Diagnosis of Pinched Nerve

Pinched Nerve Diagnosis: Book Excerpts

• Ask the Following Questions - PARESTHESIAS OF THE LOWER EXTREMITY
• Ask the Following Questions - PARESTHESIAS OF THE UPPER EXTREMITY
• Differential Diagnosis - Paresthesias
• Differential Diagnosis - Paresthesias
• Approach to the Diagnosis - PARESTHESIAS, DYSESTHESIAS, AND NUMBNESS
• History and physical examination - Paresthesia
• History and physical examination - Paresthesia
• History - Paresthesia and Dysesthesia
• History - Paresthesia
• History and physical examination - Paresthesia

Diagnosis of Pinched Nerve: medical news summaries:

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Diagnostic Tests for Pinched Nerve: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Pinched Nerve.

PARESTHESIAS OF THE LOWER EXTREMITY: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Are the pulses diminished? The presence of diminished pulses should suggest peripheral arteriosclerosis or Leriche's syndrome.
2. Is there associated pain in the involved extremity? The presence of pain in the involved extremity should suggest lumbar spondylosis, spinal stenosis, cauda equina tumor, spondylolisthesis, herniated disk, and pelvic tumors.
3. Is there a positive straight-leg raising test and/or decreased Achilles reflex? These findings suggest a herniated disk of L4-5 or L5 to S1, lumbar spondylosis, spinal stenosis, a cauda equina tumor, or spondylolisthesis.
4. Is there a positive femoral stretch test or decreased knee jerk? These findings suggest a herniated disk of L3-4 or L2-3 or lumbar spondylosis.
5. Are there diffuse hyperactive reflexes? These findings suggest multiple sclerosis, pernicious anemia, degenerative diseases of the spinal cord such as syringomyelia, spinal cord tumor, or other space-occupying lesions. It may also suggest anterior spinal artery occlusion.
6. Are there diffuse hypoactive reflexes? The presence of diffuse hypoactive reflexes would suggest poliomyelitis, Guillain-Barré syndrome, cauda equina tumor, metastatic tumor of the lumbar spine, and, occasionally, pernicious anemia or peroneal neuropathy. Also, peripheral neuropathy will present with diffuse hypoactive reflexes.
7. Is there incontinence associated with the hypoactive reflexes? The presence of incontinence with the hypoactive reflexes may indicate poliomyelitis, cauda equina tumor, or metastatic tumors to the lumbar spine.

DIAGNOSTIC WORKUP

The basic diagnostic workup includes a CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel, VDRL test, and x-ray of the lumbosacral spine. A serum B ₁₂ and folic acid should be done if pernicious anemia is suspected. If these tests are negative, an orthopedic or neurologic specialist should be consulted. A CT scan of the lumbosacral spine, a nerve conduction velocity study, and an EMG may all be necessary in the workup. MRI is more expensive and often unnecessary.

Combined myelography and CT scan is often useful in evaluating the need for surgery. A bone scan may be helpful in diagnosing occult fractures, metastases, or osteomyelitis.

If multiple sclerosis, Guillain-Barré syndrome, or central nervous system lues are suspected, a spinal tap may be done. SSEP studies are useful in diagnosing multiple sclerosis.

A neuropathy workup may be necessary. This involves a glucose tolerance test to rule out diabetes; urine tests for porphyrins and porphobilinogen to rule out porphyria; quantitative urine niacin, thiamine, pyridoxine, and other B vitamins after loading, an ANA and anti-dsDNA test to rule out collagen disease; serum protein electrophoresis and immunoelectrophoresis to diagnose various collagen diseases and macroglobulinemia; a lymph node biopsy and Kveim test for sarcoidosis; nerve conduction velocity studies and EMG to establish the presence of a neuropathy; thyroid profile to rule out hypothyroidism or hyperthyroidism; HIV antibody titers; blood levels for heavy metals such as lead to rule out lead or arsenic neuropathy; and skin and muscle biopsies to rule out various collagen diseases. A trial of therapy is often necessary to rule out the nutritional neuropathies.

Lumbar puncture, as already mentioned, is useful in diagnosing Guillain-Barré syndrome. Nerve biopsy may be necessary when all the above procedures are negative.

