Numbness: Difference between revisions
(Strip excess bold)
 
(4 intermediate revisions by 2 users not shown)
Line 1: Line 1:
==Background==
==Background==
 
[[File:23-Sensory-Homonculus.png|thumb|Sensory Homunculus.]]
[[File:Dermatomes and cutaneous nerves - anterior.png|thumb|Dermatomes — anterior]]
[[File:Dermatomes and cutaneous nerves - posterior.png|thumb|Dermatomes — posterior]]
*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==
==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===
===Localizing the problem by history & physical<ref>Rosenfeld J, Martin RA, Bauer DW. "Chapter Three - Numbness: A Practical Guide for Family Physicians." American Academy of Neurology. https://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/4.CME_and_Training/2.Training/4.Clerkship_and_Course_Director_Resources/FM_Chp3.pdf</ref>===
*Acute onset unilateral numbness (stroke until proven otherwise)
*Distribution of symptoms
*Saddle anesthesia + urinary retention ([[cauda equina syndrome]])
**Right vs. left
*Sensory level on trunk (spinal cord compression)
**Presence of facial involvement
*Rapidly ascending numbness/weakness ([[Guillain-Barré syndrome]])
**Arm vs. leg
*Numbness + bilateral leg weakness (cord compression)
**Proximal vs. distal
**Symmetric vs. asymmetric
*Characteristics of symptoms
**Sensory and motor
**Painless or Painful
**Sensory only
**Autonomic involvement
*Temporal Features
**Acute or Chronic
**Static or Progressive


==Differential Diagnosis==
==Differential Diagnosis==
{{Peripheral nerve syndromes}}
{{Peripheral neuropathy DDX}}


==Evaluation==
===By Localization===
{| {{table}}
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Region'''
| align="center" style="background:#f0f0f0;"|'''Level'''
| align="center" style="background:#f0f0f0;"|'''Distribution'''
| align="center" style="background:#f0f0f0;"|'''Distribution'''
| align="center" style="background:#f0f0f0;"|'''Facial Involvement'''
| align="center" style="background:#f0f0f0;"|'''Facial'''
| align="center" style="background:#f0f0f0;"|'''Pain'''
| align="center" style="background:#f0f0f0;"|'''Pain'''
|-
|-
| '''Brain'''||Unilateral||Often||No
| '''Brain/cortex'''||Unilateral||Often||No
|-
|-
| '''Spinal cord'''||Bilateral||No||Possible
| '''Spinal cord'''||Bilateral||No||Possible
|-
|-
| '''Nerve root'''||Unilateral||No||Yes
| '''Nerve root'''||Dermatomal/unilateral||No||Yes
|-
|-
| '''Nerve'''||Unilateral or bilateral||Possible||Yes
| '''Peripheral nerve'''||Specific nerve territory||Possible||Yes
|-
| '''Polyneuropathy'''||Distal symmetric||No||Often
|}
|}


{| {{table}}
===Central===
| align="center" style="background:#f0f0f0;"|'''Cause'''
*[[Stroke]]/[[TIA]]: acute onset, unilateral, often with other deficits
| align="center" style="background:#f0f0f0;"|'''Acute (Days)'''
*[[Spinal cord compression]]: bilateral, sensory level, weakness (see [[Epidural compression syndromes]])
| align="center" style="background:#f0f0f0;"|'''Chronic (Weeks-Months)'''
*[[Transverse myelitis]], [[MS]]
|-
 
| Immune||Guillain-Barre & variants, vasculitis||Chronic demylinating neuropathy
===Peripheral===
|-
*[[Guillain-Barré syndrome]]: ascending weakness + paresthesias, areflexia
| Toxins||Botulism, buckthorn, diphtheria, tick, arsenic, organophosphates, thallium, vacor||Heavy metals, environmental chemicals
*Radiculopathy: dermatomal, often with pain
|-
*Diabetic neuropathy: distal, symmetric, stocking-glove
| Drugs||Captopril, gangliosides, gold, nitrofurantoin, suramin, zimeldine||chemotheraputic agents
*Carpal tunnel / ulnar neuropathy: specific nerve distribution
|-
*[[Cauda equina syndrome]]: saddle anesthesia, urinary retention, bilateral leg symptoms
| Metabolic||Porphyria||Porphyria, diabetes
 
|-
==Evaluation==
| Nutritional||||Vitamin toxicity or deficiency
*Thorough neurologic exam: sensory testing (light touch, pinprick, proprioception), motor strength, reflexes, gait
|-
*Acute unilateral: CT/CTA head → stroke protocol
| Hereditary||||Hereditary motor and sensory neuropothy, hereditary sensory neuropathy
*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==
==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==
 
*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


==See Also==
==See Also==
*[[Focal neurologic deficits]]
*[[Focal neurologic deficits]]
 
*[[Weakness]]
==External Links==
*[[Stroke]]
 
*[[Cauda equina syndrome]]
*[[Guillain-Barré syndrome]]


==References==
==References==
Line 74: Line 86:


[[Category:Symptoms]]
[[Category:Symptoms]]
[[Category:Neurology]]

Latest revision as of 09:26, 22 March 2026

Background

Sensory Homunculus.
Dermatomes — anterior
Dermatomes — posterior
  • 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



^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

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

See Also

References

Retrieved from "https://www.wikem.org/w/index.php?title=Numbness&oldid=389109"