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Pain in upper left back and left arm and hand parasthesias
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Pain in upper left back and left arm and hand parasthesias

I hope you can help me. I am a 42 year old nurse, right handed, with an insidious onset of left upper back pain and left hand and arm numbness. Several weeks ago I noticed a feeling of numbness and tingling in my left hand and arm, localized to what I think is the c7 nerve root. The parasthesias occur in the index and middle finger, dorsal aspect of the forearm, and dorsolateral aspect of the upper arm. I am also having tingling and numbess right below the left clavile, starting from the axilla to the left sternal border, and the lateral border of the left scapula. It is positional, ie if I bend over or crouch, also in bed when I lie on either side. This feeling abates when I flex my neck forward and arch my back. I am having constant numb feeling in my index and medial aspect of 3rd finger. MD thoughht cervical radiculopathy, went for cervical MRI which shows: general spondylosis
c5-c6 and c6-c7 broad based central/left paracentral disc protrusion that abuts nerve roots and partially fills in the lateral recesses. Mild to severe neural foramina stenosis (severe left at c6-c7, mild everywhere else).
Saw neurosurgeon who thinks the MRI films/report do not correlate with clinical picture, went for MRI of brachial plexus for his dx of "brachial plexus neuritis" (pending), and EMG which showed no carpal tunnel but some kind of nerve pathology with no denervation. I am on Neurontin and percocet. Both neurosurgeon and neurologist do not have a answer for me. I am in pain and cannot work. I am thinking of going for a second opinion. Think it is my neck and nerve root impingment
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Avatar_n_tn
Your symptoms could indeed be consistent with a C5 and C6 radiculopathy (or pinched nerve root) - the C6 sensory area includes the lateral aspect of the arm down to the index and 3rd fingers, and C5 the lateral upper arm, and around the shoulder area (including the back/shoulder area). I don't know if you have any weakness to correspond to this localization. Moving your neck forward can reduce the spinal fluid space and make things tighter in the spinal cord/root area, while exteding the neck can free up more space.

I cannot comment on the MRI severity, although you do have a disc there causing some compression ?not just a conincidence
Neuralgic amyatrophy is possible I suppose but would be unusual to be purely sensory (actually it more commonly affects purely motor nerves), the pain is incredibly severe, and would not be positional as you describe.

The EMG (even if done at correctly at least 3 weeks after the onset of symptoms) may not be diagnostic as spinal muscle fibrillations  are not always present with pinched nerve roots, but should be able to detect any serious changes in the C5 and C6 innervated muscles.
The diagnosis is a clinical judgement call, maybe a second opinion would not be a bad idea
The Cleveland Clinic Spine Center is you are in the area could help
Good luck
4 Comments
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Avatar_n_tn
Do you recall lifting a particularly heavy patient before the onset of this pain/parasthesia?  Did you have any infections, illness or vaccinations in the month or so previous? Have you had a chest x-ray, and if so were cervical ribs present?

I am admittedly a layperson, but am somewhat educated in matters of the brachial plexus due to my own experience.  I developed brachial neuritis following a delayed hypersensitivity reaction to the Td vaccine, a severe reaction over two years ago.  I think you are right to question this dx -when the pain first hits, it is horrific, 9+ on a scale of 1-10, followed by weakness and muscle wasting of the shoulder girdle.  The pain is NOT positional, the strongest meds don't touch it, this severe pain resolves after a few days to a few weeks though mild to moderate pain may persist for months.  The muscle wasting is pronounced and affects muscles from more than a single nerve root, but only some muscles of any one nerve root - this "patchy" presentation is classic for brachial neuritis, and should be observeable on an EMG wihtin 3-4 weeks after onset.

Due to the brachial neuritis, my rt shoulder dropped almost 2 inches; this, the inflammation/swelling and some congenital abnormalities which made me predisposed, led to my developing Thoracic Outlet Syndrome.  The nerves were compressed at the scalenes, between the clavicle and first rib (due to the drooping shoulder, the clavicle is also lower) and later it was discovered the medial cord was also compressed at the pec minor.  I had EMG abnormalities and have pretty severe atrophy in the rt hand, esp. the interosseous muscle between the thumb and index finger.

Although TOS is controversial, if there are EMG abnormalities then something is affecting the nerves obviously.  I belong to a TOS web-based forum, and many members are nurses, they seem to have TOS due to the strain on the brachial plexus from all the heavy lifting of patients - either a stretch injury, or trauma to the scalenes, causing inflammation and scar tissue.  Continuing to work through the pain until they could no longer function likely added to the original trauma, inflammation and scar matter.  

Your problem may be related to your c-spine issues, however you don't mention neck pain?  TOS IS positional, and worse at night, often sleeping on your back is the only way to get relief.  Your mention of sx being relieved by forward flexion of the head and arching the back particularly interested me, as with TOS, this forward posture is what we instinctively seek to relieve strain on the brachial plexus, the pecs are also very tight and tender due to the inflammation.

There are very reputable Drs who do believe in TOS of all types, Dr Allan Belzberg at John Hopkins is one. If you are on the East Coast, Dr Allen Togut in Wilkes-Barre PA specializes in dx and managment of TOS patients, he spends 2 1/2-3 hours on each new patient exam and is incredibly knowledgeable.  He does not perform or advocate surgery, and is a great asset for w/c cases if you do have TOS.

I sincerely hope you do not have TOS, but wd hate for you to have c-spine surgery only to find the pain continues.  If you want more info or have questions, visit http://brain.hastypastry.net/forums and look for the Thoracic Outlet Syndrome Forum - there's a wealth of articles, a Dr's list and many members with similar symptoms, including several nurses.

Best wishes,
beth
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Avatar_n_tn
Dear Beth, thank you for the comments and information.
My second MRI came back essentially normal, except for a mild thoracic scoliosis convex to the left. No illnesses, no injuries, vaccinations, or infections. I have no muscle wasting, no change in muscle strength. I do not think it is brachial neuritis nor TOS. What is disturbing is I cannot get in to the neurosurgeon for several weeks, in the mean time I am in pain (sometimes a 10 on the 0-10 scale) and cannot work, and I have constant numbness in my index finger along with the positional numbness I experience in my hand, forearm, and front and back of upper chest. I am going to seek a second  opinion from someone in a Boston hospital. I cannot be out of work for months.
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Avatar_n_tn
Donot forget that the pathology of c spondylosis involoving compertion of arterial&venous supply of roots &cord ending in clinical pictures,&donot appear in MRI.&exetend above &below the actual lesion several segments
i think medical treatment is benficial
vasodilator+duritic+drug to releafe venous engorgament,Daflon+dexamethasone+neurotrophic (cerebrolysin)
Dont forget that thalamic infarction commonly take a parial part of the body ,CT of brain is idicated
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