Neuropathy

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Things are not always as they appear:Yesterday,I saw a patient.She is diabetic,59 years old.Chief complaint:Thick nails.As I like to do with all my diabetic patients,I asked her a few questions,including whether she gets any pain burning or numbness in her feet.She said she gets pins and needles type pain in her feet.I start to go into my whole spiel about diabetes,nerve damage,sorbitol,the whole 9 yards.As she shifts in the chair,she tells me to be patient because she has back trouble.A light bulb goes off.I ask her:Is there pain shooting down your leg into your foot?A:Yes.Next question:The pins and needles is in one foot or two?A:Only one.It seemed to me,therefore that she does NOT have diabetic neuropathy at this time.If so,she would have symptoms in both feet.She has a radiculopathy type pain related to a herniated disc.The moral of the story.....If someone is diabetic and presents with neuropathy,the cause of the latter may not always be diabetes.I had a patient 3 years ago with neuropathic ulcers.Suspected cause was not diabetes.It was AIDS(people with this horrible disease can lose sensation in their feet and have gait and other neurogenic and dermatologic maladies including ulcerations).

 

I have always asked about back pain & / or injuries as part of my neuropathy assessment. It seemed logical to me.

 

We have a particular patient that comes regularly to our teaching clinic - students routinely do monofilament and vibration testing and report the results...they generally report a couple of sites not felt with the monofiament and vibration is reduced - we never have reason to doubt what the student is saying. A while back we recruited him into one of our research projects and in a very controlled environment found nothing wrong with monofilament testing and vibration testing .... either the students got it wrong or thats the difference between a busy clinic with lots going on in the environment vs a controlled research environment.

 

getting the patient to fully understand the process of the test and how to respond in the correct manner is an equally important factor

 

I had a similar case recently - diabetic with neuropathy actually caused by spinal injuries sustained in a car accident. I guess the advice is still the same though - this person is still neuropathic and at risk of ulceration.