Case Study | 1. Hand Numbness & Spine Disease

My father had complained of numbness & tingling in his hands for years. Fiat medicine got him nowhere. One look at his spine, and the problem was clear. But, his doctors did not know it.

Photo by Mathew Schwartz on Unsplash

NEWS:

This article will be the first in a series of case studies which will be available to all paid subscribers. This will give me the flexibility of discussing new research and exploring common ailments, week-to-week.

Keeps things fresh for both of us.

Background

For years my father had complained of intermittent numbness and tingling in his hands (and sometimes feet), usually in 1 or 2 specific locations.

From the perspective of Fiat Medicine, he had many potential contributing factors.

• Years of physical labor with repetitive motions

• Chronic antibiotic use - specifically fluoroquinolones

• At one point he was diagnosed with ‘pre-diabetes’

• Put on a statin by his primary care provider

If these predisposing factors were not enough, a crack team of Neurologists has put together a diagnostic algorithm to figure out what is going on.

Simple, no?

Case Report

Maybe as his son, I have an unfair advantage in that I am very well aware of his history. The history of a presenting illness is probably the most important component of any patient-doctor encounter.

Unfortunately, taking a history is a dying art. Some say it’s physical examination skills - but, that art is already dead. Next on the chopping block is history-taking.

If you ask my father about his history of neurologic pain, he would recount the following:

• Decades of migraines

• Professional wrestling

• Years of physical labor - including operating heavy machinery

• ‘cracking’ joints in his fingers, neck, and back for decades

Common things being common, this should prompt an evaluation of the nervous system. Which they did - after months and months of waiting. He underwent an MRI of his cervical and thoracic spine.

When ordered, this is usually the sequence of events:

• Clinician orders MRI

• Radiologist reads the MRI, and composes a report with this final Impression

• Clinician reads the impression, without reading the body of the report or looking at the images

• Clinician decides the problem is not related to the spine because of the wording in the impression

Let’s now take a look at my father’s MRI reports.

Cervical Spine MRI:

Thoracic Spine MRI:

The impression one gets from the cervical spine MRI is not concerning, though not technically false. If the ordering physician looks at that report, it is hard to fault them in thinking “his neck must be fine.”

Although the thoracic spine report is somewhat more elaborate, it will get dismissed because the hands are innervated by the brachial plexus, which is a convoluted mesh of the nerve roots from higher up in the spine:

Brachial Plexus - nerve supply to the upper extremities

So far, on the basis of these reports his doctor dismissed that this was related to a spinal nerve root problem.

After months of tinkering to no avail, he was referred to a neurologist who performed an electromyogram - using electrodes to gauge the activity of your peripheral nerves. This was also negative.

So, as far as his doctors were concerned - it was not a nerve problem.

Spine Lesson

Before we look at my father’s imaging, let’s take a look at a normal cervical spine.

And an average (normal-ish) MRI of the cervical spine:

I don’t have the real estate to go over the spine in detail, but maybe a future video/presentation if the audience desires it.

When we look at a spine MRI, from a biomechanical perspective we look for a couple of things:

• Degenerative joints including: articular facets, uncovertebral joints, intervertebral discs, ligaments

• Bones

• Neural foramen (from which nerve roots exit)

• Spinal canal (which houses your spinal cord)

Now, my Father’s Cervical Spine:

Doesn’t look all that different, right?

Couple of things to note here…