In a 62‑year‑old woman with MRI‑proven moderate‑to‑severe cervical foraminal stenosis at C4‑C6, high‑grade stenosis at C5‑C6, and a congenitally narrow cervical canal (anteroposterior diameter 8 mm), what is the clinical significance of her right hand being frequently colder than the left for several hours?

Unilateral Hand Coldness in Cervical Stenosis: Clinical Significance and Management

The frequent coldness of the right hand compared to the left in this patient with severe cervical foraminal stenosis at C5-C6 represents a significant vascular or autonomic symptom that warrants urgent evaluation for cervical myelopathy, progressive radiculopathy, or sympathetic chain involvement—this is not an incidental finding and demands immediate neurological assessment and consideration for surgical decompression.

Understanding the Clinical Context

This 62-year-old woman presents with a particularly concerning anatomical scenario:

• Congenitally narrow canal (8 mm AP diameter): This is critically stenotic, as congenital cervical stenosis is defined by canal areas below specific thresholds, with sagittal canal diameters <13 mm strongly associated with stenosis 1. Her 8 mm measurement places her at extremely high risk for spinal cord injury from even minor trauma 1.

• High-grade stenosis at C5-C6: This level is the most common site for both foraminal stenosis (prevalence 19-24%) and symptomatic compression 2. The C5-C6 nerve roots control critical upper extremity function and carry sympathetic fibers 2.

• Multilevel involvement (C4-C6): The combination of congenital narrowing and acquired degenerative stenosis creates a "double-crush" phenomenon that significantly increases the risk of neurological deterioration 3.

Why Unilateral Coldness Is Clinically Significant

The persistent coldness of one hand for several hours suggests three possible mechanisms, all of which are serious:

1. Sympathetic Nerve Involvement

• Cervical nerve roots C5-C8 carry sympathetic fibers that regulate vascular tone in the upper extremity 3.
• Foraminal stenosis at C5-C6 can compress these sympathetic fibers, causing vasomotor dysfunction manifesting as coldness, color changes, or temperature asymmetry 3.
• This is not a benign finding—it indicates active nerve compression requiring intervention 3.

2. Early Myelopathic Sign

• Hand symptoms in the setting of severe canal stenosis (8 mm) should raise immediate concern for cervical myelopathy 3.
• Myelopathy can present with subtle autonomic or vascular symptoms before classic findings like hyperreflexia, gait instability, or hand clumsiness appear 3.
• Critical point: Patients with congenitally narrow canals are at high risk for catastrophic spinal cord injury from minor trauma, and any new neurological symptom demands urgent evaluation 4, 5.

3. Progressive Radiculopathy with Vascular Component

• Severe foraminal stenosis can cause both sensory/motor radiculopathy and associated vascular symptoms through nerve root compression 6.
• The C5-C6 level is particularly prone to stenosis from uncovertebral joint osteophytes, which can compress both neural and vascular structures 6.

Immediate Evaluation Required

Red-Flag Assessment

Perform a focused neurological examination immediately to detect myelopathic signs 3:

• Motor examination: Test for hand clumsiness, finger abduction weakness (C8-T1), grip strength asymmetry, and proximal arm weakness 3.
• Sensory examination: Assess for dermatomal sensory loss in C5-C6 distribution (lateral arm, thumb, index finger) and any sensory level 3.
• Reflex examination: Check for hyperreflexia, inverted radial reflex, positive Hoffmann's sign, or Babinski sign 3.
• Gait assessment: Observe for ataxia, spasticity, or difficulty with tandem walking 3.
• Bowel/bladder function: Ask specifically about urinary urgency, frequency, or retention 3.

Any positive myelopathic sign mandates immediate surgical referral 3.

Vascular and Autonomic Assessment

• Temperature comparison: Document objective temperature difference between hands using infrared thermometry if available.
• Color changes: Note any pallor, cyanosis, or rubor in the affected hand.
• Pulse examination: Palpate radial and ulnar pulses bilaterally to exclude peripheral vascular disease.
• Provocative maneuvers: Assess whether neck position (flexion, extension, rotation) reproduces or worsens the coldness.

Management Algorithm

If Myelopathic Signs Are Present

Urgent surgical decompression is indicated 3:

• The combination of an 8 mm canal and myelopathic symptoms carries a high risk of permanent neurological deficit without intervention 4, 5.
• Anterior cervical decompression and fusion (ACDF) at C5-C6 (and possibly C4-C5, C6-C7 depending on imaging) is the standard approach 3.
• Do not delay: Progressive myelopathy can lead to irreversible spinal cord damage 3.

If No Myelopathy But Persistent Radicular Symptoms

Structured conservative trial with close monitoring 3:

• Initial conservative management (6-12 weeks): Physical therapy focusing on cervical traction, NSAIDs, activity modification, and avoidance of neck extension 3.
• Reassessment at 4-6 weeks: Repeat neurological examination to detect any progression 3.
• Surgical referral if:
  • Symptoms persist beyond 3-4 months 3
  • Any progression of numbness, weakness, or coldness 3
  • Development of myelopathic signs 3
  • Patient preference for definitive treatment given the severity of stenosis 3

Special Considerations for This Patient

The 8 mm canal diameter is a critical factor 5, 1:

• This places her at extremely high risk for acute spinal cord injury from minor trauma (e.g., fall, whiplash, sudden neck movement) 4, 5.
• Even in the absence of current myelopathy, the combination of congenital stenosis and high-grade acquired stenosis at C5-C6 creates a "no-reserve" situation where the spinal cord has no room to tolerate further compression 5, 1.
• Consider prophylactic surgical decompression even if conservative management initially improves symptoms, given the catastrophic risk profile 4, 5.

Expected Surgical Outcomes

If surgery is pursued, the evidence supports excellent outcomes for radiculopathy 3:

• Pain and sensory improvement: Significant improvement at 3-4 months compared to conservative management (p < 0.05) 3.
• Functional recovery: Superior recovery of wrist extension, elbow extension, and shoulder strength at 12 months 3.
• Success rates: 52-99% relief of arm/neck pain, weakness, and sensory loss 3.
• Recurrence: Up to 30% may experience recurrent symptoms, often at adjacent levels 3.

Common Pitfalls to Avoid

• Do not dismiss unilateral coldness as "just circulation": In the context of severe cervical stenosis, this is a neurological symptom until proven otherwise 3.
• Do not rely on absence of classic myelopathic signs: Subtle autonomic or vascular symptoms may precede overt myelopathy 3.
• Do not delay imaging: If not already done, obtain MRI cervical spine without contrast immediately to assess for cord signal changes, which would indicate myelopathy 7.
• Do not attempt epidural steroid injections alone: For moderate-to-severe structural foraminal stenosis, injections are insufficient and definitive surgical decompression is required 3.
• Do not underestimate the risk of the 8 mm canal: This is a "ticking time bomb" for spinal cord injury and warrants aggressive management 5, 1.

Bottom Line

This patient's unilateral hand coldness is a red flag for active nerve compression or early myelopathy in the setting of critically severe cervical stenosis. Immediate neurological examination is mandatory, and surgical decompression should be strongly considered even if myelopathy is not yet overt, given the catastrophic risk profile of an 8 mm canal with high-grade stenosis at C5-C6 4, 3, 5, 1.