A Man With Neck Pain and Numbness in the Hands

A 69-year-old man came with a 3-month history of numbness and tingling primarily in the hands and only some mild numbness in the bottom of his feet and toes. The hand tingling got worse when he made a fist; he also noticed that he lost his grip when he played golf. He denied nocturnal pain or numbness. He had neck pain for a long time with limitation of movements and had been told this was from osteoarthritis.

Past medical history was remarkable for kidney stones, hemorrhoidectomy, a fistula repair, and right hip replacement. He is a retired executive who did not smoke or drink.

Examination revealed normal cranial nerves and mentation. Muscle strength and tone were normal and symmetrical. Reflexes were normal, and there were no pathologic reflexes. Sensory examination was normal except for decreased vibration and position senses and two-point discrimination in the fingers and toes. Phalen test was negative, and he had no Tinel’s sign at the wrist. There was mild limitation of neck movements in all directions. The Romberg test was negative. There were no Babinski signs, and the rest of the examination was normal.

What is the Most Likely Diagnosis?

This patient presented with numbness and tingling in the hands and feet, which was somewhat more prominent in the hands. A polyneuropathy was a consideration, and this could be associated with carpal tunnel syndrome as suggested by his hand symptoms; there was, however, no clinical finding of carpal tunnel syndrome.

Common causes of neuropathy should be evaluated first. These include diabetes, thyroid disease, and B ₁₂ deficiency which could cause prominent hand symptoms. He was on no medications nor had he been exposed to toxins.

Because the patient had cervical osteoarthritis, it was also possible that cervical spondylosis produced the symptoms, but these were also present in the legs, and there was no evidence of long tract involvement to explain the leg symptoms. The patient also needed to be worked up for conditions that cause neck stiffness, including rheumatoid arthritis.

What Tests were Done?

A complete metabolic panel was normal. Erythrocyte sedimentation rate was 4 mm/h (normal, <20 mm/h); mean corpuscular volume was 109 fL (normal, 80–100 fL); mean corpuscular hemoglobin was 36.1 pg (normal, 27–33 pg); red blood count was normal; hemoglobin was 14.5 g/dL (normal, 13.8–17.2 g/dL); hematocrit was 43.7% (normal, 41%–50%); B ₁₂ was 203 pg/mL (normal, 200–1100 pg/mL); and folate was 20.7 ng/mL (normal, ≥3.1 ng/mL). Thyroid-stimulating hormone, rheumatoid factor, and fluorescent antinuclear antibody test were normal.

MRI of the neck showed degenerative changes ( Fig. 46-1 ), with narrowing of the neuroforamina of the right C5–C6 and C6–C7 without neural axis pathology.