FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Cord & peripheral

Peripheral neuropathy

Diffuse peripheral nerve dysfunction — many causes

Overview

Dysfunction of peripheral nerves, most commonly a length-dependent, symmetrical "glove-and-stocking" sensorimotor neuropathy. The exam tests identifying the CAUSE (diabetes the commonest) and the predominantly-motor vs predominantly-sensory pattern.

Recognise

  • Glove-and-stocking sensory loss/paraesthesiae (longest nerves first — feet before hands)
  • Causes mnemonic ABCDE: Alcohol, B12 deficiency, CKD/Cancer, Diabetes/Drugs (isoniazid, chemo), Every vasculitis/inflammatory
  • Motor-predominant (e.g. lead, GBS, CMT, Charcot-Marie-Tooth) vs sensory-predominant (diabetes, B12, alcohol)

Red flags

  • Rapidly progressive/ascending weakness (GBS), autonomic involvement, foot ulceration (diabetic insensate foot)

Differentials & how to tell them apart

Radiculopathyfollows a nerve-root dermatome/myotome, not glove-and-stocking
Mononeuritis multiplex≥2 named nerves separately — think vasculitis/diabetes
Charcot-Marie-Toothinherited, distal wasting ("inverted champagne bottle"), pes cavus, hammer toes, family history
Guillain-Barréacute, ascending, areflexic, post-infective

Investigations

Identify the cause: glucose/HbA1c, B12/folate, U&E, LFTs/GGT, TFTs, ESR/immunoglobulins/electrophoresis, B12; nerve conduction studies (axonal vs demyelinating).

Management

Identify and treat the cause; neuropathic-pain agent (amitriptyline/duloxetine/gabapentin/pregabalin)

  1. 1Establish the pattern (sensory vs motor, symmetrical vs multifocal) and SCREEN FOR THE CAUSE (the ABCDE list); manage neuropathic pain (amitriptyline, duloxetine, gabapentin, or pregabalin).Gate: A rapidly ascending, areflexic weakness is GBS (an emergency needing FVC monitoring), not a chronic peripheral neuropathy — do not manage it as routine
  2. 2Treat the underlying cause (glycaemic control, B12, stop the toxin/drug, treat vasculitis); foot care in diabetes; OT/physio.
Treat the cause + neuropathic agents — amitriptyline, duloxetine, gabapentin or pregabalin for neuropathic pain

Key points

Glove-and-stocking + a cause from the ABCDE list. Inherited distal wasting with pes cavus = Charcot-Marie-Tooth. Multiple separate named nerves = mononeuritis multiplex (vasculitis/diabetes).

Monitor & prognosis

Cause-specific control, pain, foot health, function.

Depends on cause; some reversible (B12, drug), others progressive.

Source: NICE CKS; NICE NG (neuropathic pain)