A Man With Hand Weakness and Numbness After Skiing

A 45-year-old man had been in good health until right after he was snow skiing in Colorado, at which time he felt numb and weak in his hands; these symptoms progressed over the following week. He went to the emergency room where he had a CT scan of the head and an MRI, which were normal. He then had an EMG that showed a “polyneuropathy” and a lumbar puncture that showed elevated spinal fluid protein, and he received intravenous IgG treatment, but his hands remained numb and weak. He denied weakness in his legs. The patient was referred to us for evaluation.

Past medical history included numbness in the right calf 25 years before and a history of numbness in the ulnar nerve distribution 5 years before; both improved without treatment.

He was an attorney, drank alcohol on occasion, and did not smoke. Family history was noncontributory. His medications included allopurinol for hyperuricemia and simvastatin for mild hyperlipidemia.

Examination revealed mild weakness in the interosseous muscles of the hands but significant weakness in the abductor pollicis brevis (APB) muscles with mild atrophy of both thenar eminences. Other muscles of the upper and lower extremities were normal. Reflexes were 1+ in the upper extremities and knee and trace at the ankles. There was no nerve hypertrophy or fasciculations. Vibration sense was absent at the toes and diminished at the ankles; this was normal in the fingers. There was decreased pain and touch sensations up to the ankle on the right and 4–6 cm above the ankle on the left as well as diminished pain sensation in both median nerve distributions. He had positive Phalen and Tinel tests on the right median nerve at the wrist. He had no high arches. The rest of the examination was normal.