What is the appropriate management for a patient with numbness in both upper arms?

Management of Bilateral Upper Arm Numbness

Bilateral upper arm numbness requires urgent evaluation for cervical spinal cord pathology, particularly central cord syndrome or cervical myelopathy, which can present with bilateral hand and arm numbness with or without burning dysesthesias. 1, 2

Immediate Diagnostic Priorities

Red Flag Assessment

• Obtain urgent cervical spine MRI if the patient has bilateral arm numbness, especially if accompanied by:

  • Burning dysesthesias in the forearms 1
  • Any lower extremity symptoms or weakness 1
  • Perianal or saddle numbness 2
  • New-onset urinary symptoms 2
  • Greater upper extremity weakness than lower extremity involvement (classic central cord syndrome pattern) 1

• Do not rely on conventional x-rays or CT scans to exclude spinal cord pathology—full spinal column MRI is required 2

• Urgent MRI within 12 hours is mandatory when cauda equina syndrome is suspected based on new-onset urinary symptoms with back pain or saddle numbness 2

Physical Examination Specifics

• Assess deep tendon reflexes, particularly triceps reflex (most common neurologic finding in cervical radiculopathy) 3
• Test pinprick response and muscle weakness 4
• Patient-perceived location of numbness in the hands is the most useful neurological test for establishing the affected cervical level (66% agreement rate with neuroimaging) 4
• Perform Spurling test, shoulder abduction test, and upper limb tension test to confirm cervical radiculopathy 3
• Upper limb neurodynamic tests (ULNT 1-3 combined) show 97% sensitivity and 88.2% concordance with MRI findings 5

Differential Diagnosis Algorithm

Central vs. Peripheral Pathology

1. Cervical spinal cord pathology (most concerning):

   • Central cord syndrome presents with bilateral hand numbness and burning dysesthesias 1
   • MRI showing spinal cord signal changes from C3-C7 with canal narrowing confirms diagnosis 1
   • Cervical spine injury without fracture/dislocation (SCIwoFD) can occur with congenital stenosis and degenerative changes 1

2. Peripheral neuropathy:

   • Diabetic peripheral neuropathy typically presents in "stocking-and-glove" distribution starting distally 1
   • Assess temperature/pinprick sensation (small fiber) and vibration with 128-Hz tuning fork (large fiber function) 1
   • Consider thyroid dysfunction, vitamin deficiencies, and toxic exposures 1

3. Cervical radiculopathy:

   • Most prevalent in persons 50-54 years of age 3
   • Painful neck movements and muscle spasm are most common findings 3
   • Overall prognosis is favorable with most patients improving over time 6, 3

Treatment Algorithm

For Confirmed Cervical Radiculopathy (Non-Operative)

• Reassure patients that most cases resolve regardless of treatment type 3
• Physical therapy involving strengthening, stretching, and potentially traction 3
• NSAIDs and muscle relaxants 3
• Cervical collars for short-term immobilization 6
• Selective nerve blocks for targeted nerve root pain 6
• Consider epidural steroid injections (higher risk of serious complications) 3

For Peripheral Neuropathy with Numbness/Tingling

• Duloxetine is the first-line pharmacologic treatment 7, 1
• Physical activity should be offered for neuropathy symptoms 7, 1
• Acetaminophen, NSAIDs, and/or acupuncture for associated pain 7, 1

For Diabetic Neuropathy

• Improved glycemic control prevents progression but does not reverse neuronal loss 1
• Treat other causes including thyroid dysfunction and vitamin deficiencies 1

Critical Pitfalls to Avoid

• Do not delay imaging if central cord syndrome is suspected—electrodiagnostic studies should not delay urgent MRI 1
• Early surgical decompression may worsen neurological deficits in some SCIwoFD cases due to metabolic disturbances 2
• Individual neurological tests (other than hand numbness location) have <50% agreement rate with imaging and may not be reliable alone 4
• Imaging is not required for typical cervical radiculopathy unless there is trauma history, persistent symptoms after 4-6 weeks, or red flags for malignancy, myelopathy, or abscess 3