RBC transketolase activity is decreased in beriberi and the serum pyruvate and lactate levels are elevated.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PARESTHESIAS OF THE UPPER EXTREMITY: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Are there paresthesias of the face or cranial nerve signs? These findings would suggest a diagnosis of cerebral vascular disease, a space-occupying lesion of the brain, migraine, or multiple sclerosis.
2. Is there pain in the involved extremity? Pain in the involved extremity, particularly radicular pain, should suggest a herniated cervical disk, spinal cord tumor, or cervical spondylosis. However, many other conditions, such as brachial plexus neuropathy, thoracic outlet syndrome, a cervical rib, Pancoast's tumor, Raynaud's disease, and sympathetic dystrophy, should also be considered. Finally, the various entrapment syndromes should be considered, such as carpal tunnel syndrome and ulnar nerve entrapment at the elbow.
3. Are the Adson's tests positive? If the radial pulse diminishes in certain positions of the neck and shoulders, a thoracic outlet syndrome or cervical rib should be considered.
4. Is the Tinel's sign positive at the wrist or elbow? A positive Tinel's sign at the wrist would suggest a carpal tunnel syndrome and can be confirmed by positive Phalen's test. Positive Tinel's sign at the elbow would suggest ulnar entrapment syndrome. The ulnar nerve may also be entrapped in Guyon's canal and the median nerve may be trapped at the elbow in a pronator syndrome.
5. Is the cervical compression test positive? The presence of a positive cervical compression test or positive Sperling's test would suggest cervical spondylosis and herniated cervical disk.
6. Are there hyperactive reflexes? The presence of hyperactive reflexes in the upper or lower extremity would suggest a spinal cord tumor, multiple sclerosis, degenerative disease of the spinal cord such as syringomyelia or amyotrophic lateral sclerosis, anterior spinal artery occlusion, and cervical spondylosis.
7. Are there normal or hypoactive reflexes noted? The presence of normal or hypoactive reflexes in the involved extremity should prompt consideration of peripheral neuropathy, pernicious anemia, and brachial plexus neuropathy.

DIAGNOSTIC WORKUP

A CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel, and plain films of the cervical spine constitute the basic workup of paresthesias of the upper extremities. If these are negative, the next logical step is to consult a neurologist or neurosurgeon.

If there are paresthesias of the face or cranial nerve signs, MRI or CT scan of the brain will probably be the most logical test to order next. If not, MRI of the cervical spine will be useful. Nerve conduction velocity studies, EMG, and dermatomal SSEP studies complete the workup in most cases. However, SSEP studies and a spinal tap may be necessary to diagnose multiple sclerosis. If tabes dorsalis is suspected, a blood or spinal fluid fluorescent Treponema pallidum antibody test may be done. Immunoelectrophoresis may diagnose a monoclonal gammopathy.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Paresthesias: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Nerve compression or entrapment neuropathy
  –Lumbosacral disc herniation with nerve root compression
  –Posterior tibial nerve compression (tarsal tunnel syndrome)
  –Peroneal nerve compression (foot drop)
  –Cervical spine spondylosis/disc herniation with nerve root compression
  –Median nerve compression (carpal tunnel syndrome, often seen in hypothyroidism and pregnancy)
  –Ulnar nerve compression
  –Long thoracic nerve compression (winged scapula)
• Infections (e.g., HIV/AIDS, herpes zoster, Lyme disease)
• Diabetic neuropathy (bilateral symptoms)
• Alcoholic neuropathy
  –Bilateral symptoms
  –Due to thiamine deficiency (vitamin B₁)
• and/or direct toxic effect of alcohol
• Vitamin B₁₂ deficiency
• Uremia
• Vasculitis or collagen vascular disease
• Tumor (including hematologic malignancy)
  –Carcinomatous infiltration or direct compression
  –Paraneoplastic syndrome (especially lung cancer)
• Toxins
  –Industrial exposures (e.g., lead, mercury, pesticides)
  –Medications (e.g., pyridoxine, isoniazid, vincristine, cisplatin, antiretrovirals, hydralazine)
• Guillain-Barré syndrome (usually bilateral)
• Hereditary motor or sensory neuropathies
• Amyloidosis
• Porphyria
• Paraproteinemias (e.g., multiple myeloma)
• Amyotrophic lateral sclerosis
• Alcohol withdrawal (sensation of “crawling bugs”)
• Trigeminal neuralgia

