Tingling and

Numbness
Group 12:
CORPUS, KRIZZELLE
ODIGILI, PHILIP
REPATO, ALDRIN A.
REYES, SARAH M.
ROSARIO, WINSTONE
RUDANI, KAUSHAL
SANTILLAN, KENNETH S.
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OUTLINE
I. Tingling and Numbness
Synopsis
Terminology
Epidemiology
Anatomy and Pathways
Dermatomes
Clinical Practice Guidelines:
Risk

Factors
History Taking
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OUTLINE
Diagnosis
Clinical

Examination
Lab. Test
Algorithm
Red Flags

II. Hypothetical Case

III. Evidence Based Medicine
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SYNOPSIS
Numbness and tingling are abnormal sensations

that can occur anywhere in your body, but are

often felt in your fingers, hands, feet, arms, or legs.

Tingling pins and needles

-an abnormal positive symptom of a disordered

sensation.

Numbness considered as a negative symptom

due to loss of sensory function and diminished or
absent feeling
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Harrison's Principles of Internal

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SYNOPSIS
Two Categories of abnormal Symptoms:
Positive and Negative Symptoms
Prototypical Positive Symptom:
Tingling ( pins and needles)
Itch, pricking, lightning like shooting feelings

(lancinations), aching, knifelike, twisting,

pulling, tightening, burning, searing
electrical or raw feelings
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SYNOPSIS
Positive Phenomena
trains of impulses generated at sites of lowered

threshold or heightened excitability along a

peripheral or central sensory pathway.

Negative Phenomena
loss of sensory function.
diminished or absent feeling.
Numbness
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TERMINOLOGY
Paresthesias refers to tingling or pins-and-needles

sensations but may include a wide variety of other

abnormal sensations, except pain; it is sometimes implies
that the abnormal sensations are perceived spontaneously.
Dysthesias more general term

-Denotes all type of abnormal sensations, including painful

ones, regardless of whether a stimulus is evident.
Hypesthesia or hypoesthesia refers to a reduction of

cutaneous sensation to a specific type of testing such as

pressure, light touch, and warm or cold stimuli
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TERMINOLOGY
Anesthesia a complete absence of skin sensation to the

same stimuli plus pinprick

Hypalgesia or analgesia to reduce or absent pain
perception (nociception)
Hyperesthesia pain or increased sensitivity in response
to touch.
Allodynia describes the situation in which a nonpainful
stimulus, once perceived, is experience as painful sensation
by application of vibrating tuning fork.
Hyperalgesia denotes severe pain in response to a
mildly noxious stimulus
Hyperpathia encompasses all phenomena described by
hyperesthesia, allodynia, and hyperalgesia.
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EPIDEMIOLOGY
As age progresses, one out of three people

suffer from neuropathy or nerve damage.

It is also estimated that around 10 to 15
million Filipinos have neuropathy.
Neuropathy affects people who have an
unbalanced diet and unhealthy lifestyle, which
includes smoking, alcohol drinking, or those
who had injuries or have diabetes.

ANATOMY

Spinothalamic Pathway

DERMATOMES

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DERMATOMES
an area of skin that is served by a single spinal

nerve.
derived from the cells of a somite.
Familiarity with the dermatomes is clinically useful
in localizing the lesion to a nerve root or spinal
cord particularly in radiculopathy.
The 31 spine segments on each side give rise to
31 spinal nerves, which are composed of 8
cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1
coccygeal spinal nerve. Dermatomes exist for
each of these spinal nerves, except the first cervical
spinal nerve. Sensory information from a specific
dermatome is transmitted by the sensory nerve
fibers to the spinal nerve of a specific segment of
the spinal cord.
thorax and abdomen, the dermatomes are evenly
spaced segments stacked up on top of each other,
and each is supplied by a different spinal nerve.

REFERENCE:
http://emedicine.medsc
ape.com/article/187838
8-overview

arms and legs; differ from the pattern of the trunk

dermatomes, because they run longitudinally along
the limbs. The general pattern is similar in all
people, but significant variations exist in dermatome
maps from person to person

