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Suggest Treatment For Symptoms Of Peripheral Neuropathy
Question: I have previously communicated with Dr. XXXXXXX Panwar, neurologist, but that has now closed other than uploading reports option. Due to technical difficulties, I am not able to upload the MRI films. Here's what the report says: Clinical indications 56-year old female with low back pain extending into the left leg. Bilateral leg twitching and tingling in the feet. Problems increasing since January 2015 with walking. No trauma. No surgery. No cancer. MRI of the lumbar spine without contrast revealed:
At L1-L2, there's no evidence for disc herniation, foraminal encroachment or canal stenosis.
At L2-L3, thre's no evidence for disc herniation, foraminal encroachment or canal stenosis.
At L3-L4, there's a small broad-based left lateral disc herniation that slightly displaces the exiting left L3 nerve root. This may represent the etiology of this patient's L-sided symptoms. There's also mild diffuse degenerative disc bulging. The fact joints are minimally degenerated and hypertrophic. These abnormalities combine to cause concentric mild central canal narrowing but without XXXXXXX canal stenosis. The foramen are patent. No other disc herniations are found. At L4-L5, mild diffuse degenerative disc bulging is present. The facet joints are minimally degenerated. The canal is patent. No focal disc herniations are found. The foramen are patent. At L5-s1, no significant disc herniation or canal stenosis is found. Within the sacrum, there;s a small intrasacral meningocele incidentally noted, of doubtful clinical significance. My PCP gave me a course of oral steroids that seemed to ever so slightly help the left-sided leg pain, but did nothing for the twitching. He said that there findings are not impressive and do not explain my right-sided symptoms. He referred me for an EMG/NCV, which was completely normal. My PCP is perplexed. He is going to refer me for a neurology consult. In the meantime, he ordered a complete blood work panel (I am still awaiting results) and is trying to get insurance approval for brain MRI, cervical MRI and thoracic MRI as the neurologist will certainly want them and we might as well get them done as it will be 4-8 weeks before I can get in to see a neurologist. He does not think that I am pre-diabetic despite my weight as my A1c was 5.4 and my fasting glucose was 100 when taken in September. He does not think my values indicate glucose intolerance small fiber neuropathy. He wants me to immediately stop taking all supplements so as not to complicate the picture until the neurology evaluation can be completed. He says that I have neuropathy symptoms with no clinical findings so he is stumped. He thinks that the problem is either some kind of neurological issue that needs to be chased down by a neurologist or else it is anxiety based. In the meantime, the mild bilateral foot tingling continues. The leg fasciculations continue and appear to be exacerbated by exercise/brisk walking. I have a mild burning sensation in both hands that came on at the same time about one week ago. It comes and goes. I am worried about possible multiple sclerosis or some kind of neuropathy, perhaps idiopathic. Your thoughts would be most appreciate.
At L1-L2, there's no evidence for disc herniation, foraminal encroachment or canal stenosis.
At L2-L3, thre's no evidence for disc herniation, foraminal encroachment or canal stenosis.
At L3-L4, there's a small broad-based left lateral disc herniation that slightly displaces the exiting left L3 nerve root. This may represent the etiology of this patient's L-sided symptoms. There's also mild diffuse degenerative disc bulging. The fact joints are minimally degenerated and hypertrophic. These abnormalities combine to cause concentric mild central canal narrowing but without XXXXXXX canal stenosis. The foramen are patent. No other disc herniations are found. At L4-L5, mild diffuse degenerative disc bulging is present. The facet joints are minimally degenerated. The canal is patent. No focal disc herniations are found. The foramen are patent. At L5-s1, no significant disc herniation or canal stenosis is found. Within the sacrum, there;s a small intrasacral meningocele incidentally noted, of doubtful clinical significance. My PCP gave me a course of oral steroids that seemed to ever so slightly help the left-sided leg pain, but did nothing for the twitching. He said that there findings are not impressive and do not explain my right-sided symptoms. He referred me for an EMG/NCV, which was completely normal. My PCP is perplexed. He is going to refer me for a neurology consult. In the meantime, he ordered a complete blood work panel (I am still awaiting results) and is trying to get insurance approval for brain MRI, cervical MRI and thoracic MRI as the neurologist will certainly want them and we might as well get them done as it will be 4-8 weeks before I can get in to see a neurologist. He does not think that I am pre-diabetic despite my weight as my A1c was 5.4 and my fasting glucose was 100 when taken in September. He does not think my values indicate glucose intolerance small fiber neuropathy. He wants me to immediately stop taking all supplements so as not to complicate the picture until the neurology evaluation can be completed. He says that I have neuropathy symptoms with no clinical findings so he is stumped. He thinks that the problem is either some kind of neurological issue that needs to be chased down by a neurologist or else it is anxiety based. In the meantime, the mild bilateral foot tingling continues. The leg fasciculations continue and appear to be exacerbated by exercise/brisk walking. I have a mild burning sensation in both hands that came on at the same time about one week ago. It comes and goes. I am worried about possible multiple sclerosis or some kind of neuropathy, perhaps idiopathic. Your thoughts would be most appreciate.