Workup and Diagnosis

• A complete history and physical examination is necessary to determine the etiology of most cases
  –Time course of onset
  –Anatomic distribution (focal, unilateral, bilateral)
  –History of trauma, diabetes, alcohol abuse, cancer, or collagen vascular disease
  –Associated weakness, cramping, pain, or loss of position or temperature sense
  –Comprehensive neurologic exam with a focus on cervical or lumbosacral nerve patterns
• Initial tests may include fasting CBC, electrolytes, calcium, magnesium, TSH, glucose, BUN/creatinine, hemoglobin A_1C, ESR, vitamin B₁₂, thiamine level, and chest X-ray
  –Additional tests may be indicated based on history (e.g., lead level, SPEP and UPEP to rule out paraproteinemia, Lyme titers)
• Electromyography may be used to differentiate neuropathic versus myopathic causes of muscle atrophy
• Nerve conduction studies
• Nerve biopsy (usually the sural nerve) is reserved for proof of histologic processes that have an impact on management (e.g., amyloidosis)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Paresthesias: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Peripheral neuropathies (with or without pain)
  –Entrapment neuropathies
  –Carpal tunnel
  –Lateral femoral cutaneous syndrome
  –Pressure palsy
  –Charcot-Marie-Tooth disease
  –Amyloid neuropathy
  –Symmetric peripheral neuropathy
• Central nervous system etiologies
  –Stroke
  –Brain tumor
  –Head trauma
  –Abscess
  –Encephalitis
  –Systemic lupus erythematosus (SLE)
  –Multiple sclerosis
  –Transverse myelitis
  –Vitamin B12 deficiency
• Metabolic
  –Diabetes
  –Hypothyroidism
  –Alcoholism
  –Amyloidosis
  –Uremia
• Hyperventilation causing respiratory alkalosis
• Connective tissue disorders
  –Rheumatoid arthritis
  –SLE
  –Sjögren syndrome
• Toxins
  –Chemotherapy
  –Heavy metal poisoning (e.g., lead, arsenic, and other metals)
  –Medications (e.g., HIV medications, metronidazole, vincristine)
• Neoplastic
  –Multiple myeloma
  –Monoclonal gammopathy
• Infectious
  –HIV
  –Lyme disease
  –Syphilis

Workup and Diagnosis

• History
  –Age of onset, frequency, duration
  –Worsening with movement
  –Recent trauma
  –Exposure to heavy metals or toxins
  –Medications (e.g., chemotherapy, antibiotics)
  –Family history of neuropathy/muscle problems
• Associated symptoms
  –Weakness, falls, pain (back pain, regional pain)
• Physical exam
  –Vital signs (temperature, heart rate, blood pressure)
  –Musculoskeletal exam (joint or muscle tenderness, spine tenderness, bony pain, neck stiffness)
  –Neurologic examination: Detailed sensory examination (vibratory, pinprick, position sense) to evaluate for nerve root, spinal cord, or central etiology

• Initial labs
  –CBC, chemistry panel, U/A, TSH, ESR
• Secondary evaluation
  –Serum folate, serum B12, syphilis serology, ANA
  –Electromyogram, nerve conduction velocities
  –X-ray of the affected extremity
  –CT or MRI of the brain
  –Nerve biopsy
  –Muscle biopsy
  –Serum electrophoresis

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

PARESTHESIAS, DYSESTHESIAS, AND NUMBNESS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

This would be the same as the workup of weakness in one or more extremities. If the condition is in the hand, one would check for Tinel and Adson signs and x-ray the cervical spine for a cervical rib or disk degeneration. The next step is nerve conduction studies and EMG. Objective signs of radiculopathy are a clear indication for an MRI or cervical myelography, preferably combined with a CT scan. MRI may reveal tiny disk herniations. With associated pain in certain roots, indicated. If there is coldness in the hand, a stellate ganglion block may be helpful.

If the condition is in the lower extremity, a careful examination of the arterial pulses, particularly the femoral, is performed. If these are abnormal, a flow study or femoral angiography may be indicated. X-rays of the spine to rule out a herniated disk or tumor of the spine are done routinely. One must not forget a pelvic examination in a female. If other neurologic signs are present, an MRI or CT scan examination may be necessary. When a disk herniation is still likely, myelography should be ordered. EMG has the same usefulness here as in the upper extremity. When a cerebral lesion is suspected, a CT scan, MRI, and four-vessel angiography should be considered.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Paresthesia: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

First, explore the paresthesia. When did abnormal sensations begin? Have the patient describe their character and distribution. Also, ask about associated signs and symptoms, such as sensory loss and paresis or paralysis. Next, take a medical history, including neurologic, cardiovascular, metabolic, renal, and chronic inflammatory disorders, such as arthritis or lupus. Has the patient recently sustained a traumatic injury or had surgery or an invasive procedure that may have damaged peripheral nerves?

Focus the physical examination on the patient’s neurologic status. Assess his level of consciousness (LOC) and cranial nerve function. Test muscle strength and deep tendon reflexes (DTRs) in limbs affected by paresthesia. Systematically evaluate light touch, pain, temperature, vibration, and position sensation. (See Testing for analgesia, pages 38 and 39.) Also, note skin color and temperature, and palpate pulses.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Paresthesia: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

First, explore the paresthesia. When did the abnormal sensations begin? Have the patient describe their character and distribution. Ask about associated signs and symptoms, such as sensory loss and paresis or paralysis. Next, take a medical history, including neurologic, cardiovascular, metabolic, renal, and chronic inflammatory disorders, such as arthritis or lupus. Has the patient recently sustained a traumatic injury or had surgery or an invasive procedure that may have damaged peripheral nerves?