LOCALIZATION
NERVE AND ROOT
Nerve trunk lesion- cause a sensory
abnormalities
Root radicular lesion deep aching pain along
the course of the related nerve trunk
Upper Cervical cord lesion affects both hands
and feet
Upper motor lesion- sphincter involvement
Central/Brainstem Lesion- Sensory
disturbance, affects all extremities, causes
syngomyelia
Spinal cord Lesion- Sensory dissociation,
Harrison's Principles of Internal
numbness
or paresthesias
in both feet.
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LOCALIZATION
BRAINSTEM
Small lesion in the brainstem- damage both ipsilateral

descending tigeminak tract and ascending spinothalamic fibers

Lesion in the tegmentum of Pons and Midbrain- causes
pansensory loss contralaterally
Lesion in the Thalamus- lanular infarction, which affects VPL
nucleus, causes Thalamic pain referred to as, Dejenne-Rpussy
syndrome.
CORTEX
Parietal lobe lesion- contralateral hemineglect, hemi
inattention, tendency not to use the affected hand or arm
Anterior Parietal infarction- pseudothalamic syndrome with
contralateralloss of primary sensationfrom head to toe,
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RISK FACTORS
Extra weight. Being overweight or obese may

increase the pressure on your lateral femoral

cutaneous nerve.
Pregnancy. A growing belly puts added pressure
on your groin, through which the lateral femoral
cutaneous nerve passes.
Diabetes. Diabetes-related nerve injury can lead
to meralgia paresthetica.
Age. People between the ages of 30 and 60 are
at a higher risk.
Lifestyle habits. A sedentary lifestyle and poor
nutrition(Vitamin B complex) are major risk factors

HISTORY TAKING
What part or parts of your body have numbness

or tingling? The trunk? Your legs or feet? Your

arms, hands, or fingers?
Which side of your body is involved?
Which area of that body part? For example, is
your inner thigh, calf, or foot affected? Your palm,
fingers, thumb, wrist, or forearm?
Does the numbness or tingling affect your face?
Around your eyes? Your cheeks? Around your
mouth? Is one or both sides of your face
involved?
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HISTORY TAKING
Does the part of your body with numbness or

tingling change colors? Does it feel cold or

warm?
Do you have other abnormal sensations?
Do you ignore everything on the affected
side?
How long have you had the numbness or
tingling?
When did it start?
Does anything make it worse, such as
exercise or standing
for long periods of time?
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REVIEW OF SYSTEM
General

Weight loss or gain

Fatigue
Fever or chills
Weakness
Trouble sleeping

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Neurologic

Dizziness
Fainting
Seizures
Weakness
Numbness
Tingling
Tremor

BATESS Guide to Physical

Examination and History Taking, 11th
edition

19

DIFFERENTIAL DIAGNOSIS
Common:
DM 1 and 2
Alcoholism
Upper and Lower Extremity Neuropathies
Acute Stress Disorder
Hyperventilation
Stroke Syndrome
Renal Failure
Herpes zoster (Postherpetic neuralgia)
HIV/AIDS
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DIAGNOSIS, A Symptom-based
Approach in Internal Medicine., CS
Madgaonkar

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Differential Diagnosis
Occasional
Drugs
Nutritional Deficiency
Restless Legs Syndrome
Guillain-Barr syndrome
Cranial Nerve Neuropathies
Hypothyroidism
Leprosy
Sarcoidosis
Lyme Disease
Metabolic
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DIAGNOSIS, A Symptom-based
Approach in Internal Medicine., CS
Madgaonkar

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Differential Diagnosis
Rare
Vasculitis Syndrome
Multiple Myeloma
Hodgkins disease
Paraneoplastic syndrome
Malignancy
Diphtheria
Porphyria
Toxins
Dejerine-Roussy syndrome
CIDP
Hereditary
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DIAGNOSIS, A Symptom-based
Approach in Internal Medicine., CS
Madgaonkar

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Clinical Examination of
Sensation
Primary Sensation
Pain- Pins
Temperature- warm or cold
Touch- wisp
Joint Position Testing- proprioception
Vibration- tuning fork
Quantitative Sensory Testing
serial evaluation of cutaneous sensations in
clinical trials
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CLINICAL EXAM
Chronic inflammatory demyelinating

polyradiculoneuropathy(CIDP)

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DIAGNOSIS, A Symptom-based
Approach in Internal Medicine., CS
Madgaonkar

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CLINICAL
EXAMINATION OF
SENSATION
Cortical Sensation
Two-point Discrimination- special caliper
Touch Localization- light pressure; wisp of
cotton wool
Bilateral Simultaneous Stimulations
Graphesthesia- letters, numbers palm of
hand
Stereognosis- keys, paper clips, coins.

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LABORATORY TESTS
General Lab tests
CBC-iron deficiency anemia, macrocytic
anemia and Leukocytosis
ESR- systemic and inflammatory processes
Blood, Glucose, Urea, Creatinine,
Electrolytes
CXR-rule out lung cancer and sarcoidosis
X-ray

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LABORATORY TESTS
Specific Lab tests
TSH- hypothyroidism.
Nerve Conduction Study (NCS)-type of PN,
axonal from demyelinating neuropathies.
CT/MRI- stroke; cervical, thoracic, spinal
compressive syndromes; thoracic outlet
syndrome; multiple sclerosis; brachial
plexusevidence of infiltrating Pancoast lesion.

