PARESTHESIAS OF THE UPPER EXTREMITY

Ask the Following Questions:

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.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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