe pain, carbamazepine, tramadol, and antidepressants amitriptyline or nortriptyline can be used. Brachial plexus tumors should be surgically removed in principle, and it is best to perform nerve transplantation at the same time. Perinatal brachial plexus injury can heal itself, but if the biceps brachii muscle strength does not start to recover within 3 months, surgical release, concurrent nerve transplantation and functional reconstruction should be considered.

Intercostal neuralgia

The cause should be eliminated first. For patients with severe pain, analgesics such as non-hormonal antipyretic analgesics, morphine preparations, etc. can also be given, and nerve block therapy can also be used. Herpes zoster infection can be applied to local skin with lidocaine or capsaicin. Early application of the antiviral drug acyclovir can reduce the damage to the nerves by the virus, accelerate the healing of skin damage and reduce post-rash neuralgia. Oral acyclovir is not recommended for herpes zoster complicated by immunodeficiency.

3.lumbosacral plexus disease

Different treatment methods can be selected according to different causes. Carbamazepine or other analgesics can be used when the pain is severe, such as acetaminophen (paracetamol) plus codeine, and other non-steroidal analgesics, such as ibuprofen (isobutylphenacetate), naphthalene Puson et al. Muscle cramps can be diazepam (diazepam); or cyclobenzaprine.

(1) In severe cases of sciatica , dexamethasone can be administered intravenously; prednisone can be administered orally. It can also be closed with procaine or gleazone.

(2) In the acute phase of lumbar disc herniation, resting on a hard bed for 1 to 2 weeks can often stabilize the symptoms. Lateral femoral cutaneous neuritis can be applied locally. The method was to locally inject lidocaine or hydrocortisone 10 cm below the superior iliac spine. Can also be combined with acupuncture and physical therapy, conservative treatment can be relieved. When the curative effect is not good, pelvic traction or prednisone epidural injection can be used. Individual cases of ineffective or chronic recurrence can be considered surgical treatment. At the same time, neurotrophic therapy and functional rehabilitation training should be strengthened.