eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Diabetic Lumbosacral Plexopathy

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

Introduction

Background

Proximal neuropathy in diabetes mellitus (DM) is a condition in which patients develop severe aching or burning and lancinating pain in the hip and thigh. This is followed by weakness and wasting of the thigh muscles, which often occur asymmetrically. This disabling condition occurs in type 1 and type 2 DM. Bruns first described the disorder in patients with DM in 1890.1 In 1955, Garland coined the term diabetic amyotrophy, although the name Bruns-Garland syndrome also is used to describe the condition.2,3,4

Diabetic amyotrophy, which is distinct from other types of diabetic neuropathy, usually has its onset during or after middle age (although it can occur in younger individuals). Concomitant distal, predominantly sensory, neuropathy may exist. The results of most electrodiagnostic studies are consistent with a neurogenic lesion that could be associated with lumbosacral plexopathy, radiculopathy, or proximal crural neuropathy.5,6,7,8

Related eMedicine topics:
 Diabetes Mellitus, Type 1 - A Review
Diabetes Mellitus, Type 2 - A Review
Diabetes Mellitus, Type 1 [Endocrinology]
Diabetes Mellitus, Type 2 [Endocrinology]
Diabetes Mellitus, Type 1 [Pediatrics: General Medicine]
Diabetes Mellitus, Type 2 [Pediatrics: General Medicine]
Diabetic Neuropathy
Neoplastic Lumbosacral Plexopathy
Radiation-Induced Lumbosacral Plexopathy

Pathophysiology

The underlying pathogenesis and the site of the lesion are not clearly understood and remain subjects of controversy.5,9 The condition most likely is caused by inflammatory, immune-mediated vascular radiculoplexopathy.10,11,12,13 Most authors now favor an immune vasculopathy as the cause of diabetic amyotrophy. Studies suggest a role for immunomodulating agents in certain types of diabetic neuropathy, including diabetic amyotrophy.14 Diabetic lumbosacral plexopathy often occurs in conjunction with weight loss and is associated with only mildly elevated serum glucose levels.

Frequency

United States

The overall prevalence of diabetic lumbosacral plexopathy (DLP) is 0.08% of individuals with diabetes; however, DLP is more frequent with diabetes type 2 (1.1%) than with type 1 (0.3%).

Mortality/Morbidity

Morbidity related to diabetic lumbosacral plexopathy is mainly secondary to pain, proximal muscle wasting, and weakness, causing difficulty getting up from a chair and climbing stairs.

Race

No race predilection exists for diabetic lumbosacral plexopathy.

Sex

No sex predilection exists for diabetic lumbosacral plexopathy.

Age

Diabetic lumbosacral plexopathy (DLP) occurs most commonly in patients aged 50 years or older. In a series of 12 cases reported by Casey and Harrison, no patient was younger than 50 years, and 10 patients were older than 60 years.15 In a large series of 105 patients with diabetic amyotrophy, reported by Bastron and Thomas, the age of onset ranged from 36-83 years; symptoms progressed over an average of 6.2 months, with 9.5% of patients having painless muscle weakness.16 DLP is rare in children, and only 3 cases of DLP in children aged 13-16 years have been reported in the literature.

Clinical

History

The following findings commonly are reported in the history of patients with diabetic lumbosacral plexopathy:

  • Asymmetrical pain in the hip, buttock, or thigh is common.
  • Proximal weakness in quadriceps, hip adductors, and iliopsoas muscles is characteristic.
  • Poor blood sugar control generally is noted.
  • Patients may have underlying distal symmetrical polyneuropathy (DSPN).
  • Gradual onset with bilateral presentation is typical in patients with DSPN; patients usually are insulin dependent.
  • Patients without DSPN usually have a sudden, unilateral onset. This symptom sometimes is the initial presenting feature of diabetes mellitus.17
  • Significant recent weight loss frequently is reported. The patient's history commonly includes a loss of 10-40 pounds.

Physical

During the physical examination, common findings in patients with diabetic lumbosacral plexopathy may include the following:

  • Proximal lower limb muscle weakness and wasting are characteristic. The patient has particular difficulty getting up from a squatting position.
  • Minimal sensory loss is observed.
  • The knee-jerk reflex is absent, with commonly preserved ankle jerks; however, ankle jerks also may be absent with underlying distal symmetrical polyneuropathy.
  • Features may be localized to the lumbosacral plexus or the upper lumbar roots.

Causes

The exact cause of diabetic lumbosacral plexopathy is not known.18 Features associated with the condition include the following:

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
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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].

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Further Reading

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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

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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.

 
 
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