Causes of Upper Extremity Paresthesia

[Sharn Penndroen]

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Okay, I've got a question about a real life patient that I'm a little confused on. Thought I'd get some opinions here on the differential diagnosis of upper extremity paresthesia.

ID: 50 yo WM
CC: "My hands get numb when I drive a long distance."

When asked, pt says that the tingling spreads from his hands to his forearms and then all the way up his arms. His arms feel like they are completely "asleep". Pt denies weakness in limbs and when cannot identify anything that improves the symtoms. Pt denies swelling in upper extremity while symptoms are present.

Pt is in good shape and leads an active lifestyle. Normotensive. BMI in normal range.

Brother has diabetes (Type I) that was brought on in adulthood after a viral infection that caused crossreactive antibodies to form with the islet cells. Father and mother deceased. Father had advanced Alzheimer's Disease. Mother suffered from paranoid schizophrenia.

Pt came in saying that, "I think I have that carpal tunnel stuff."

*****

Now my problem here, is that from the little I know, the onset coming on with long driving fits carpel tunnel, but I've never heard of the paresthesia spreading down the entire arm.

My guess is that it would be some kind of vascular claudication since it starts in the distal portion of the limb and travels proximally. But I've only read about claudication in the lower extremity.

I'm kind of at a loss, an was wondering if any of you neurologist could enlighten me a little on the good list of possiblities for a differential diagnosis on this man.

If you need more info, I can try to give it to you but I think I've given you everything I have.

 

[TruTrooper]

Okay, I've got a question about a real life patient that I'm a little confused on. Thought I'd get some opinions here on the differential diagnosis of upper extremity paresthesia.

ID: 50 yo WM
CC: "My hands get numb when I drive a long distance."

When asked, pt says that the tingling spreads from his hands to his forearms and then all the way up his arms. His arms feel like they are completely "asleep". Pt denies weakness in limbs and when cannot identify anything that improves the symtoms. Pt denies swelling in upper extremity while symptoms are present.

Pt is in good shape and leads an active lifestyle. Normotensive. BMI in normal range.

Brother has diabetes (Type I) that was brought on in adulthood after a viral infection that caused crossreactive antibodies to form with the islet cells. Father and mother deceased. Father had advanced Alzheimer's Disease. Mother suffered from paranoid schizophrenia.

Pt came in saying that, "I think I have that carpal tunnel stuff."

*****

Now my problem here, is that from the little I know, the onset coming on with long driving fits carpel tunnel, but I've never heard of the paresthesia spreading down the entire arm.

My guess is that it would be some kind of vascular claudication since it starts in the distal portion of the limb and travels proximally. But I've only read about claudication in the lower extremity.

I'm kind of at a loss, an was wondering if any of you neurologist could enlighten me a little on the good list of possiblities for a differential diagnosis on this man.

If you need more info, I can try to give it to you but I think I've given you everything I have.

I am not a Neurologist but I think I do okay despite my deficiency. 🙂

Some cases of Carpal Tunnel Syndrome do extend way up to the shoulder from the wrist although the cases that just extend up to the forearm or arm are more frequent. Of course, this is consistent with the distribution of the Median N. which is the nerve affected in Carpal Tunnel Syndrome.

Is this guy a truck driver or something?

 

[play274]

Radiating hand numbness can be a complication of CTS (median neuropathy at the wrist), but the differential is wider than that. Based on your case presentation with bilateral arm symptoms which seem to radiate distally, one can localize to the (in relative order of likelihood):

(1) peripheral nerve - rather than simply median nerve, ulnar/other nerves should be considered
(2) brachial plexus
(3) nerve roots (radiculitis - and considering the bilateral aspect of the symptoms, an extradural mass at the dorsal aspect of the C-spine should be considered)
(4) cervical cord - much less likely but possible, per your vignette (ie. a syrinx)
(5) vascular claudication (ie. thoracic outlet syndrome) - may be considered but is definitely not at the top of your differential for the specific presentation

What's next?
(I) Obtain a electrodiagnostic testing of both arms.
(II) Obtain MRI of C-spine w/ + w/o gadolinium.
(III) If electrodiagnostic testing suggests brachial plexus, obtain MRI of the plexus.

Some interesting nuggets:
(a) CTS can cause radiation of symptoms proximal to the wrist and does not have to simply involve the classic dermatomal distribution (digits 1, 2, 3, and lateral 4th).
(b) It has been published that typing on a computer is not a risk factor for CTS. However, there are activities (ie. using a jackhammer) that have been found to be statistically significant in causing CTS.

Hope that helps.

-274

 

[TruTrooper]

Radiating hand numbness can be a complication of CTS (median neuropathy at the wrist), but the differential is wider than that. One can localize to the:

(1) peripheral nerve
(2) brachial plexus
(3) nerve roots (radiculitis - and considering the bilateral aspect of the symptoms, an extradural mass at the dorsal aspect of the C-spine should be considered)
(4) cervical cord - much less likely but possible, per your vignette (ie. a syrinx)
(5) vascular claudication (ie. thoracic outlet syndrome) - may be considered but is definitely not at the top of your differential for the specific presentation

What's next?
(I) Obtain a electrodiagnostic testing of both arms.
(II) Obtain MRI of C-spine w/ + w/o gadolinium.
(III) If electrodiagnostic testing suggests brachial plexus, obtain MRI of the plexus.