Brief Answer:
Neuropathy possible, MS unlikely.
Detailed Answer:
I read your question carefully and I understand your concern. I actually considered writing back hours ago but wasn't sure whether you wished Dr Panwar to follow up or the question was directed to any member of the neurology panel.
Usually neurological involvement is divided in central and peripheral nervous system involvement. The signs between these two groups are usually different from each other. Your description of sensory symptoms of tingling in both lower limbs and lately in the hands as well, coupled with fasciculations are found typically in peripheral nerve system involvement not in the central one, so you shouldn't worry much about MS which affects central pathways. Also your age is not typical for MS. So I don't really expect much from the brain MRI.
Those symptoms as I said (and you yourself mentioned) are characteristic of peripheral neuropathy. Reading that MRI report I agree with your physician it shouldn't be related to nerve root compression, the fact that you have symptoms in your hands as well confirms that.
Most peripheral neuropathies do show some alterations on EMG, however they can result normal in the case of small fiber involvement, skin biopsy is the test which detects that. While diabetes is the most common cause, its absence doesn't exclude the diagnosis as there are many other rarer causes like thyroid disorders, electrolytes, celiac disease, amyloidosis, rheumatological conditions, some blood conditions, toxins, paraneoplastic syndromes, HIV, vitamin B12 deficiency etc.
So as you can see many tests might be needed like: K/Ca/Mg/Phos, creatine kinase, vit B12, thyroid function tests, Lyme disease antibodies, urine and serum protein electrophoresis, liver and kidney function tests, HIV, ANA (antinuclear antibodies), XXXXXXX ACE level, hepatitis B and C virus, cryoglobulins.
Apart from those some cases can remain unexplained, idiopathic but to say that more tests must be completed.
Of course there is also the benign alternative of anxiety, but to reach to that conclusion the above mentioned issues must be excluded.
I understand that apart from excluding MS I might have not done much to narrow the list of possibilities which might look a little confusing. But to conclude on a positive note though, I would say that most of those conditions I mentioned (rheumatological and infectious conditions) usually have other manifestations, so are not that likely and considering the normal EMG anxiety might well be the cause. Your physician (and I) are just trying to be thorough.
I remain at your disposal for further questions.
Neuropathy possible, MS unlikely.
Detailed Answer:
I read your question carefully and I understand your concern. I actually considered writing back hours ago but wasn't sure whether you wished Dr Panwar to follow up or the question was directed to any member of the neurology panel.
Usually neurological involvement is divided in central and peripheral nervous system involvement. The signs between these two groups are usually different from each other. Your description of sensory symptoms of tingling in both lower limbs and lately in the hands as well, coupled with fasciculations are found typically in peripheral nerve system involvement not in the central one, so you shouldn't worry much about MS which affects central pathways. Also your age is not typical for MS. So I don't really expect much from the brain MRI.
Those symptoms as I said (and you yourself mentioned) are characteristic of peripheral neuropathy. Reading that MRI report I agree with your physician it shouldn't be related to nerve root compression, the fact that you have symptoms in your hands as well confirms that.
Most peripheral neuropathies do show some alterations on EMG, however they can result normal in the case of small fiber involvement, skin biopsy is the test which detects that. While diabetes is the most common cause, its absence doesn't exclude the diagnosis as there are many other rarer causes like thyroid disorders, electrolytes, celiac disease, amyloidosis, rheumatological conditions, some blood conditions, toxins, paraneoplastic syndromes, HIV, vitamin B12 deficiency etc.
So as you can see many tests might be needed like: K/Ca/Mg/Phos, creatine kinase, vit B12, thyroid function tests, Lyme disease antibodies, urine and serum protein electrophoresis, liver and kidney function tests, HIV, ANA (antinuclear antibodies), XXXXXXX ACE level, hepatitis B and C virus, cryoglobulins.
Apart from those some cases can remain unexplained, idiopathic but to say that more tests must be completed.
Of course there is also the benign alternative of anxiety, but to reach to that conclusion the above mentioned issues must be excluded.
I understand that apart from excluding MS I might have not done much to narrow the list of possibilities which might look a little confusing. But to conclude on a positive note though, I would say that most of those conditions I mentioned (rheumatological and infectious conditions) usually have other manifestations, so are not that likely and considering the normal EMG anxiety might well be the cause. Your physician (and I) are just trying to be thorough.
