Numbness: Difference between revisions
(Expanded with concise EM-focused content: localization-based approach, red flags, central vs peripheral, management by cause, disposition) |
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[[File:Dermatomes and cutaneous nerves - posterior.png|thumb|Dermatomes — posterior]] | [[File:Dermatomes and cutaneous nerves - posterior.png|thumb|Dermatomes — posterior]] | ||
*Numbness (paresthesias/hypoesthesia) is a common ED complaint | *Numbness (paresthesias/hypoesthesia) is a common ED complaint | ||
*Key EM role: distinguish | *Key EM role: distinguish central causes (stroke, spinal cord compression) from peripheral causes | ||
*Pattern of numbness is the most important clue to localization | *Pattern of numbness is the most important clue to localization | ||
==Clinical Features== | ==Clinical Features== | ||
===Localizing by History and Physical=== | ===Localizing by History and Physical=== | ||
* | *Distribution: unilateral face + arm + leg = cortical (stroke); bilateral distal = peripheral neuropathy; dermatomal = radiculopathy; stocking-glove = polyneuropathy | ||
* | *Onset: acute (minutes-hours) = vascular; subacute (days-weeks) = inflammatory; chronic = metabolic/degenerative | ||
* | *Associated weakness: combined motor + sensory = more concerning for central or cord lesion | ||
* | *Sensory level: band-like numbness at a specific dermatome level = spinal cord pathology | ||
===Red Flags=== | ===Red Flags=== | ||
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===Central=== | ===Central=== | ||
* | *[[Stroke]]/[[TIA]]: acute onset, unilateral, often with other deficits | ||
* | *[[Spinal cord compression]]: bilateral, sensory level, weakness (see [[Epidural compression syndromes]]) | ||
* | *[[Transverse myelitis]], [[MS]] | ||
===Peripheral=== | ===Peripheral=== | ||
* | *[[Guillain-Barré syndrome]]: ascending weakness + paresthesias, areflexia | ||
* | *Radiculopathy: dermatomal, often with pain | ||
* | *Diabetic neuropathy: distal, symmetric, stocking-glove | ||
* | *Carpal tunnel / ulnar neuropathy: specific nerve distribution | ||
* | *[[Cauda equina syndrome]]: saddle anesthesia, urinary retention, bilateral leg symptoms | ||
==Evaluation== | ==Evaluation== | ||
*Thorough neurologic exam: sensory testing (light touch, pinprick, proprioception), motor strength, reflexes, gait | *Thorough neurologic exam: sensory testing (light touch, pinprick, proprioception), motor strength, reflexes, gait | ||
* | *Acute unilateral: CT/CTA head → stroke protocol | ||
* | *Bilateral with sensory level: emergent MRI spine (cord compression) | ||
* | *Saddle anesthesia: emergent MRI lumbar spine, bladder scan for post-void residual | ||
* | *Ascending weakness: LP for GBS (albuminocytologic dissociation), respiratory monitoring | ||
*[[BMP]], [[CBC]], [[glucose]], [[TSH]], B12 for polyneuropathy workup (can be outpatient) | *[[BMP]], [[CBC]], [[glucose]], [[TSH]], B12 for polyneuropathy workup (can be outpatient) | ||
==Management== | ==Management== | ||
* | *Stroke: activate stroke protocol (see [[Stroke]]) | ||
* | *Cord compression: IV [[dexamethasone]], emergent neurosurgery/oncology, emergent MRI | ||
* | *Cauda equina: emergent MRI, surgical consultation | ||
* | *GBS: ICU if respiratory compromise, IVIG or plasmapheresis, neurology consultation | ||
* | *Peripheral neuropathy: outpatient workup unless acute/progressive | ||
* | *Radiculopathy: pain management, outpatient follow-up unless red flags | ||
==Disposition== | ==Disposition== | ||
Latest revision as of 09:26, 22 March 2026
Background
- Numbness (paresthesias/hypoesthesia) is a common ED complaint
- Key EM role: distinguish central causes (stroke, spinal cord compression) from peripheral causes
- Pattern of numbness is the most important clue to localization
Clinical Features
Localizing by History and Physical
