eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Diabetic Lumbosacral Plexopathy: Differential Diagnoses & Workup

Author: Divakara Kedlaya, MBBS, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Contributor Information and Disclosures

Updated: Oct 10, 2008

Differential Diagnoses

Amyotrophic Lateral Sclerosis
Mononeuritis Multiplex
Cauda Equina Syndrome
Neoplastic Lumbosacral Plexopathy
Guillain-Barre Syndrome
Postpolio Syndrome
Hypothyroid Myopathy
Radiation-Induced Lumbosacral Plexopathy
Limb-Girdle Muscular Dystrophy
Lumbar Spondylolysis and Spondylolisthesis
Meralgia Paresthetica

Other Problems to Be Considered

Immune-mediated lichen planus - vasculitis
Hemorrhage
Hematoma
Intra-arterial injections
Ischemic lumbar plexopathy
Obstetric-gynecologic complications or complications following any pelvic surgery
Other causes of lumbosacral plexopathy
Lumbar radiculopathy

Workup

Laboratory Studies

  • Laboratory studies (eg, fasting blood glucose, hemoglobin A 1c ) should be performed to diagnose or evaluate control of diabetes mellitus.
  • Cerebrospinal fluid (CSF) proteins may be elevated, sometimes more than 1 g on lumbar puncture.
  • Other lab studies to rule out other causes of neuropathy, as well as cancer and bleeding diathesis, are important.

Imaging Studies

  • Lumbar spine and pelvic radiographs should be performed to evaluate for other causes.
  • Computerized tomography (CT) scanning or magnetic resonance imaging (MRI) of the lumbosacral spine and pelvis may be indicated in some cases to rule out mass lesions.20

Procedures

  • Electromyography (EMG) and nerve conduction studies (NCS) should be performed.21,22
    • In patients without distal symmetrical polyneuropathy (DSPN), needle EMG usually shows positive sharp waves and fibrillation potentials in iliopsoas, hip adductors, and quadriceps, but other muscles also may be involved.
    • In patients with underlying DSPN, in addition to the above findings, sural sensory nerve action potential (SNAP) is usually absent, and amplitudes in peroneal and tibial compound motor action potential (CMAP) are reduced.
    • Femoral nerve motor conduction studies may show asymmetrical amplitudes.
    • Paraspinal muscle needle EMG may show fibrillations and positive sharp waves, but the results are usually within the reference range.

Histologic Findings

Biopsies rarely are indicated, and systematic studies are lacking in the literature. Early in the disease course, epineurial and perivascular inflammation around the small vessels may be caused by infiltration by mononuclear cells, with or without polymorphonuclear cells. Endoneurium and subperineurial space immunoglobulin-M (IgM) deposition should be expected. Activated complement (C5b-9) deposition in the endothelium of small vessels also is common. Reduced numbers of myelinated and unmyelinated axons may be observed. Differential fascicular loss of axons also is characteristic.

More on Diabetic Lumbosacral Plexopathy

Overview: Diabetic Lumbosacral Plexopathy
Differential Diagnoses & Workup: Diabetic Lumbosacral Plexopathy
Treatment & Medication: Diabetic Lumbosacral Plexopathy
Follow-up: Diabetic Lumbosacral Plexopathy
References
[ CLOSE WINDOW ]

References

  1. Bruns L. Uberneuritsche lahmungen beim diabetes mellitus. Berl Klin Wochenschr. 1890;27:509-15.

  2. Garland H. Diabetic amyotrophy. Br Med J. Nov 26 1955;2(4951):1287-90. [Medline]. [Full Text].

  3. Asbury AK. Proximal diabetic neuropathy. Ann Neurol. Sep 1977;2(3):179-80. [Medline].

  4. Locke S, Lawrence DG, Legg MA. Diabetic amyotrophy. Am J Med. Jun 1963;34:775-85. [Medline].

  5. Sander HW, Chokroverty S. Diabetic amyotrophy: current concepts. Semin Neurol. Jun 1996;16(2):173-8. [Medline].

  6. Tracy JA, Dyck PJ. The spectrum of diabetic neuropathies. Phys Med Rehabil Clin N Am. Feb 2008;19(1):1-26, v. [Medline].

  7. Raff MC, Asbury AK. Ischemic mononeuropathy and mononeuropathy multiplex in diabetes mellitus. N Engl J Med. Jul 4 1968;279(1):17-21. [Medline].

  8. Taylor BV, Dunne JW. Diabetic amyotrophy progressing to severe quadriparesis. Muscle Nerve. Oct 2004;30(4):505-9. [Medline].

