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What Causes Bilateral Pain In The Arms And Hands Despite A Normal MRI Report?
Question: I have had burning in my hands, forearms and sometimes feet for about 6 months. I had a herniated disk 6 months ago that left me with a drop foot. The neurosurgeon did a disectomy on L5 but said that was not why I was having the bilateral pain in my arms and hands. I am on 800 mg of gabapentin 5Xday and still have bad pain at night just burning until hands until fingers feel crippled. I have seen a rhumatologist who ruled out lupus because all blood tests have come out normal. I had an endoscopy and the biopsies came back normal. I have been hospitalzed 3 times because the pain is soo bad. I am in great shape, was a marathon runner before the herniated disk, no diabetes, MRIs show ho sign of neck injuries or MS. Please help .... also currently the veins under my tongue are swollen. I have been tested for everything.
Brief Answer:
Have you had proper an EMG/NCV of the upper extremities?
Detailed Answer:
Good morning. Thank you for your questions on this network. I am of course, assuming accuracy in the statement that nothing is amiss in the neck nor in the brain as far as a demyelinating condition such as MS since you've not uploaded any of the diagnostic study results for review.
However, can you be specific in terms of the blood work that has been done in your case? I will not include the rheumatological studies that I normally get done to screen for these symptoms since you've been seen by a rheumatologist and ruled out for the more common problems with these symptoms.
The metabolic panel that I as a neurologist would want to see completed in someone with the symptoms you refer would be the following:
1. CBC with differential
2. Liver, renal enzymes and tests
3. GTT (glucose tolerance test- now a recognized testing parameter in people with neuropathy but NO DIABETES)
4. Vitamin B12 (at least to a level of 400+), folate, Vit. D (at least to a level of 60-80), FULL Thyroid panel to include (Free T4, Total T4, Free T3, Total T3, TSH, microsomal enzyme assay)
If all the above were absolutely normal and without remark then, the next thing I would consider would be an EMG/NCV of the upper extremities looking for something on the order of an entrapment neuropathy at the level of the wrist elbows or wrists. This would be the same as looking for either a Carpal Tunnel Syndrome or some type of combination between a carpal tunnel and cubital tunnel syndrome (ulnar entrapment at the elbow...though this is a bit less likely given the major symptoms that you're referring).
In terms of medication I've had good overall success in changing people from gabapentin who are not responding as desired with their painful neuropathies to Lyrica or Pregabalin to be taken 2-3x/daily in divided doses. In more severe cases of painful neuropathies that are refractory to gabapentin and pregabalin I have seen success with medications such as nortriptyline 1-3x/daily. capsacin cream applied to the hands and forearms (this burns a bit), and also mexiletine but you would need to get a cardiac screen/EKG before starting that drug. And in very bad cases of painful neuropathies unresponsive to best medical treatment I've also used BOTOX injections in the hands and wrists which seems to slow down the pain in the forearms as well. But this is a bit more aggressive because with BOTOX injections may come some weakness in hand muscle function and that may not be something you would like to have in exchange for fixing the neuropathy.
I've also used compounding pharmacies that can come up with creams that combine gabapentin and lidocaine in a cream that can improve neuropathic pain control.
If I've adequately addressed your concerns could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating to our encounter if you feel my suggestions have helped? Again, many thanks for posing your question.
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.
This query has utilized a total of 20 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Have you had proper an EMG/NCV of the upper extremities?
Detailed Answer:
Good morning. Thank you for your questions on this network. I am of course, assuming accuracy in the statement that nothing is amiss in the neck nor in the brain as far as a demyelinating condition such as MS since you've not uploaded any of the diagnostic study results for review.
However, can you be specific in terms of the blood work that has been done in your case? I will not include the rheumatological studies that I normally get done to screen for these symptoms since you've been seen by a rheumatologist and ruled out for the more common problems with these symptoms.
The metabolic panel that I as a neurologist would want to see completed in someone with the symptoms you refer would be the following:
1. CBC with differential
2. Liver, renal enzymes and tests
3. GTT (glucose tolerance test- now a recognized testing parameter in people with neuropathy but NO DIABETES)
4. Vitamin B12 (at least to a level of 400+), folate, Vit. D (at least to a level of 60-80), FULL Thyroid panel to include (Free T4, Total T4, Free T3, Total T3, TSH, microsomal enzyme assay)
If all the above were absolutely normal and without remark then, the next thing I would consider would be an EMG/NCV of the upper extremities looking for something on the order of an entrapment neuropathy at the level of the wrist elbows or wrists. This would be the same as looking for either a Carpal Tunnel Syndrome or some type of combination between a carpal tunnel and cubital tunnel syndrome (ulnar entrapment at the elbow...though this is a bit less likely given the major symptoms that you're referring).
In terms of medication I've had good overall success in changing people from gabapentin who are not responding as desired with their painful neuropathies to Lyrica or Pregabalin to be taken 2-3x/daily in divided doses. In more severe cases of painful neuropathies that are refractory to gabapentin and pregabalin I have seen success with medications such as nortriptyline 1-3x/daily. capsacin cream applied to the hands and forearms (this burns a bit), and also mexiletine but you would need to get a cardiac screen/EKG before starting that drug. And in very bad cases of painful neuropathies unresponsive to best medical treatment I've also used BOTOX injections in the hands and wrists which seems to slow down the pain in the forearms as well. But this is a bit more aggressive because with BOTOX injections may come some weakness in hand muscle function and that may not be something you would like to have in exchange for fixing the neuropathy.
I've also used compounding pharmacies that can come up with creams that combine gabapentin and lidocaine in a cream that can improve neuropathic pain control.
If I've adequately addressed your concerns could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating to our encounter if you feel my suggestions have helped? Again, many thanks for posing your question.
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.
This query has utilized a total of 20 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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