Diagnostic Approach to Nocturnal Paresthesias

Immediate Diagnostic Priorities

Bilateral upper extremity paresthesias warrant urgent cervical spine imaging to exclude central cord syndrome or cervical myelopathy, according to the American College of Radiology 1, 2
Central cord syndrome classically presents with bilateral hand numbness and burning dysesthesias in the forearms, with greater upper extremity involvement, as noted by the American Academy of Neurology 2
The positional nature of symptoms suggests mechanical compression that may be exacerbated by neck positioning during sleep, as reported in Cancer Treatment Reviews 1
Decreased strength in the legs or arms, difficulty controlling the legs or arms, unsteady gait or legs giving way, numbness or tingling radiating down from chest, stomach, groin, or legs, and back or neck pain that worsens when lying down during sleep are critical "alarm symptoms" to assess, according to the American College of Physicians 1

MRI of the full cervical spine is the first-choice imaging modality when cervical spinal pathology is suspected, as recommended by the American College of Radiology 1
Electromyography with nerve conduction studies should be considered to differentiate peripheral nerve entrapment from cervical radiculopathy, according to the American Association of Neuromuscular and Electrodiagnostic Medicine 2, 5
Sensory testing, motor strength assessment, reflexes, and gait assessment are essential components of the neurological examination, as noted by the European Federation of Neurological Societies 2, 3, 4, 5

Immediate neurosurgical consultation is recommended for suspected cervical cord pathology, according to the American Association of Neurological Surgeons 2
MRI within 12 hours is recommended if clinical suspicion of cord compression exists, as reported in Cancer Treatment Reviews 1
Trial of conservative measures, including sleep positioning modifications, ergonomic workplace assessment, and avoidance of prolonged positioning of joints at end range, can be offered while awaiting imaging, as suggested by the European Urology Association 3, 6
Duloxetine is first-line pharmacologic treatment for neuropathic symptoms, including numbness and tingling, according to the American Academy of Neurology 2, 5