  9. Williams IR, Mayer RF. Subacute proximal diabetic neuropathy. Neurology. Feb 1976;26(2):108-16. [Medline].

  10. Dyck PJ, Norell JE, Dyck PJ. Microvasculitis and ischemia in diabetic lumbosacral radiculoplexus neuropathy. Neurology. Dec 10 1999;53(9):2113-21. [Medline].

  11. Harrison MJ, Casey EB. Diabetic amyotrophy. Br Med J. Jul 29 1972;3(5821):293. [Medline]. [Full Text].

  12. Pascoe MK, Low PA, Windebank AJ. Subacute diabetic proximal neuropathy. Mayo Clin Proc. Dec 1997;72(12):1123-32. [Medline].

  13. Kawamura N, Dyck PJ, Schmeichel AM, et al. Inflammatory mediators in diabetic and non-diabetic lumbosacral radiculoplexus neuropathy. Acta Neuropathol. Feb 2008;115(2):231-9. [Medline].

  14. Dyck PJ, Windebank AJ. Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: new insights into pathophysiology and treatment. Muscle Nerve. Apr 2002;25(4):477-91. [Medline].

  15. Casey EB, Harrison MJ. Diabetic amyotrophy: a follow-up study. Br Med J. Mar 11 1972;1(5801):656-9. [Medline]. [Full Text].

  16. Bastron JA, Thomas JE. Diabetic polyradiculopathy: clinical and electromyographic findings in 105 patients. Mayo Clin Proc. Dec 1981;56(12):725-32. [Medline].

  17. Barohn RJ, Sahenk Z, Warmolts JR. The Bruns-Garland syndrome (diabetic amyotrophy). Revisited 100 years later. Arch Neurol. Nov 1991;48(11):1130-5. [Medline].

  18. Brown MJ, Asbury AK. Diabetic neuropathy. Ann Neurol. Jan 1984;15(1):2-12. [Medline].

  19. Russell JW, Berent-Spillson A, Vincent AM, et al. Oxidative injury and neuropathy in diabetes and impaired glucose tolerance. Neurobiol Dis. Jun 2008;30(3):420-9. [Medline].

  20. O'Neill BJ, Flanders AE, Escandon SL, et al. Treatable lumbosacral polyradiculitis masquerading as diabetic amyotrophy. J Neurol Sci. Oct 22 1997;151(2):223-5. [Medline].

  21. Tataroglu C, Bicerol B, Kiylioglu N, et al. Proximal femoral conductions in patients with lumbosacral radiculoplexus neuropathy. Clin Neurol Neurosurg. Oct 2007;109(8):654-60. [Medline].

  22. Subramony SH, Wilbourn AJ. Diabetic proximal neuropathy. Clinical and electromyographic studies. J Neurol Sci. Feb 1982;53(2):293-304. [Medline].

  23. Fernandes Filho JA, Nathan BM, Palmert MR, et al. Diabetic amyotrophy in an adolescent responsive to intravenous immunoglobulin. Muscle Nerve. Dec 2005;32(6):818-20. [Medline].

  24. Kawagashira Y, Watanabe H, Oki Y, et al. Intravenous immunoglobulin therapy markedly ameliorates muscle weakness and severe pain in proximal diabetic neuropathy. J Neurol Neurosurg Psychiatry. Aug 2007;78(8):899-901. [Medline].

  25. Wada Y, Yanagihara C, Nishimura Y, et al. A case of diabetic amyotrophy with severe atrophy and weakness of shoulder girdle muscles showing good response to intravenous immune globulin. Diabetes Res Clin Pract. Jan 2007;75(1):107-10. [Medline].

  26. Gulve EA. Exercise and glycemic control in diabetes: benefits, challenges, and adjustments to pharmacotherapy. Phys Ther. Sep 18 2008;[Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

diabetic lumbosacral plexopathy, diabetes mellitus, diabetes mellitus type 1, diabetes mellitus type 2, type 1 diabetes, diabetes type 1, type 2 diabetes, diabetes 1, diabetes 2, diabetic neuropathy, neuropathy, lumbosacral, lumbar sacral, plexopathy, lumbosacral plexopathy, proximal neuropathy, amyotrophy, diabetic amyotrophy, distal symmetrical polyneuropathy, DSPN, polyneuropathy, Bruns-Garland syndrome, diabetic proximal neuropathy, diabetic lumbosacral polyradiculopathy, polyradiculopathy, diabetic lumbosacral radiculoplexus neuropathy(DLRPN), diabetic femoral neuropathy, ischemic mononeuropathymultiplex associated with diabetes mellitus, proximal lower limb motor neuropathy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Divakara Kedlaya, MBBS, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Divakara Kedlaya, MBBS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Teresa L Massagli, MD, Residency Director, Professor, Department of Rehabilitation Medicine and Pediatrics, University of Washington School of Medicine
Teresa L Massagli, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.