Some interesting nuggets:
(a) CTS can cause radiation of symptoms proximal to the wrist and does not have to simply involve the classic dermatomal distribution (digits 1, 2, 3, and lateral 4th).
(b) It has been published that typing on a computer is not a risk factor for CTS. However, there are activities (ie. using a jackhammer) that have been found to be statistically significant in causing CTS.

Hope that helps.

-274

I thought of that differential but the the parethesia travels from the hands upward which makes the others less likely but, of course, still plausible. We can also throw tendosynovitis and more stuff, really.

EMG and nerve conduction studies may be in order anyway or the more conservative approach of wrist braces, NSAIDS, and observation.

 

[fedor]

I am not a Neurologist but I think I do okay despite my deficiency. 🙂

If not a neurologist, what are you? EM?

 

[TruTrooper]

Sharn, from Jackson, huh? My family lives in Jackson and I have a brother at U of Miss Med. He could be on your team, you know? Ever notice a guy dressed like a Stormtrooper running around the wards?

 

[TruTrooper]

If not a neurologist, what are you? EM?

Oh, nooo. Sorry for the confusion. I am just a poor, poor Neurology nerd. Instead of a white coat, I sport white armor. 😉

 

[play274]

I thought of that differential but the the parethesia travels from the hands upward which makes the others less likely but, of course, still plausible. We can also throw tendosynovitis and more stuff, really.

It's nice to see some cases being discussed on the board, isn't it?

In response:

Tenosynovitis (ie. De Quervain's):
(a) without significant pain and
(b) with symptoms of numbness and tingling?
With all due respect, I would disagree with the inclusion of tenosynovitis per the history that is provided. (BTW, I added a couple notes to the original post to make the response a bit more clear).

Also, in the role as a consultant, I feel that localization and a complete differential should always be verbalized. Not only is it best management for the patient and primary physician, it's also fun.

Best regards,
-274

 

[TruTrooper]

It's nice to see some cases being discussed on the board, isn't it?

In response:

Tenosynovitis (ie. De Quervain's):
(a) without significant pain and
(b) with symptoms of numbness and tingling?
In all due respect, I would disagree with the inclusion of tenosynovitis per the history that is provided.

Also, in the role as a consultant, I feel that localization and a complete differential should always be verbalized. Not only is it best management for the patient and primary physician, it's also fun.

Best regards,
-274

I agree. I just have the personal pet peeve of the laundry list differential but of course, I realize that it is the way things must be done. You are right.

But no tenosynovitis? Com'n, it definitely has a place under bilateral Upper exts. vascular claudication. 😀

Yes, it is good to discuss some cases on this board and to see it active at all. I think I can hear the board breathing now. Would a weekly Grand Rounds be too much to ask?

 

[play274]

But no tenosynovitis? Com'n, it definitely has a place under bilateral Upper exts. vascular claudication. 😀

No, it does not. Read up on De Quervain's tenosynovitis and then tell me what you think. I do not believe that you will find strong evidence for tenosynovitis presenting (a) with numbness and tingling and (b) without pain. Have fun and best of luck in the match!

-274

 

[TruTrooper]

No, it does not. Read up on De Quervain's tenosynovitis and then tell me what you think. I do not believe that you will find strong evidence for tenosynovitis presenting (a) with numbness and tingling and (b) without pain. Have fun and best of luck in the match!

-274

No, I agree. My point was that they are both long shots for this case. Thnx.

 

[play274]

No, I agree. My point was that they are both long shots for this case with teno being much longer. Thnx.

Actually vascular claudication (arterial/venous thoracic outlet syndrome aka TOS) would still be on the list, whereas tenosynovitis would not even be considered per the history that was provided (not a long-shot).

To elucidate my point, I'll quickly review the "supposed" three types of thoracic outlet syndrome:
(1) Neurologic TOS - More common with middle-aged women, almost always on one side of the body, and most commonly causing hand numbness and muscle atrophy w/weakness.
(2) Disputed TOS - Prominently presents with weakness and fatigue and is the center of much controversy.
(3) Vascular TOS usually occurs on one side of the body. Arterial TOS can present with hand numbness, pain, temperature sensitivity, and even limb ischemia/ulcers. Venous TOS is similar and develops suddenly - usually following prolonged limb exertion. --> With this in mind, it would be included in the differential - not bilateral but does have some similar clinical characteristics.

Definitely read up on this material, and make sure that your sources are valid (ie. Bradley, Dyck, Preston and Shapiro). Also, please correct me - if I am incorrect with my descriptions of TOS; it was off the top of my head, and - admittedly - I did not include a type that some people call "traumatic TOS."

Good night. It was nice chatting with you, Tru!

-274

 

[TruTrooper]

Actually vascular claudication (arterial/venous thoracic outlet syndrome aka TOS) would still be on the list, whereas tenosynovitis would not even be considered per the history that was provided (not a long-shot).

