Abstract
The peripheral nervous system involves all nerves lying outside the spinal cord and brainstem except the olfactory and optic nerves that are extensions of the central nervous system itself. All peripheral nerve axons are invested either with a wrapping of myelin made by Schwann cells (myelinated nerve) or by cytoplasm of Schwann cells (unmyelinated nerve). The chapter begins with a discussion of common major clinical features and mechanisms of damage of all motor and sensory nerves. Three common diseases of peripheral nerves are then discussed in detail: diabetic distal symmetrical polyneuropathy, carpal tunnel syndrome, Bell’s palsy or idiopathic peripheral facial nerve palsy, with attention to their pathophysiology, major clinical features, major laboratory findings, and principles of management and prognosis.
A 30-year-old woman, pregnant with her first child, noted intermittent wrist pain predominantly at night, for which she shakes her hands to relieve. Over time, she has wrist pain most of the time and it has moved into the palm of the hand. Several weeks ago, she noticed numbness and tingling in her fingertips—especially her thumb and index finger. In her job as an academic neurologist, she types notes and papers and these symptoms are becoming more intrusive. She makes an appointment with one of her colleagues who performs a physical exam and nerve conduction studies. She is diagnosed with carpal tunnel syndrome Carpal tunnel syndrome (CTS) (as she suspected) and begins conservative treatment with good response.
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Recommended Reading
Alfonso C, Jann S, Massa R, Torreggiani A. Diagnosis, treatment and follow-up of the carpal tunnel syndrome. Neurol Sci. 2010;31:243–52. (A synthesis of current knowledge in carpal tunnel syndrome).
British Medical Research Council. Aids to the examination of the peripheral nervous system. 5th edn. Philadelphia: Saunders; 2010. (Superb booklet that outlines how to test each muscle, describes areas of sensation for all peripheral nerves, and easily can be kept in doctor’s bag).
Gilden DH. Bell’s Palsy. N Engl J Med. 2004;351:1323–31. (Excellent review with good illustrations).
Said G. Diabetic neuropathy—a review. Nat Clin Pract Neurol. 2007;3(6):331–40. (Good review of the pathophysiology, clinical presentation and treatment of diabetic neuropathy).
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This video shows a 48 year-old woman with Chronic Inflammatory Demyelinating Polyneuropathy
Segment 1: Motor Exam
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Exam of muscle bulk in feet shows weaknessin small muscles of foot resulting in high arch.
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Strength in lower extremities is 4/5 with weaknessgreater distally than proximally.
Segment 2: Reflex Exam
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2+ reflexes (normal) in brachioradialis, biceps and patellar bilaterally
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Absent Achilles reflexes bilaterally
Segment 3: Gait Exam
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Ankle dorsiflexion weakness results in toedragging.
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Davis, L., Pirio Richardson, S. (2015). Disorders of Peripheral Nerves. In: Fundamentals of Neurologic Disease. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2359-5_6
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DOI: https://doi.org/10.1007/978-1-4939-2359-5_6
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Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4939-2358-8
Online ISBN: 978-1-4939-2359-5
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