Focus the physical examination on the patient’s neurologic status. (See Differential diagnosis: Paresthesia, pages 602 and 603.) Assess his level of consciousness (LOC) and cranial nerve function. Test muscle strength and deep tendon reflexes (DTRs) in limbs affected by paresthesia. Systematically evaluate light touch, pain, temperature, vibration, and position sensation. (See Testing for analgesia, pages 48 and 49.) Note skin color and temperature, and palpate pulses.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Paresthesia and Dysesthesia: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Do these sensations occur in a special nerve distribution or in a certain anatomic location? Do they occur in response to a stimulus? Are they intermittent, or persistent and continuous? Was onset acute or insidious? How have the symptoms progressed? Any chronic medical illnesses?

1. Glove and stocking distribution: suggests diabetes, vitamin B₁₂ or folate deficiency, alcohol, or intoxications (heavy metals, industrial chemicals or medications).

2. Dermatomal distribution: suggests herpes zoster, vasculitis.

3. Other distributions: nonspecific pattern suggests idiopathic paresthesia, whereas extremity pattern suggests hyperventilation.

B. Is there an exposure to solvents, pesticides, heavy metals, or recent viral illness? Is there abuse of alcohol or symptoms of systemic dysfunction or chronic illness?

C. Would the patient otherwise feel in good health if free of the paresthesia? The answer to this question provides an idea of the patient’s general health and a clue to a systemic illness.

D. Is this a sensation that is unfamiliar to the patient (dysesthesia) or a familiar pain “like a toothache” (nerve trunk pain-aching sensation)?

E. What makes it better or worse (dysesthesia—worse after activity, little makes it better; nerve root pain—better with rest, worse with movement, nerve stretch, or palpation)?

 F. What is the distribution of the pain (dysesthesia—cutaneous or subcutaneous; symmetrical distally; nerve trunk origin—deep and relatively proximal) (2)?

Physical examination

A. General examination. Perform a thorough examination and check for hypertension, tachypnea, and tachycardia.

B. Nervous system. Perform a sensory examination in the area of complaint: touch, pinprick, heat or cold, proprioception, and motor examination, including deep tendon reflexes.

1. Decreased sharp touch and thermal sensation suggest small fiber neuropathies (spinothalmic tract syringomyelia).

 2. Decreased position sense, vibratory, or motor dysfunction but retention of most other cutaneous sensations are found with large fiber neuropathies.

 3. Sometimes paresthesias alone do not suggest their origins, but when combined with other neurologic deficits, the cause becomes more clear.

4. Are the signs symmetrical? Do they occur in a graded fashion (polyneuropathy), somewhat asymmetric findings or multifocal signs (multiple mononeuropathy), or damaged individual cutaneous nerves?

C. Look for other physical signs of chronic disease such as alcoholism, diabetes, malnutrition, pulmonary disease, and acquired immunodeficiency syndrome.

D. Avoid testing a patient who is extremely fatigued (unreliable sensory examination). An overly cooperative patient may read too much into an examination and may discern very small differences that are not clinically significant. Do not prompt too much—give general directives.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Paresthesia: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

First, explore the paresthesia. When did the abnormal sensations begin? Have the patient describe their character and distribution. Also, ask about associated signs and symptoms, such as sensory loss and paresis or paralysis. Next, take a medical history, including neurologic, cardiovascular, metabolic, renal, and chronic inflammatory disorders, such as arthritis or lupus. Has the patient recently sustained a traumatic injury or had surgery or an invasive procedure that may have damaged peripheral nerves?

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Paresthesia: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

First, explore the paresthesia. When did abnormal sensations begin? Have the patient describe their character and distribution. Also, ask about associated signs and symptoms, such as sensory loss and paresis or paralysis. Next, take a medical history, including neurologic, cardiovascular, metabolic, renal, and chronic inflammatory disorders, such as arthritis or lupus. Has the patient recently sustained a traumatic injury or had surgery or an invasive procedure that may have damaged peripheral nerves?

Focus the physical examination on the patient's neurologic status. Assess his level of consciousness (LOC) and cranial nerve function. Test muscle strength and deep tendon reflexes (DTRs) in limbs affected by paresthesia. Systematically evaluate light touch, pain, temperature, vibration, and position sensation. (See Testing for analgesia, pages 32 and 33.) Also, note skin color and temperature, and palpate pulses.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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