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LABORATORY TESTS
Specific Lab tests
Nerve Biopsy- inflammatory, infectious, and
metabolic PNs.
Lyme Titer- Lyme disease

manifestations.

CSF Analysis- inflammatory, infectious, variety

of immunemediated PNs
Serum Protein Electrophoresis and
Immunofixation- multiple myeloma or
osteosclerotic myeloma
Toxic Screen
Genetic Test
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ALGORITHM OF TINGLING
AND NUMBNESS RELATED
NEUROPATHIES

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RED FLAGS
Sudden onset of numbness
Sudden or rapid onset of weakness
Dyspnea
Signs of cauda equina or conus medullaris
syndrome
Neurologic deficits below a spinal segment

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http://www.gponline.com

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RED FLAGS
Loss of sensation on

both the face and body

(on the same side or
opposite sides)
behavioural or memory
changes
Fever or other systemic
upset
Disturbances of
autonomous nervous
system or objective
muscular weakness
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http://www.gponline.com

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RED FLAGS OF NUMBNESS/TINGLING

Sudden onset of numbness
Sudden or rapid onset of
weakness
Dyspnea
Signs of cauda equina or conus
medullaris syndrome
Neurologic deficits below a spinal
segment
Loss of sensation on both the
face and body (on the same side
or opposite sides)
behavioural or memory changes
Fever or other systemic upset
Disturbances of autonomous
nervous system or objective
muscular weakness
REFERENCES: MSD Manual
http://www.gponline.com

HYPOTHETICAL
CASE

Hypothetical Case
A 56-year-old man, previously well, presents to his

primary care physician with a 4-month history of burning pain in the soles of his feet. The pain is described
as being worse at nightfrequently has prevented him
from falling asleep, and has recently been awakening
him from sleep. He found that acetaminophen tablets
did not relieve the pain. He had noticed some daytime
numbness and tingling sensations starting at about the
same time, and in the same distribution as the pain. He
did not have weakness, low back pain, bowel or
bladder disturbances, but has experienced erectile
dysfunction in the last 1 to 2 months.

CHIEF COMPLAIN
Burning Pain in the soles of his feet
Daytime tingling and numbness sensations
Erectile Dysfunction for the last 1-2 months

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MEDICAL HISTORY
The patients medical history was significant

for an appendectomy 20 years ago

Hypertension for 1 year, and an episode of
acute gout in the left first toe 5 years ago
Seasonal allergies to grass and ragweed. He
takes metoprolol 25 mg once daily.

REVIEW OF SYSTEMS
feels well and his weight is stable.
has a good appetite.
experiences light-headedness on standing quickly,

but does not have syncopal episodes.

does not have headaches, nor does he have
changes in vision or bulbar functions.
He denies shortness of breath, chest pain, or
palpitations;
furthermore, there is no history of nausea,
vomiting, or abdominal pain, but he has noted
chronic constipation

FAMILY HISTORY
The patients father died at age 65 of a

myocar dial infarction.

His mother had type 2 diabetes mellitus, and
died at age 70 of a stroke.
He has 2 brothers, aged 60 and 54the first
has diabetes, hypertension, and obesity, and
the second has a history of myocardial
infarction.
The patient has 3 children, 2 of whom are
overweight.

SOCIAL HISTORY
The patient was born and raised in Oshawa, Ontario,

Canada, and works at General Motors as a line

inspector.
enjoys watching sports on television.
He looks after the yard, but does not play any sports or
belong to a gym.
drinks 2 to 3 beers daily and double this amount on
weekend days.
smokes 2 packs of cigarettes daily, and has done so for
30 years.
has not used recreational drugs such as marijuana,
cocaine, or heroin

PHYSICAL
EXAMINATION
appears to be an alert, cooperative, and obese man
who appears older than his stated age
mild distress due to discomfort in his feet
Weight: 230 lbs,
BP 150/95 mm Hg
HR:104 bpm and regular
RRis 16 breaths per minute
Body Temp: 37C.
The cranial nerves are normal.
His neck is supple.
There is a soft left carotid bruit heard during systole.
There is no jugular venous distension.

PHYSICAL
EXAMINATION
The thyroid is normal in size.
The chest is normal and breath sounds normal.
The second heart sound is accentuated, and there

are no murmurs or thrills.

