Median Neuropathy Differential Diagnoses

Updated: Oct 27, 2014
  • Author: Friedhelm Sandbrink, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
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DDx

Diagnostic Considerations

CTS versus C6 or C7 radiculopathy

  • Cervical radiculopathy usually causes neck and shoulder pain and restricted neck movements in acute radiculopathy.
  • Cervical radiculopathy has absence of nocturnal pain and paresthesias.
  • In cervical radiculopathy, paresthesias are usually limited to 1 side, whereas in CTS they are often bilateral. Root compression maneuvers may elicit paresthesias in radiculopathy.
  • Cervical radiculopathy of C6, produces weakness in C6-innervated muscles (biceps brachii, deltoid, pronator teres, brachioradialis) and depressed biceps tendon reflex; sensory loss may be restricted to thumb or digits 1-2 and may involve the dorsal more than palmar aspects.
  • Cervical radiculopathy of C7 produces weakness in C7-innervated muscles including triceps and finger extensors, and depressed triceps tendon reflex; sensory loss over the region of the middle finger involves the dorsal and palmar aspects.
  • In cervical radiculopathy of C6 or C7, the intrinsic hand muscles are not affected due to C8/T1 innervation.
  • In cervical radiculopathy, the median nerve sensory nerve conduction study results are normal.

CTS versus proximal median nerve problem

  • The flexor pollicis longus muscle is innervated by the anterior interosseus branch of the median nerve. This muscle flexes the distal phalanx of the thumb and is not involved in CTS
  • In CTS, sensation over the thenar area is spared, as it is innervated by the palmar cutaneous sensory branch that exits from the median nerve proximal to the wrist.

CTS versus de Quervain tenosynovitis syndrome

  • Tenosynovitis develops in the abductor pollicis longus and extensor pollicis brevis tendons, which are held in a groove of the radius by a firm segment of the extensor retinaculum.
  • Signs and symptoms include the following: (1) pain in the radial aspect of the wrist and thumb that is aggravated by movement of the wrist and thumb; (2) pain and paresthesias radiating into the thumb, dorsum of the hand, and index finger due to irritation of the radial nerve by severe inflammation; and (3) pain when the thumb is flexed into the palm while the examiner deviates the wrist in the ulnar direction (ie, Finkelstein test).

CTS versus lacunar/thalamic infarcts

Sensory symptoms in thalamic infarcts may affect the hand unilaterally. The paresthesias are more constant and associated with the perioral involvement.

Differential Diagnoses