I remain at your disposal for further questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr. Taka: Thank you for your thoughtful response. I just found out that the labs done so far - B-12, ESR, CRP, ANA and proteins were all normal. While it is reassuring to think that I likely do not have MS, I am concerned about peripheral neuropathy. My understanding is that unless you can determine the cause of small fiber neuropathy, all you can do is treat the pain, and that the disease is progressive and will therefore become more painful and debilitating over time and can even develop into large fiber neuropathy. How often does that occur? Given preliminary labs and the fact that to my knowledge I have never been anywhere that I may have been exposed to Lyme disease and do not have the Hep B or C virus, I am worried that the cause may be idiopathic and that at age 56, I am facing a lifetime of pain and potential disability. After having some mild tingling in my right foot that began last summer, in late January I began developing mild tingling in my left foot, as well as fasciculations with some cramping and stiffness in my legs, left moreso than right. Those symptoms have continued. In mid-March, I suddenly developed mild burning pain in my hands/fingers. It comes and goes. If this is due to neuropathy versus anxiety (and I assume that my neurologist--once I can finally get in to see him--will want a skin biopsy and other tests to determine that), does it seem to you that my condition is progressing rather quickly and, if so, what might that indicate about cause and prognosis? Finally, my research indicates that there are some promising ongoing clinical studies with respect to the use of Metanx as potentially stopping or reversing PN. There are also some studies that suggest taking Methylcobalamin and Alpha Lipoic Acid supplements may be helpful. What do you think about those? I am not a person who wants to take pain medications and do not want to end up as someone unable to work and function and at the mercy of the various medications given to control neuropathic pain, all of which have very significant side effects. I am highly motivated to eat right, exercise, and do everything in my own power to help my condition, whatever that turns out to be. If it turns that I have idiopathic neuropathy, do you think that I have a reasonable likelihood of living a normal life?
Brief Answer:
Read below.
Detailed Answer:
The prognosis of small fiber neuropathy is not as bleak as you seem to think it is. Exact predictions are hard to be made as long term studies are needed, but judging from those existing studies only 13% evolve into involving large fibers and the pain worsened in only one third of cases. So you have every chance of living a normal life.
However I wouldn't want you to jump into too early conclusions, I said that it was possible, but that term does not constitute a diagnosis. There are other criteria for the diagnosis which include changes of temperature sensitivity on neurological exam.
Also while there can often be an association with fasciculations, now in this second part of your question you seem to be stressing on stiffness and cramping as well which are not a characteristic feature at all, that lowers the probability of that diagnosis.
So since until now we have a normal physical neurological exam by the PCP, a normal EMG, no alarming findings on lumbar MRI, normal blood tests I would try to relax.
If the MRIs you PCP is trying to schedule result normal and neurologist finds no other signs most probably it is a benign cause such as anxiety, benign fasciculation syndrome, or in light of your cramping issues the more rare cramp fasciculation syndrome (a variant of the benign fasciculation syndrome, often accompanied with the tingling like paresthesias).
As for the Metanx question, it contains some vitamins which can have a beneficial effect on the nerves although it's a mild one, so yes you can try it. Methylcobalamin is already in Metanx, so either one or the other. Alpha Lipoic acid does have a temporary beneficial effect in diabetic neuropathy, but its efficacy in other types of neuropathy has not been proven.
I hope to have been of help.
Read below.
Detailed Answer:
The prognosis of small fiber neuropathy is not as bleak as you seem to think it is. Exact predictions are hard to be made as long term studies are needed, but judging from those existing studies only 13% evolve into involving large fibers and the pain worsened in only one third of cases. So you have every chance of living a normal life.
However I wouldn't want you to jump into too early conclusions, I said that it was possible, but that term does not constitute a diagnosis. There are other criteria for the diagnosis which include changes of temperature sensitivity on neurological exam.
Also while there can often be an association with fasciculations, now in this second part of your question you seem to be stressing on stiffness and cramping as well which are not a characteristic feature at all, that lowers the probability of that diagnosis.
So since until now we have a normal physical neurological exam by the PCP, a normal EMG, no alarming findings on lumbar MRI, normal blood tests I would try to relax.
If the MRIs you PCP is trying to schedule result normal and neurologist finds no other signs most probably it is a benign cause such as anxiety, benign fasciculation syndrome, or in light of your cramping issues the more rare cramp fasciculation syndrome (a variant of the benign fasciculation syndrome, often accompanied with the tingling like paresthesias).
As for the Metanx question, it contains some vitamins which can have a beneficial effect on the nerves although it's a mild one, so yes you can try it. Methylcobalamin is already in Metanx, so either one or the other. Alpha Lipoic acid does have a temporary beneficial effect in diabetic neuropathy, but its efficacy in other types of neuropathy has not been proven.
I hope to have been of help.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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