Case: 45-year-old Man with Hands Numbness

00:00 Now, let's talk about a case.

00:02 This is a 45-year-old right handed man who works as a software engineer and presents with new complaints of numbness in the hands.

00:09 He says that for the past six months, he has had numbness in his hands.

00:13 This initially began in his right hand and he's right handed, and then more recently, he developed symptoms in his left hand.

00:19 He says that the symptoms are worse at the end of the day and awaken him at night, where he will shake his hands for relief.

00:26 He reports numbness and tingling in the first three digits of his hands.

00:30 So the first, second, and third digit in each hand, the fourth and fifth, the fifth digits are spared.

00:36 Over the past few weeks, he has noticed subjective weakness in the right hand with opening jars around his home.

00:42 Examination shows no muscle atrophy, he does have mild weakness in the thumb and index finger with opposition.

00:49 There's reduced sensation over the first three digits, no symptoms in the lower extremities and normal deep tendon reflexes.

00:56 So what's the diagnosis? Well, there are a number of things to think about in this case.

01:01 The first is the distribution.

01:03 This problem involves the first three fingers and not the fourth and fifth digit, and that is very sensitive and specific for a problem affecting the median nerve.

01:14 The median nerve innervates, the thumb, index, and middle finger and does not provide nervous innervation to the fourth and fifth digit.

01:24 In addition, we also see that this problem is worse at night, and he wakes up and shakes his hand, which is something we commonly see in patients with carpal tunnel syndrome.

01:32 And we don't have other findings to suggest a more systemic polyneuropathy.

01:36 There's no symptoms in the lower extremities and normal deep tendon reflexes.

01:40 So what's the diagnosis? Is this carpal tunnel syndrome, AIDP or Guillain-Barre syndrome, diabetic polyneuropathy, or a cervical radiculopathy? This is not the typical presentation for diabetic polyneuropathy.

01:56 That's a chronic onset.

01:58 Length dependent polyneuropathy that begins in the legs and ascends into the hands.

02:02 And we don't have any of those symptoms present in this patient.

02:06 Cervical radiculopathy could cause symptoms in the upper extremity, but it would be quite uncommon to have onset of upper extremity symptoms in both hands at the same time.

02:16 And typically central cord problems affect a tape length distribution as opposed to the distal hands.

02:22 And then lastly, AIDP or Guillain-Barré presents with a sudden rapid ascending polyneuropathy and not focal neuropathic symptoms only in the hands.

02:33 Well, this is a classic and typical presentation of a patient with carpal tunnel syndrome.