Diagnostic Tests for Pinched Nerve
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PARESTHESIAS OF THE LOWER EXTREMITY:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PARESTHESIAS OF THE UPPER EXTREMITY:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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.
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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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
(2–4)
A. Clinical laboratory tests that may be useful include complete blood count; liver, renal, and thyroid function tests; sedimentation rate; antinuclear antibodies; vitamin B12; and folate. Perform heavy metals and toxin assays if the history is suggestive.
B. The electromyelogram or nerve conduction study is the gold standard in assessing the origin of the neuropathy associated with the paresthesia, if indeed one exists. It can differentiate between axonal and demyelinating causes.
C. A nerve biopsy is most useful in suspected inflammatory disorders (vasculitis, amyloidosis). It is also useful in suspected, selected small-fiber neuropathies, and in undiagnosed chronic neuropathy where significant debilitation has occurred.
Diagnostic assessment
The positive phenomena of paresthesia and dysesthesia do not necessarily mean a devastating diagnosis. They can be troublesome with no clinical diagnosis or be harbingers of peripheral neuropathy. The negative phenomena usually are a more ominous sign. Positive phenomena can act as troublesome symptoms that have no clinical diagnosis or as harbingers of more complicated syndromes of the peripheral neuropathies. If there is a documented neurologic deficit, especially once the motor system becomes involved, then it is more imperative to make a diagnosis. The most frequent neuropathy seen in clinical practice is the diabetic neuropathy (5). The real emergent diagnosis is that of Guillian-Barré syndrome, in which paresthesia can rapidly progress to full motor loss within days. Important is the association of symptoms to true sensory or motor deficits, systemic illness, toxin or medication exposure, or the rapidity of worsening symptoms.
References
1. Asbury A. Numbness, tingling and sensory loss. In: Braunwald E, Fauci AS, Isselbacher DL, et al., ed. Harrison’s Principles of internal medicine, 14th ed. New York: McGraw-Hill, 1998:2457–2469.
2. Asbury AK, Thomas PK. Peripheral nerve disorders. Cambridge: Butterworth Heinemann, 1995:8.
3. Bradley W, Daroff R, Fenichel G, Marsden CD. Neurology in clinical practice, 2nd ed. Vols. I and II. Boston: Butterworth Heineman, 1996.
4. Haerer AF. The neurologic examination, 5th ed. Philadelphia: JB Lippincott, 1992.
5. Poncelet AN. An algorithm for the evaluation of peripheral neuropathy. Am Fam Physician 1998;57(4):755–760.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Paresthesia:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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. Also, note skin color and temperature, and palpate pulses.
» 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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