He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?


#1

A 67-year old male recently attended A&E, with a 3 month history of bilateral paraesthesias and twitching affecting the thumb, first finger and lateral forearm. He denied any trauma. A MRI scan of his spine was performed and revealed cervical canal stenosis with mild cord compression. He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?

Refer to spinal surgery services
Refer for locally commissioned cervical root injections and review after 6 weeks
Enlist on the weekly minor ops clinic for carpal tunnel decompression
Commence neuropathic analgesia in the first instance and consider surgical evaluation if this does not work
Refer to physiology services and review in 6 weeks

Dr. Kasper:
Refer to spinal surgery services

Bilateral median nerve dysfunction is very suggestive of a diagnosis of degenerative cervical myelopathy (DCM) rather than bilateral carpal tunnel syndrome (option C). DCM should be suspected in elderly patients presenting with limb neurology. His twitches are probably fibrillations, a sign of lower motor neuron dysfunction.

Degenerative cervical myelopathy is associated with a delay in diagnosis, estimated to be >2 years in some studies [1]. It is most commonly misdiagnosed as carpal tunnel syndrome and in one study, 43% of patients who underwent surgery for degenerative cervical myelopathy, had been initially diagnosed with carpal tunnel syndrome [1]. Management of these patients should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression. Physiotherapy and analgesia does not replace surgical opinion, though they may be used alongside (options D and E). Nerve root injections do not have a role in management (option B).