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Updated: Jun 18 2021

Multiple Sclerosis

  • summary
    • Multiple Sclerosis is a chronic inflammatory disease caused by demyelination and widespread axonal injury in the central nervous system, leading to progressive motor and sensory dysfunction.
    • Diagnosis is made with MRI with gadolinium of brain and spinal cord.
    • Treatment is medical management with immunomodulators, antispasticity agents and physical therapy. Currently, there is no cure for the condition. 
  • Epidemiology
    • Incidence
      • 5 per 100,000 people in the US
    • Demographics
      • 20-40 years old
      • women>men
      • northern latitude
    • Risk factors
      • genetic
        • not considered a hereditary disease
      • environment
        • stress
        • smoking
        • decreased sunlight/low vitamin D exposure
  • Etiology
    • Pathophysiology
      • pathophysiology
        • believed to be caused by a combination of genetic, environmental and infectious factors
        • recent research suggests a T-cell mediated autoimmune mechanism
    • Associated conditions
      • orthopaedic
        • increased fracture risk
          • relating to increased risk of falling and decreased bone mineral density
        • osteoporosis
          • relating to physical inactivity, vitamin D deficiency, immunomodulatory medication
        • gait abnormalities
          • muscle paralysis causing foot drop, etc
        • muscle and joint spasticity
  • Presentation
    • History
      • clinically defined by two or more episodes of neurological dysfunction (brain, spinal cord or optic nerves) that are separated in time and space
    • Symptoms
      • symptoms of disease are based on the systems involved
        • psych
          • fatigue, depression, mood disorders
        • central nervous system
          • optic neuritis, diplopia, nystagmus
        • ENT
          • dysarthria, dysphagia
        • MSK
          • weakness, loss of balance and coordination, spasms, ataxia, falls
        • neuro
          • parasthesis, hypoesthesia, peculiar sensory phenomena's (e.g. sensation of wetness)
        • GI
          • incontinence, diarrhea, constipation
        • urology
          • incontinence, frequency, retention
    • Physical exam
      • inspection
        • assess for gait abnormalities (e.g. wide-based gait, limb ataxia, slapping foot)
        • joint or muscle contractures
      • neurological examination
        • muscle spasticity
        • increased deep tendon reflexes
        • muscle weakness
        • Babinski positive
      • special tests
        • fundoscopy
          • MLF syndrome (Internuclear Ophthalmoplegia)
        • Lhermitte's sign
  • Evaluation
    • Laboratory studies
      • CBC, lytes, TSH, comprehensive metabolic panel
        • used to exclude concomitant illnesses
        • usually normal
      • CSF analysis
        • mononucleur pleocytosis (25%)
        • elevated CSF IgG (80%)
        • oligoclonal bands on electrophoresis
    • Imaging studies
      • MRI
        • indications
          • obtain MRI with gadolinium of brain and spinal cord
        • findings
          • multiple focal demyelination scattered in brain and spinal cord
          • asymmetric periventricular plaques
  • Differential
    • Cervical myelopathy, CNS mass lesion, vitamin B12 deficiency, sarcoidosis, CNS infections
  • Treatment
    • Nonoperative
      • immunomodulators
        • indications
          • treatment attempt to return function after an attack, prevent new attacks, and prevent disability
        • modalities
          • corticosteroids
            • indicated for acute exacerbations
          • prophylactic immunosuppresants (interferon beta)
            • may decrease the number and severity of relapses
            • has been shown to decrease the progression of relapsing remitting multiple sclerosis
      • antispasticity agents
        • indications
          • increased muscle tone with spasms
        • modalities
          • oral agents
            • baclofen, gabapentin, clonazapem
          • botox injections
      • physiotherapy
        • indications
          • improve gait and balance
        • modalities
          • gentle stretching exercises for spasticity
          • progressive resistant-training
      • osteoporosis management
  • Complications
    • Increased fracture risk
      • relating to increased risk of falling and decreased bone mineral density
    • Osteoporosis
      • relating to physical inactivity, vitamin D deficiency, immunomodulatory medication
  • Prognosis
    • Patterns of disease progression
      • remitting-relapsing (most common)
      • primary progressive
      • secondary progressive
      • progressive relapsing
    • Life expectancy
      • 5 to 10 years lower than that of unaffected people
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