What is the best course of treatment for a patient with unilateral numbness and tingling in their left hand, which began after a fall one month ago, and considering their overall medical history and demographic information?

Unilateral Left Hand Numbness and Tingling Following Fall

Given the unilateral presentation in the left hand following trauma one month ago, this patient requires urgent evaluation for cervical spinal cord injury without fracture (SCIwoFD), which can present with isolated hand symptoms and may worsen with premature surgical intervention. 1

Immediate Diagnostic Priorities

Rule Out Spinal Cord Injury

• Obtain urgent MRI of the cervical spine (C3-C7) to evaluate for spinal cord signal changes, canal stenosis, and ligamentous injury, as unilateral hand numbness following a fall can represent central cord syndrome or incomplete spinal cord injury 1
• The 2025 World Neurosurgery guidelines emphasize that SCIwoFD has a distinct mechanism from fracture-associated injuries, and early surgical decompression may be harmful rather than beneficial 1
• Look specifically for loss of cervical lordosis, congenital canal narrowing, and degenerative changes that predispose to cord injury with minor trauma 1

Critical Clinical Assessment

• Perform detailed motor examination of both upper extremities, testing biceps (C5), triceps (C7), wrist extensors (C6), finger flexors (C8), and finger abductors (T1) strength bilaterally 1
• Assess sensory distribution carefully—isolated unilateral hand involvement does NOT fit typical patterns of medication-induced neuropathy (which is bilateral and symmetric) or carpal tunnel syndrome (which affects thumb, index, and middle fingers) 2, 3
• Examine for cervical radiculopathy signs, particularly C6-C7 distribution which can affect hand function, though typically involves multiple fingers 2

Differential Diagnosis Framework

Primary Concern: Central Cord Syndrome

• Unilateral hand weakness and numbness following ground-level fall is a classic presentation of incomplete spinal cord injury 1
• The 37-year-old case in the 2025 guidelines showed similar presentation (numbness and weakness in hands after fall) with subsequent worsening after early surgical intervention 1
• Key warning: The illustrative case demonstrated that urgent decompression within 48 hours resulted in worse neurologic outcomes, with progression from grade 4/5 to 0/5 finger strength 1

Secondary Considerations

• Peripheral nerve injury from the fall itself—assess for Tinel's sign at the wrist and elbow, though isolated unilateral presentation makes systemic neuropathy unlikely 2, 3
• Cervical radiculopathy (C6-C7 level)—can cause hand symptoms but usually involves multiple dermatomes 2
• Digital nerve compression from local trauma—however, this would be limited to specific finger distributions, not the entire hand 2

Diagnostic Algorithm

Week 1-2 Post-Presentation

1. Urgent cervical spine MRI without and with contrast to evaluate cord signal, canal diameter, and ligamentous integrity 1
2. Defer nerve conduction studies initially—these are more useful at 4 weeks post-injury when Wallerian degeneration is complete 4, 5
3. Document baseline neurologic examination with detailed motor and sensory mapping 1

Week 4 Post-Injury

• Comprehensive electrodiagnostic studies (NCS/EMG) if MRI shows no cord pathology, to evaluate for peripheral nerve injury or radiculopathy 4, 5, 6
• NCS/EMG at 4 weeks can localize injury site, determine severity, and help with prognosis 4, 5
• In neuropraxia, compound muscle action potentials are present distally but show conduction block proximally 4

Management Strategy

Conservative Approach (Preferred for SCIwoFD)

• Avoid early surgical intervention unless there is documented progressive neurologic deterioration or evidence of ongoing cord compression 1
• The 2025 meta-analysis suggests that SCIwoFD may not require surgery or may be harmed by it, contrary to traditional teaching 1
• Close neurologic monitoring with serial examinations every 1-2 weeks for the first 2 months 1

Symptomatic Management

• Wrist splinting in neutral position if carpal tunnel syndrome is contributing (though less likely given unilateral presentation) 3
• Duloxetine for neuropathic pain if present (first-line for neuropathic symptoms) 1
• Physical activity and gentle range of motion to prevent deconditioning, but avoid high-impact activities 1
• Pregabalin 75-150 mg twice daily as alternative for neuropathic pain, starting at 75 mg BID and titrating based on response 7

Surgical Consideration Criteria

• Progressive motor weakness on serial examinations 1
• MRI evidence of significant cord compression with clinical correlation 1
• Failure of conservative management after 8-12 weeks with documented lack of improvement 1

Critical Pitfalls to Avoid

1. Do not rush to surgical decompression based solely on MRI findings without considering the natural history of SCIwoFD 1
2. Do not assume bilateral symptoms are required for spinal cord pathology—unilateral presentations occur, particularly in incomplete injuries 1
3. Do not perform NCS/EMG too early (before 3-4 weeks)—results may be falsely normal due to incomplete Wallerian degeneration 4, 5
4. Do not attribute symptoms to medication side effects (if patient is on chemotherapy or aromatase inhibitors) without considering traumatic etiology, as drug-induced neuropathy is bilateral and symmetric 1, 2

Follow-Up Timeline

• Week 2: Repeat neurologic examination and review MRI results 1
• Week 4: Consider NCS/EMG if no cord pathology identified 4, 5
• Week 8: Reassess for surgical candidacy if no improvement 1
• Month 6: Final assessment of recovery trajectory 1