This topic contains 10 replies, has 5 voices, and was last updated by 
Paul Nottoli February 13, 2019 at 6:51 am.
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Brandon Cohen DC, CSCS
Sorry for the format. If anyone can tell me how to copy and paste here without it going crazy, you’ll get a huge hug (or no hug if you aren’t a hugger).
Please ask questions and add any input. Thanks,
42 YO Female
Lx: B. anterior and posterior hands and fingers
Quality: Numbness and paresthesia
Intensity: 7/10 worst 3/10 avg
Palliative: Getting up and moving around in the morning
Provocative: upon waking, hands overhead for long periods of time (10 minutes)
Temporal Factors: Only in the morning upon waking
Mechanism: unknown
Neurological: numbness and paresthesia (mostly numbness)
Onset: 3 weeks
Radiation/Referral: none
Occupation: interior designer/mom
Recreation: CF past 3 years, 5 x week, hot yoga 1 x week, no sx with activities.
OTHER: Patient also has pain in the forearms, reports it as a “twang” and worse with pronation and supination. Uses fasciablaster to forearms, which is kind of helpful. Occasional cervical spine tightness (nothing recent). MVA in 1998 fx to t5 and t8, L. clavicle, and forearm. Titanium plate in forearm. Sleeps on her side, wakes up on either her side or back. Relatively new bed. No Imaging
Post history thoughts: Dx:
1. potential disc with cord compression
2. Stress/metabolic component
3. B. nerve entrapment in forearms
4. Adhesion
Exam:
UCF: 27 no sx
CF: 63 no sx
CTF: 72 mild B. upper trapezius tension
CR: 83 B
WE: 90 B
WEF: 37R, 28L
SA: full, no pain
Pushup test: sore on the wrists, strong
Adhesions:
B. Accessory nerve 2
L. levator scapula 1
B. Nerve roots at scalenes 3
B. median nerve at transverse carpal ligament 2
B. Median nerve at pronator teres 2
B. Radial nerve at wrist extensors 2
Post exam:
1. Multiple nerve entrapments
2. Metabolic/Stress
3. Adhesion
4. Disc
There are several things that are a little wild to me on this one. I still think multiple cervical discs are a priority. The provocative are confusing to me, and I would think there to be sx with her workouts, which there aren’t. I have to dial in on the stress component as she is a working mother who works out 6+ times/week. (She reports working out with varying intensities, and going hard 1 x week).
We started tx on CTF, and ROM is now 80 degrees (2 visits), and during the second visit by the end, scalenes palpated clean to me. I checked brachial chords and generated very minimal tension. My next process is to check nerve entrapments at the forearm, and after talking with Dr. Stepien, realize that I should order MRI cervical spine to rule out the disc issues.
If you’ve read this far, please enjoy this picture from my neighbourhood.
Help…
Keith Puri, DC
Just a few questions and thoughts –
Where exactly in her fingers does she get the numbness and does it follow any specific dermatomal, cutaneous or peripheral nerve distribution?
If cord compression was on your original DDX list, does she have a positive Hoffman’s sign or any s/s consistent with an UMNL?
If her the numbness in her fingers does not follow any specific nerve distribution pattern, have you performed any tests for TOS and if so, where you able to reproduce her C/C? If hands overhead for a long time is +ve for her, I might perform Roo’s test and see if this reproduces her known symptoms. That said, I’m pretty confident my hands would go numb if I kept them overhead for 10+ minutes. This +ve factor might be less important and could detract from the primary pathology.
I might disagree with ordering an MRI to rule in/out multi-level disc pathology. In reviewing your data I do not see anything in the E/M that is reverse compatible with a disc or cord compression. Her symptom quality is certainly consistent with a nerve issue but her primary +ve factor is worse upon waking and -ve is moving around. Yes, she has an approximate 20% loss in CTF and ROT but neither of those ranges reproduced any s/s consistent with her C/C. This sounds more like a peripheral or cutaneous nerve compression issue.
I agree, there are a few outliers in her case that are not reverse compatible and stress/metabolic can certainly be a contributing factor. If a peripheral or cutaneous nerve compression is pathology but the exact location is uncertain a magnetic resonance neurography (MRN or neurography) might help to name it.
