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Ask Dr. Muneeb Ali Your Own Question
Dr. Muneeb Ali
Dr. Muneeb Ali, Intensivist
Category: Neurology
Satisfied Customers: 4257
Experience:  Experience of Neurology of over 4 years, well versed in EEG, NCS and EMG alongwith MRIs and CT scans
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I have a new question. I was recently diagnosed with small

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Hi,
I have a new question. I was recently diagnosed with small fiber neuropathy (mainly in my feet, but moving upwards toward ankles and lower legs). I don't have diabetes or any diseases. I had an EMG which was normal, so he said it must be small fiber neuropathy. My question is... Can this be caused by back problems? I have a pinched nerve in my L4, and possibly spinal stenosis. Can this cause neuropathy? Because I have days where the small fiber neuropathy isn't really that bad and is more in my toes/feet. Then not even a couple of days later and all day i've been in so much pain with excruciating fire and shocks and pain in my feet, and now I feel it half way up the outside of my calves (which I didn't feel a few days ago). What could make things change so much in just a few days? I have only had neuropathy for 2 years, but lately it's escalating and some weeks are ok, and others are crazy painful/burning. I would love to know your opinion on this. Thanks so much!

Hi,

Im sorry to hear about your symptoms. Now while your back problems can cause similar sort of pain in the legs but it would be easily differentiated on the EMG. Neuropathy and nerve compression due to back issues have a different pattern on EMG. So if the EMG was consistent with small fiber neuropathy then it is likely to be the diagnosis. Secondly if this was caused by the problem in the back then in most cases, not all, the pain was radiate down from the back or hip into the legs rather than occur only in the lower leg and calf region. So this is why i think you do have neuropathy rather than spinal stenosis or nerve root compression. Or i should say that your symptoms are more consistent with neuropathy rather than stenosis etc.

Now as to why the pain worsened over the course of a few days, that is hard to say. the reason being small fiber neuropathy is usually thought to be idiopathic which means that the cause is unknown. However that being said in some cases neuropathy can flare up as a result of other issues like infection, dehydration, electrolyte imbalances, trauma or any other medical condition which might have worsened over the last few weeks. This can cause an acute attack of the problem at any time. Secondly it is possible that the neuropathy is actually worsening over time which can occur in a majority of the cases. It slowly progresses to a certain level. Now the next step here could be a nerve biopsy if you want a definitive diagnosis, that will truly determine if you do have small fiber neuropathy however at this point in time, i would not recommend it at it would change your treatment significantly. You should be started on Lyrica or neurontin and if you are already on these drugs then your dose should be adjusted. Secondly you should look into the possibility of TENS therapy as well which can help a certain subset of patients in managing the pain. Newer drugs like desvenlafaxine can be helpful as well along with amitriptyline etc.

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Customer: replied 4 months ago.
Thank you so much for your detailed response. It helps a lot to make sense of everything that is happening. One question regarding your response....When you said:
"Now the next step here could be a nerve biopsy if you want a definitive diagnosis, that will truly determine if you do have small fiber neuropathy however at this point in time, i would not recommend it at it would change your treatment significantly."
What do you mean with the above statement? Why do you think I shouldn't have the biopsy? How would it change my treatment significantly?
Also, I have neurontin, but it's hard to tolerate more than 600mg (makes my heart race and pressure in chest feeling). My prescription is for 2700mg a day, but I can't do more than 300-600. I'm going to ask to try Lyrica.
Last question - is there anything I can do to treat it... or is it going to get worse and worse year by year. I can't take this pain forever. And I'm 40, so I fear how bad it will be at 60+.

I meant to say that while a nerve biopsy could be diagnostic, it WOULD NOT change the treatment plan per se. I missed writing the NOT, that was a typo sorry about that. The treatment plan would remain the same in most cases without any major changes.

Lyrica is a much better option when compared to neurontin, it has been shown to control nerve pain in a better manner than neurontin. You can be started on a relatively high dose of 100 mg twice a day and then it can be built up as needed.

Well the thing with small fiber neuropathy is that it does progress with time however the progression usually stops after reaching a certain point, now when would that stop, that cant be said definitively. Each patient is different some patients dont have any progression at all while others progress slowly over teh course of several years and still others progress for a couple of years and then the progression stops all of a sudden. While it cant be cured but it can certainly be treated effectively with medication and as i said TENS therapy. Usually by adjusting your drugs, the pain and burning is effectively controlled.

Do you have any more questions?

Please leave a POSITIVE rating by clicking on the stars above, until you do i am not compensated for my time. You can continue to ask follow-up questions even after the POSITIVE rating. You can also ask questions from me directly by going on the link below,

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Would you like to know anything else? If done for now, please remember to leave a positive rating as that is the only way we are compensated for our time spent helping you. You can continue to ask follow-up questions even after the rating.

Customer: replied 4 months ago.
Thank you so much! Because of your detailed response, I think I figured out what was making it so extremely painful (burning). It was because I started taking Hydrochlorothyazide because I have ankle edema, and I thought this medication would help reduce the edema and help my feet. But instead it made it worse... I'm guessing it's this because I know it takes away a lot of electrolytes. What do you think? Was this maybe the reason?

It is possible because HCTZ can certainly cause electrolyte imbalances infact it is notorious for it, secondly it can also increase the uric acid in the body so if the pain is centered more around the joints its worthwhile to have this checked as well. A simple way to see if HCTZ is the cause is to get simple blood tests done, if they are deranged then you can suspect them to be the cause. The deficient electrolytes can be replaced and if your symptoms subside you will know it was actually this issue which was worsening the neuropathy, if not, then you will know it is the disease progressing.

Do you have any more questions?

Please leave a POSITIVE rating by clicking on the stars above, until you do i am not compensated for my time. You can continue to ask follow-up questions even after the POSITIVE rating. You can also ask questions from me directly by going on the link below,

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Customer: replied 4 months ago.
Thank you so much! I'm feeling a little better already since stopping the HTCZ. Thanks again :-)

You're welcome, do remember to leave a POSITIVE rating by clicking on the stars above your screen as that is how we are compensated for helping you today. Any BONUSES would be well appreciated! :)

Dr. Muneeb Ali and 2 other Neurology Specialists are ready to help you
Customer: replied 4 months ago.
I didn't see a place to add a new question, so I will ask it here. You mentioned getting a TENS unit. I am going to, but wondered where I should place the sticky pads of it? On my calf or ankle? My small fiber neuropathy is most painful/burning in my feet, but also spreads up into my ankles and a little bit into my calves. So does it matter where I stick it onto me?

Yes it does matter, it would be best if you place the pads on upper surface of the feet as that is the location where you have the most pain.

Customer: replied 4 months ago.
Thank you :-) I will put them on the places that are the most painful/burning (bottom of toes and feet, and front and back of calves). Thank you!

Youre more than welcome.