Updated: 3/28/2018

Multiple Sclerosis

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Introduction
  • A chronic inflammatory disease that causes demyelination and widespread axonal injury in the central nervous system, leading to motor and sensory dysfunction
  • 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
  • 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
  • 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
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
 

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