Carl Nottoli, DC
Can you be more descriptive on the finger distribution?
Is it all the 5 fingers? Dorsal and palmar? Any hand sx?
Brandon Cohen DC, CSCS
I just checked on it again. She has whole hand symptoms (numbness). Anterior and posterior.
She will occasionally and intermittently feel paresthesia in the right distal 2nd and 3rd digits with varied activities.
Carl Nottoli, DC
Here are some thoughts bouncing around in my head with this case:
What is the likelihood she has central disc herniations compressing cervical nerve roots B from C6-C8, with really good cervical function? I would say nearly impossible.
What’s the likelihood a 42 year old female could have neuroforaminal stenosis due to degenerative spine changes B from C6-C8, with really good cervical function? Again, nearly impossible.
What’s the likelihood she has multiple peripheral nerve entrapments that aren’t aggravated by use, responsible for her symptoms based on her history? Not likely.
What’s the likelihood a 42 year old female has a metabolic problem that’s now manifesting as stocking glove neuropathy? To me, this makes more sense.
Could she still have disc herniations and peripheral nerve entrapments? Sure. But those still aren’t reverse compatible. When peripheral nerves demyelinate or lose nutrient flow (diabetes), they will die off in the periphery first then work proximal. Especially in the lack of inflammation which typically runs proximal to distal as the nerve becomes sensitized and depolarizes.
She needs blood work and a metabolic work up first. I would add in the basic order markers for inflammation (CRP, Homocysteine, IL-6, ESR) and heavy metal testing. This would be the least invasive and most cost effective data gathering.
Brandon Cohen DC, CSCS
Carl and Keith-
That’s all very helpful. My initial thoughts were metabolic/stress, but I didn’t know where to go from there. I like to have suggestions as to what might be causing these problems. Initially I thought disc, but the exam did not demonstrate that. Unlikely at best. I’ll hold off on the imaging.
I’ll have to read both those posts a couple more times. Thanks for the help.
William Brady, DC
Keith and Carl had great answers! Very impressive.
I would also add to the metabolic category that it could be hypothyroid.
Brandon Cohen DC, CSCS
A bit of an update;
I saw her this morning, and she has results from recent blood work (within the last 6 months) which she will bring in.
Also turns out she has discoid lupus, Raynaud’s disease (does not associate these new symptoms), and Sjogren’s, which didn’t come up in the “any other past medical history, or anything else I should know” portion of the consult.
Also, further clarification on the symptoms. Only fingers 2-5, no palm numbness. Denies symptoms in the feet.
Neck palpates clean, and we are working on the forearms (forearm symptoms are unrelated to the numbness)
Keith Puri, DC
There are the outliers!
I know I am not the best historian but it’s amazing what patients forget or fail to report during their history. Given her, multiple autoimmune disease diagnoses, is she under the active care of a rheumatologist? If so, has she brought these new symptoms to their attention? If not, I would refer her back to them for a workup to see if this numbness is a manifestation of her lupus or Sjogren’s. If she has, I suggest getting a copy of those records to review. It sounds like she’s developing a small fiber polyneuropathy secondary to her autoimmune diseases. Tough case.
Brandon Cohen DC, CSCS
Further update:
Finished out working the cervical spine tissues. No improvement with hand symptoms.
We discussed her symptoms and how they might be related to her Sjogren’s. She recently had blood work done, and promised to bring it in. She sees the rheumatologist usually once a year, and saw him about a month before sx started.
I’ve seen her twice since then, and we have worked on the forearms/nerve entrapment. I did the first treatment to the forearms, and she brought in the blood work the next visit. Here are the results:
WEF: 50R 55L. No hand symptoms over the past week.
I am both happy and surprised with the results. She had dysfunction, which we resolved.
I would not be surprised if she showed up at her next appointment with the symptoms returned. She doesn’t have anything scheduled with her rheumatologist, but committed to schedule with him if/when the numbness comes back.
Treating relevant dysfunction is important, but a nerve entrapment diagnosis is not reverse compatible in this case.
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