What is the best course of action for a patient with left hand numbness and tingling after a fall one month ago?

Evaluation and Management of Hand Numbness and Tingling After Fall

This patient requires urgent neurological evaluation with cervical spine MRI and nerve conduction studies to differentiate between spinal cord injury without fracture (SCIwoFD), cervical radiculopathy, and peripheral nerve compression, as the one-month timeline places them in a critical window where delayed diagnosis could result in permanent neurological deficit. 1

Immediate Diagnostic Priorities

Cervical Spine Assessment

• Obtain cervical spine MRI immediately to evaluate for spinal cord injury without fracture, which can present with hand numbness and tingling after seemingly minor trauma 1
• The Canadian Stroke Best Practice guidelines classify patients presenting between 48 hours and two weeks with hemibody sensory loss as increased risk requiring evaluation within 24 hours, but at one month post-fall, this patient needs urgent assessment for delayed spinal cord complications 1
• Look specifically for loss of cervical lordosis, congenital canal narrowing, and spinal cord signal changes on T2-weighted sequences, as these findings indicate SCIwoFD even without fracture 1

Critical Warning: Surgical Timing Considerations

• Do NOT rush to surgical decompression if SCIwoFD is identified, as recent evidence from 2025 suggests early surgery may be harmful in this population, contrary to traditional teaching 1
• The mechanism of SCIwoFD differs fundamentally from traumatic SCI with fracture-dislocation, and the original 1954 observations by Schneider remain relevant: conservative management may be superior 1
• One illustrative case showed a 37-year-old with similar presentation who underwent urgent decompression within 48 hours and experienced worsening neurological function postoperatively, with increased cord signal and expansion on MRI 1

Differential Diagnosis Workup

Peripheral Nerve Entrapment

• Perform nerve conduction studies and EMG to evaluate for carpal tunnel syndrome, which is the most common mononeuropathy with 5% prevalence and presents with numbness and tingling in median nerve distribution 2, 3
• Carpal tunnel syndrome characteristically causes nocturnal paresthesias in thumb, index, and long fingers, and can be precipitated by trauma 4
• Neuromuscular ultrasound can identify median nerve enlargement, hypoechogenic appearance, and increased intraneural vascularity at the carpal tunnel 5, 6

Cervical Radiculopathy

• Evaluate for C6-7 nerve root compression, which can mimic carpal tunnel syndrome with radiating pain and tingling in the hand 5
• Combined NCS/EMG and ultrasound techniques are essential to differentiate between peripheral entrapment and radiculopathy when physical examination is inconclusive 5

Stroke/TIA Considerations

• While less likely given the trauma history, the Canadian guidelines note that patients with hemibody sensory loss without motor weakness require vascular imaging to exclude stroke 1
• Obtain CT angiography "aortic arch-to-vertex" if any concern for cerebrovascular etiology 1

Management Algorithm

If SCIwoFD is Confirmed:

1. Avoid urgent surgical intervention unless there is progressive neurological deterioration 1
2. Implement close neurological monitoring with serial examinations
3. Consider conservative management with cervical collar and activity modification
4. Arrange neurosurgical consultation for ongoing management decisions, not immediate surgery 1

If Carpal Tunnel Syndrome is Confirmed:

1. Initiate night wrist splinting immediately, which can resolve symptoms within 4 weeks 5
2. Consider ultrasound-guided corticosteroid injection for moderate symptoms 6
3. Refer for surgical release (open or endoscopic) only if conservative measures fail or if there is evidence of motor involvement 3, 4
4. Avoid delaying surgery if irreversible motor and sensory changes are developing 4

If Cervical Radiculopathy is Confirmed:

1. Conservative management with physical therapy and NSAIDs initially
2. Consider epidural steroid injection for persistent symptoms
3. Surgical consultation if progressive motor weakness develops

Medication Considerations

Neuropathic Pain Management

• Pregabalin 75-150 mg twice daily is FDA-approved for neuropathic pain and can be initiated if pain is a prominent feature 7
• Start at lower doses (75 mg twice daily) and titrate based on response and tolerability 7
• Patients may experience pain reduction as early as Week 1 of treatment 7

Red Flags Requiring Immediate Action

• Progressive motor weakness in the hand or arm suggests evolving spinal cord compression requiring urgent neurosurgical evaluation 1
• Bilateral symptoms or symptoms involving lower extremities indicate possible central cord syndrome 1
• Burning dysesthesias that worsen acutely may indicate spinal cord ischemia or expanding injury 1
• Asymmetric, rapidly progressive, or multifocal paresthesias with motor signs could indicate Guillain-Barré syndrome or vasculitis requiring immediate hospitalization 6

Common Pitfalls to Avoid

• Do not assume this is simple carpal tunnel syndrome without imaging the cervical spine, as the trauma history mandates evaluation for SCIwoFD 1
• Do not proceed with urgent cervical decompression based solely on MRI findings without considering the specific mechanism of SCIwoFD and potential for harm 1
• Do not dismiss symptoms as "atypical" requiring only routine follow-up, as the one-month duration with persistent symptoms warrants urgent evaluation 1
• Do not rely on physical examination alone to differentiate between carpal tunnel syndrome and radiculopathy, as electrodiagnostic studies are essential 5