- Distribution: unilateral face + arm + leg = cortical (stroke); bilateral distal = peripheral neuropathy; dermatomal = radiculopathy; stocking-glove = polyneuropathy
- Onset: acute (minutes-hours) = vascular; subacute (days-weeks) = inflammatory; chronic = metabolic/degenerative
- Associated weakness: combined motor + sensory = more concerning for central or cord lesion
- Sensory level: band-like numbness at a specific dermatome level = spinal cord pathology
Red Flags
- Acute onset unilateral numbness (stroke until proven otherwise)
- Saddle anesthesia + urinary retention (cauda equina syndrome)
- Sensory level on trunk (spinal cord compression)
- Rapidly ascending numbness/weakness (Guillain-Barré syndrome)
- Numbness + bilateral leg weakness (cord compression)
Differential Diagnosis
Peripheral neuropathy
- Peripheral nerve syndromes (mononeuropathy)^
- Acute trauma
- Chronic nerve entrapment
- Mononeuritis multiplex^^
- Acute
- Diabetes mellitus
- Polyarteritis nodosum
- Connective tissue diseases (e.g., SLE, rheumatoid arthritis)
- Chronic
- Multiple compressive neuropathies
- AIDS
- Sarcoidosis
- Acromegaly
- Leprosy
- Lyme disease
- Idiopathic
- Acute
- Associated with autonomic features
- Alcohol use disorder
- Amyloidosis
- Chemotherapy-related neuropathy
- Chronic nitrous oxide abuse
- Diabetes mellitus
- Heavy metal toxicity
- Porphyria
- Primary dysautonomia
- Vitamin B12 deficiency
- Associated with pain
- Alcohol use disorder
- Amyloidosis
- Chemotherapy (heavy metal toxicity)
- Diabetes mellitus
- Idiopathic polyneuropathy
- Porphyria
- Paraneoplastic syndrome
- Vitamin B1 or B12 deficiency
- Arsenic toxicity
- Thallium toxicity
^A condition in which a single nerve is damaged or compressed.
^^A condition where damage to at least two separate peripheral nerves results in a painful, asymmetric, and asynchronous presentation of sensory and motor deficits.
By Localization
| Level | Distribution | Facial | Pain |
| Brain/cortex | Unilateral | Often | No |
| Spinal cord | Bilateral | No | Possible |
| Nerve root | Dermatomal/unilateral | No | Yes |
| Peripheral nerve | Specific nerve territory | Possible | Yes |
| Polyneuropathy | Distal symmetric | No | Often |
Central
- Stroke/TIA: acute onset, unilateral, often with other deficits
- Spinal cord compression: bilateral, sensory level, weakness (see Epidural compression syndromes)
- Transverse myelitis, MS
Peripheral
- Guillain-Barré syndrome: ascending weakness + paresthesias, areflexia
- Radiculopathy: dermatomal, often with pain
- Diabetic neuropathy: distal, symmetric, stocking-glove
- Carpal tunnel / ulnar neuropathy: specific nerve distribution
- Cauda equina syndrome: saddle anesthesia, urinary retention, bilateral leg symptoms
Evaluation
- Thorough neurologic exam: sensory testing (light touch, pinprick, proprioception), motor strength, reflexes, gait
- Acute unilateral: CT/CTA head → stroke protocol
- Bilateral with sensory level: emergent MRI spine (cord compression)
- Saddle anesthesia: emergent MRI lumbar spine, bladder scan for post-void residual
- Ascending weakness: LP for GBS (albuminocytologic dissociation), respiratory monitoring
- BMP, CBC, glucose, TSH, B12 for polyneuropathy workup (can be outpatient)
Management
- Stroke: activate stroke protocol (see Stroke)
- Cord compression: IV dexamethasone, emergent neurosurgery/oncology, emergent MRI
- Cauda equina: emergent MRI, surgical consultation
- GBS: ICU if respiratory compromise, IVIG or plasmapheresis, neurology consultation
- Peripheral neuropathy: outpatient workup unless acute/progressive
- Radiculopathy: pain management, outpatient follow-up unless red flags
Disposition
- Admit: stroke, spinal cord compression, cauda equina, GBS, acute rapidly progressive symptoms
- Discharge: stable peripheral neuropathy, chronic radiculopathy, isolated carpal tunnel — with neurology follow-up if new
- Return precautions: weakness, difficulty walking, urinary/bowel changes, worsening or spreading numbness