To elucidate my point, I'll quickly review the "supposed" three types of thoracic outlet syndrome:
(1) Neurologic TOS - More common with middle-aged women, almost always on one side of the body, and most commonly causing hand numbness and muscle atrophy w/weakness.
(2) Disputed TOS - Prominently presents with weakness and fatigue and is the center of much controversy.
(3) Vascular TOS usually occurs on one side of the body. Arterial TOS can present with hand numbness, pain, temperature sensitivity, and even limb ischemia/ulcers. Venous TOS is similar and develops suddenly - usually following prolonged limb exertion. --> With this in mind, it would be included in the differential - not bilateral but does have some similar clinical characteristics.

Definitely read up on this material, and make sure that your sources are valid (ie. Bradley, Dyck, Preston and Shapiro). Also, please correct me - if I am incorrect with my descriptions of TOS; it was off the top of my head, and - admittedly - I did not include a type that some people call "traumatic TOS."

Good night. It was nice chatting with you, Tru!

-274

I see your point here. My reservations stem from the fact that the patient described here has bilateral arm symptoms since the symtoms were presented in the plural form for the arms and direction of radiation. I would probably put tenosynovitis lower on that differerential than thoracic outlet though.

I think you just missed my humor here. My humor came in the form of throwing tenosynovitis in the list, therefore, making it even longer.

I don't think thoracic outlet syndrome is implausible here but I was poking fun at the laundry list differential (not nearly as long as some I see) just because it is just a personal pet peeve of mine. But like I say, I realize that is how things must be done in medicine and a grin just come to my face when I am sitting in Grand Rounds and I see that Powerpoint slide with two columns full of differentials with some of the latter possible Dxs being possible but so much less likely than the first 3 or 4. No matter how long that list eventually gets, I do not think it will change how we will first begin our workup. I like to give my colleagues a tough time about this but I am sure we we all get a tough time if we don't include the list of possibilities.

I want to be clear here...thoracic outlet syndrome can rightfully be on that differential although I do believe it will be checked off quickly in this case but nevertheless, including it is not in the left field. There are always variable forms that are less common than other forms of pathology.

Great talking with you too, play. Peace.

 

[Lesion Of Doom]

"I don't think thoracic outlet syndrome is implausible here but I was poking fun at the laundry list differential (not nearly as long as some I see) just because it is just a personal pet peeve of mine."


I know where you're coming from but the long list of differential diagnosis during case presentations don't bother me nearly as much when I present to an Attending. I know what the diagnosis must be and he just keep asking for more and more. So there I am just trying to think of every little thing that can swell your big toe besides gout but I know this is for my own education and skill development so I don't sigh as much now. I am sure most of us will be like those Attendings as well.

Doesn't thoracic outlet cause significant pain as well along with the parethesia? I knew I shouldn't have sold my Greenberg (sp?) text on Amazon. I can't recall the etiologies.

 

[Sharn Penndroen]

Is this guy a truck driver or something?

He's actually a chemist. Technical consultant that has to drive to different manufacturing plants to troubleshoot for them. He spends a lot of time typing on a computer but complains of symptoms only when he drives a long time (sometimes 6 hour drives, but 3 hour drives most common).

 

[Sharn Penndroen]

Radiating hand numbness can be a complication of CTS (median neuropathy at the wrist), but the differential is wider than that. Based on your case presentation with bilateral arm symptoms which seem to radiate distally, one can localize to the (in relative order of likelihood):

(1) peripheral nerve - rather than simply median nerve, ulnar/other nerves should be considered
(2) brachial plexus
(3) nerve roots (radiculitis - and considering the bilateral aspect of the symptoms, an extradural mass at the dorsal aspect of the C-spine should be considered)
(4) cervical cord - much less likely but possible, per your vignette (ie. a syrinx)
(5) vascular claudication (ie. thoracic outlet syndrome) - may be considered but is definitely not at the top of your differential for the specific presentation

What's next?
(I) Obtain a electrodiagnostic testing of both arms.
(II) Obtain MRI of C-spine w/ + w/o gadolinium.
(III) If electrodiagnostic testing suggests brachial plexus, obtain MRI of the plexus.

Some interesting nuggets:
(a) CTS can cause radiation of symptoms proximal to the wrist and does not have to simply involve the classic dermatomal distribution (digits 1, 2, 3, and lateral 4th).
(b) It has been published that typing on a computer is not a risk factor for CTS. However, there are activities (ie. using a jackhammer) that have been found to be statistically significant in causing CTS.

Hope that helps.

-274

These all make sense, but I was taught that nerve problems tend to start proximal and go distal, whereas this man's symptoms start distally and go proximal. Am I wrong in this, or is this only true some of the time?

 

[Sharn Penndroen]

I was also wondering if, since the symptoms tend to manifest when driving (both arms extended forward), would this make a brachial plexus compression more likely or maybe compression of the subclavian or brachial artery?

The other thing that makes me lean away from lesion of another peripheral nerve (ulnar) is that he says he has no weakness in his hands, which should present with an ulnar nerve compression.

Any additional thoughts?

I've learned a lot so far from this thread.