The abdomen is distended, but nontender to
palpation with normal bowel sounds and no
hepatosplenomegaly.
The genitalia are normal, as is rectal tone.
The patient has dry skin on the lower extremities.
The skin is mottled and cool when dependent

Peripheral pulses are normal, and he does not

have ecchymoses, petechiae, or rashes.

He does not have pedal edema.
The patient appears to have normal strength.
His ankle reflexes are absent.
Sensory loss in the feet is assumed to be
present on palpation, but no objective tests
are performed.
His gait is normal.

NEUROLOGY CONSULTATION
the patient had the same symptoms as

previously described
The patient has noted excessive thirst and
urination for the last 8 months. His weight has
been stable. He is becoming depressed about
the pain.
There is no family history of neuromuscular
disorders. The patient reports he has never
had any hobbies such as wood-working or
refinishing furniture with potential exposure to
toxic agents.

Normal mental status and speech

Fundoscopic examination shows mild A-V

nicking of the vessels, but the cranial nerves

are otherwise normal.
Mildly reduced muscle bulk is in the small foot
muscles and there is mild clawing of the toes.
Tone and coordination testing are normal.
The deep tendon reflexes are normal in the
upper limbs and at the knees, but absent at
the ankles.
The plantar responses are flexor.

Sensory testing shows a stocking loss of light

touch, pinprick, and temperature sensations

to the ankles, and loss of vibration sensation
at the toes, but proprioception is normal.
The posture, gait, tandem gait, and Romberg
tests are normal. The patient is able to walk
on heels and toes without difficulties.

DIFFERENTIAL
DIAGNOSIS
Diabetic Neuropathy
Cauda Equina Syndrome
Pernicious anemia and B12 Deficiency

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Diabetic Neuropathy
Decrease or loss of vibratory
Loss of pinprick sensation
Dry skin
Abdominal distension
Nausea and vomiting
Constipation
High glucose

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Cauda Equina Syndrome

Low back pain
Lower limb motor weakness and sensory

deficits
Urinary dysfunction
Bowel disturbances- constipation
Loss of anal tone and sensation.
Sexual dysfunction

Pernicious Anemia and B12

Deficiency
Peripheral loss of vibratory sense
Loss of posisition senseposition.
Reflex loss and mild-to-moderate weakness.
Babinski's responses and ataxia.
Impairment of pain, temperature and touch

sensations.

LABORATORY
FINDINGS
Glyceted Hemoglobin A1c (HbA1c) 10% abnormal
Serum immunoelectrophoresis
CBC
ESR
Vitamin B12
Folate
TSH
Liver function test
Creatinine
Calcium
Magnesium
Chest X-ray
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LABORATORY
FINDINGS
Nerve conduction studies
Quantitative sensory thresholds shows

elevated vibration perception threshold at the

toes,with normal levels at the fingers.
The cooling-detection and Heat-detection
thresholds are elevated in the feet and normal
in the hands.

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Final Diagnosis
Diabetic Neuropathy

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EVIDENCE BASED
MEDICINE

Evaluation of post-operative flow and diameter changes in brachial and ulnar

arteries in coronary artery bypass surgery patients in which the radial artery is
used as graft.

OBJECTIVE:
The radial artery is widely used in coronary bypass surgery. In these patients, forearm

and hand circulation is provided by the ulnar artery. This study aimed to investigate
post-operative changes in flow and diameter in brachial and ulnar arteries in patients
undergoing coronary bypass surgery in which the radial artery is used as graft.
METHODS:
Between September 2007 and September 2008, 20 patients (16 men, 4 women; mean
age 57.8 years; range 44 to 70 years) underwent elective coronary bypass surgery at
our clinic. The radial artery was used as graft in all cases. Pre-operatively, adequacy of
the ulnar artery for forearm circulation was investigated by Allen test and duplex
ultrasonography. Basal flow and diameter values of the brachial and ulnar arteries were
measured. Control duplex ultrasound measurements were performed at three months
post-operatively. Flow and diameter changes in the brachial and ulnar arteries were
recorded.
RESULTS:
Significant increase was shown in ulnar artery flow and diameter values in postoperative measurements. A significant increase was observed in brachial artery
diameter, accompanied by a relative decrease in flow value. There were no mortality or
ischemic complications in our study. Transientparesthesiaas a neurological
complication was observed in 4 patients.
CONCLUSION:
Radial artery use for coronary bypass surgery leads to significant changes in ulnar and
brachial arteries. All flow and diameter changes can be detected by color Doppler
ultrasonography in the early stages. These adaptation mechanisms show that the radial
artery can be safely harvested as graft material.