What causes numbness and tingling from shoulders to arm in a house cleaner (patient) that occurs only when sleeping?

Nocturnal Paresthesias in a House Cleaner: Cervical Radiculopathy vs. Peripheral Nerve Compression

This patient's numbness and tingling from shoulders to arms occurring exclusively during sleep most likely represents positional nerve compression or cervical radiculopathy, and requires urgent evaluation to exclude cervical spinal cord pathology, particularly given the bilateral distribution and occupational risk factors.

Immediate Diagnostic Priorities

Red Flag Assessment

• Bilateral upper extremity paresthesias warrant urgent cervical spine imaging to exclude central cord syndrome or cervical myelopathy 1, 2
• Central cord syndrome classically presents with bilateral hand numbness and burning dysesthesias in the forearms, with greater upper extremity involvement 2
• The positional nature (occurring only during sleep) suggests mechanical compression that may be exacerbated by neck positioning during sleep 1

Critical "Alarm Symptoms" to Assess

Immediately evaluate for the following symptoms that indicate potential spinal cord involvement 1:

• Decreased strength in the legs or arms 1
• Difficulty controlling the legs or arms 1
• Unsteady gait or legs giving way 1
• Numbness or tingling radiating down from chest, stomach, groin, or legs 1
• Back or neck pain that worsens when lying down during sleep 1

Occupational Context

House Cleaning as Risk Factor

• Repetitive overhead work, prolonged neck flexion/extension, and sustained awkward postures during cleaning activities increase risk for cervical degenerative changes 2
• These occupational factors combined with nocturnal positioning may precipitate symptoms in patients with underlying cervical stenosis or degenerative changes 2

Diagnostic Workup

Neurological Examination

Perform focused assessment for 1, 3:

• Sensory testing: Temperature, pinprick (small fiber), and vibration with 128-Hz tuning fork (large fiber) in bilateral upper extremities 2
• Motor strength: Bilateral upper extremity muscle groups, particularly hand intrinsic muscles 2
• Reflexes: Biceps, triceps, brachioradialis to assess for radiculopathy 3
• Gait assessment: To detect any lower extremity involvement suggesting myelopathy 1

Imaging

• MRI of the full cervical spine is the first-choice imaging modality when cervical spinal pathology is suspected 1
• MRI showing spinal cord signal changes with canal narrowing confirms cervical spine pathology 2
• Conventional x-rays and CT scans cannot exclude spinal cord compression 1

Electrodiagnostic Studies

• Electromyography with nerve conduction studies should be considered to differentiate peripheral nerve entrapment (such as bilateral carpal tunnel syndrome or ulnar neuropathy) from cervical radiculopathy 2, 3
• However, these studies should not delay urgent imaging if central cord pathology is suspected 2

Differential Diagnosis

Most Likely Causes in This Context

1. Cervical radiculopathy with positional exacerbation during sleep 1, 2
2. Bilateral peripheral nerve compression (carpal tunnel syndrome, ulnar neuropathy) worsened by wrist/elbow positioning during sleep 2
3. Cervical spinal stenosis with intermittent cord compression 1, 2

Less Common but Important Considerations

• Peripheral neuropathy: Typically presents in "stocking-and-glove" distribution starting distally, less likely given isolated nocturnal symptoms 2
• Thoracic outlet syndrome: Can cause positional upper extremity paresthesias but usually unilateral 3

Management Algorithm

If Alarm Symptoms Present

• Immediate neurosurgical consultation for suspected cervical cord pathology 2
• MRI within 12 hours if clinical suspicion of cord compression exists 1

If No Alarm Symptoms

• MRI within 2 weeks for persistent bilateral upper extremity symptoms 1
• Trial of conservative measures while awaiting imaging 1:
  • Sleep positioning modifications: Avoid extreme neck flexion/extension during sleep 1
  • Ergonomic workplace assessment: Modify cleaning techniques to reduce repetitive neck strain 1
  • Avoid prolonged positioning of joints at end range 3

Symptomatic Management Pending Diagnosis

• Duloxetine is first-line pharmacologic treatment for neuropathic symptoms including numbness and tingling 2, 3
• Physical activity and gentle range-of-motion exercises can be offered for symptom relief 2
• Acetaminophen or NSAIDs for associated pain 2

Critical Pitfalls to Avoid

Do Not Miss Cervical Myelopathy

• Bilateral hand numbness with burning dysesthesias requires cervical spine imaging, especially if accompanied by any lower extremity symptoms 2
• The exclusively nocturnal nature does not exclude serious pathology—positional compression can unmask underlying stenosis 1

Do Not Attribute to Peripheral Neuropathy Without Workup

• Diabetic or other metabolic neuropathies typically present with distal, symmetric symptoms in feet first, not isolated nocturnal upper extremity symptoms 2
• Assess for systemic causes (diabetes, thyroid dysfunction, vitamin B12 deficiency) but do not delay cervical imaging 2

Do Not Delay Imaging for Electrodiagnostic Studies

• If central pathology is suspected, proceed directly to MRI rather than waiting for EMG/NCS results 2