Ulnar neuropathy can manifest with numbness and/or pain along the medial aspect of the forearm and hand, and, in more severe cases, as hand intrinsic weakness. A C8 radiculopathy can also produce similar symptoms. Proximal arm involvement would favor C8 radiculopathy, whereas provocative testing over the ulnar groove is more typical of an ulnar neuropathy. Electrophysiological testing should be able to distinguish between these two clinical entities. The presence of numbness alone along the medial forearm and hands, in the authors' experience, is relatively non-specific in the absence of neurological deficits. This is a typical site of referred pain or paresthesias in patients with spondylosis involving the lower cervical motion segments.
Left-upper-chest and arm pain can be seen in a C7 radiculopathy, but may also be a manifestation of cardiac ischemia. An appropriate cardiac evaluation can help to identify the latter. A lung apex tumor can also present with upper-chest pain radiating into the arm, mimicking cervical radiculopathy. The presence of supra-clavicular lymphadenopathy and focal pain in the superior chest region supports this diagnosis and imaging studies (chest X-ray and CT scan) are needed for confirmation. Thoracic outlet syndrome is a difficult diagnosis to confirm, but should be considered in patients with radiating arm pain and numbness along the medial aspect of the forearm, extending to the hand. Associated electromyogram (EMG) and nerve conduction studies showing weakness and brachial plexus (lower-trunk) deficits support the diagnosis.
A number of neural degenerative disorders can mimic the manifestations of cervical spondylosis. In particular, multiple sclerosis and amyotrophic lateral sclerosis can involve the arms. Guillain-Barre syndrome and transverse myelitis can also affect cervical spinal cord function. The clinical manifestations of each disorder, supplemented by electrophysiological and imaging studies, can also distinguish spondylosis from these other entities. Coexistence of these entities has been reported.
Multiple sclerosis can be used to explain any focal or non-focal neurological deficit. Although an inflammatory plaque could symmetrically involve the cervical spinal cord at one level and manifest with a relatively symmetric deficit, this would be a less typical manifestation of multi ple sclerosis. One would expect asymmetries and more patchy involvement from this disorder. Also, multiple foci of involvement and multiple flare-ups of acute symptoms would be required to confirm a diagnosis of multiple sclerosis. A lumbar puncture to look for oligoclonal banding would support a diagnosis of multiple sclerosis. MRI studies of the brain and spinal cord should also enable one to distinguish between the two disorders. The absence of significant cord compression and signal change in the cord or the white matter of the brain parenchyma would indicate a demyelinating disorder.
Amyotrophic lateral sclerosis (motor neuron disease) presents with motor deficits in the absence of a sensory phenomenon or pain. The process can affect both upper and lower motor neurons. Hence, the clinical manifestations can vary from patient to patient. One can get asymmetric limb involvement. On examination, the patients typically have no sensory deficit. They may have significant wasting of muscle groups and fasciculations. In particular, involvement of multiple muscle groups with fasciculations, especially if the legs are also involved, would be typical of motor neuron disease with a preferential involvement of the lower motor neurons. In spondylosis, it is not common to have diffuse fasciculations. In isolated radiculopathy, fascic-ulations can be seen in a radicular distribution. Involvement of bulbar musculature would confirm the diagnosis of motor neuron disease and exclude spondylitic myelopathy.
The other possible causes for upper limb symptoms or gait disturbances include thoracic spinal cord compression, peripheral neuropathy, joint osteoarthritis and connective tissue disorders, particularly rheumatoid arthritis.
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