Post on 22-Dec-2015
Disorders of peripheral nerves
Symptoms and signs of disorders of nerves
• Caused by changes in axons–Increased conduction time–Increased temporal dispersion
• Expression of neural plasticity causing changes in the function of CNS structures
Anatomy of peripheral nerves
Anatomy of peripheral nerves
• Peripheral nerves have different conduction velocity
Conduction velocity in nerves and fiber tracts
• Proportional to fiber diameter• Peripheral nerves: ~50 meter/sec
(5 cm/msec)• Spinal descending tracts: ~70-100 m/sec • Cranial nerves: varies
(Auditory nerve: 20 m/sec)
Fig 4.3From: Møller: Sensory Systems, 2003
Nerve fibers with different diameter have different conduction velocity
Epineurium
Perineurium
Endoneurium
Fascicles
Nerve fiber
Node of Ranvier
Schwann cell
Myelin
Axon
From: Møller: Sensory Systems, 2003
Many nerves are mixed nerves
• Contains nerve fibers with different conduction velocity
Recording from a long nerve composed of fibers with different diameter thus different conduction velocity
Organization of the dorsal horn of the spinal cord
FROM BRODAL 1998
Many nerves are bipolar nerves
• Examples are dorsal roots
From Brodal 1998
Pathologies of peripheral nerves
Nerves:• Neurapraxia• Axonotmesis • Neurotmesis Nuclei:• Altered discharge pattern (burst activity)
Causes of injury to peripheral nerves
• Trauma• Compression (entrapment)• Irritation• Metabolic disorders• Inflammatory (neuritis)• Virus• Age related changes
Trauma to peripheral nerves
• Interruption of nerve trunk (neurotmesis)
• Interruption of axons (axonotmesis)
• Total conduction failure (neurapraxia)
• Impaired conduction (no morphologic change)
Normal
Central portion Peripheral portion
Stretched
Axon
EpineuriumPerineuriumEndoneurium
Neurapraxia
Total conduction failure (neurapraxia)
• No function
• Recovers spontaneously over days or weeks (when the cause is resolved)
• Results of spontaneous recovery are almost always good
Interruption of axons (axonotmesis)
• No function
• New axon grows from cell body (spontaneously)
Axonotmesis
• Nerve may regenerate from injured location away from the cell body
• Regeneration: 1 mm per day (approx. 1 inch per month)
• Results of spontaneous recovery are good to moderate depending on distance
Interruption of nerve trunk (neurotmesis)
• No function
• Irreversible, grafting is required
Neurotmesis
• Does not regenerate spontaneously
• Grafting is necessary to restore function
• Results of grating are good to moderate to failures
Injured nerves
Axon interrupted(Wallerian degeneration)
Interruption of axon andendoneurial sheet
Interruption ofperineurial sheet
Interruption of nerve trunk
Axon
EpineuriumPerineuriumEndoneurium
Type 2
Type 3
Type 4
Type 5
Axonotmesis
Neurotmesis
Interrupted axons
• Degenerate distally (away from cell body)
• Wallerian degeneration
• Interrupted axons regenerate from injury, provided that endoneural tube is intact
Wallerian degeneration means:
The degenerative changes the distal segment of a peripheral nerve fiber (axon and myelin) undergoes when its continuity with its cell body is interrupted by a focal lesion. Syn: orthograde degeneration, secondary degeneration.
START 9/7/05
Remaining symptoms after nerve healing of injury
• Synkinesis
• Hyperactivity
(Mostly caused by effect on central nervous system structures)
Electrophysiological manifestations of pathologies of peripheral nerves
Nerves:• Increased conduction times • Increased or decreased discharge activity• Dispersion of neural activity • Altered discharge pattern (burst activity)
Cause of neural pathologies
• Mechanical (compression, stretching)• Heat• Metabolic• Inflammation• Iatrogenic (from medical treatment)• Idiopathic (unknown)• Age
Trauma
• Gunshot to limbs
• Accidents
• Surgery (iatrogenic)
Sprouting
• Caused by injury
• Caused by regeneration
Formation of neuroma
• Sprouting of axons at cut of a nerve
• Injured perineurium
Neuroma are mechanically sensitive
Compression
• No known cause
• Scar tissue
• Changes in bone formation
Block of axoplasmatic flow
Irritation
• Scar tissue
• Blood vessels
Metabolic and chemical induced peripheral neuropathy
• Diabetes
• Uremic, hepatic and vitamin (B1,B2,B12) deficits
• Alcohol
• Chemical
Inflammatory (neuritis)
• Guillain-Barre syndrome
Virus
• Herpes simplex (causes severe pain)
Demyelination
• Ephaptic transmission
• Reflection of neural activity
• Mechanosensitivity
Injury to a peripheral nerve can cause transneural degeneration of the target cell
Functional implications of neural injuries
• Change the function of the target central neurons:– May cause expression of neural plasticity
Abnormal activity in a peripheral nerve can cause changes in the
function of the target cells
Cause of synkinesis and hyperactivity
• Plastic changes in target neurons induced by the injury
Expression of neural plasticity from injury to sensory nerves:
• Deprivation of input
• Overstimulation
Impaired conduction
• Decreased conduction velocity
• Increased refractory period
• Ectopic (out of place) activity
Irritation of peripheral nerves
• Cause change in central processing
– Pain
– Hypersensitivity
– Spasm
Irritation of nerve roots
• Cause change in central processing
• Transition between peripheral and central myelin is especially sensitive
Irritation of nerve roots
• Pain
• Hyperalgesia
• Spasm
(Expression of neural plasticity)
Start 9/12/05
Signs of peripheral nerve disorders
• Motor nerves:– Paralysis– Spasm– Electrophysiologic changes
Explanation
A sign is any abnormality indicative of disease, discoverable on examination of the patient.
Symptoms of peripheral nerve disorders
• Sensory nerves– Numbness– Tingling– Pain
A symptom is any morbid phenomenon or departure from the normal in structure, function, or sensation, experienced by the patient and indicative of disease.
Explanation
Slightly injured nerves (demyelination)
• Decreased conduction velocity
• Abnormal firing pattern
• Peripheral nerves as impulse generators
• Possible ephaptic*) transmission
*) Direct transfer of impulse activity from one nerve fiber to another
Decreased conduction velocity
• Temporal dispersion of neural activity
• Change in neural coding of sensory stimuli
Decreased conduction velocity
• The decrease is not the same for all fibers
• Temporal dispersion of neural activity
Increased spatial dispersion
• Can decrease excitation
• Can increase excitation
• Can degrade temporal information
Action potential
Threshold
Threshold
EPSP
EPSP
From Møller 2005
Temporal dispersion
1. Can decrease the activation of the target neuron
2. Can increase the duration of firing of the target neuron, which can increase or decrease activation of the following neuron.
3. Increased temporal dispersion may prevent activation of the next neuron in a chain, or it may make it possible to activate neurons that are not normally activated.
4. Increased temporal dispersion may degrade information when temporal coding is important such as in sensory systems, most pronounced in hearing
Abnormal firing pattern
• Burst firing
Threshold
Resting potential
Incoming nerve impulses
Action potential
From Møller 2005
Peripheral nerves as impulse generators
• Ectopic activity– After demyelination– Diabetic neuropathy– Adrenergic substances facilitate impulse
generation
Ectopic firing
• Burst
• Rhythmic
• After-discharges to stimulation