Physical Exam

The examination of the upper extremities should begin with a quick basic exam of the neck. Limited range of motion, particularly in extension, should raise a red flag. Palpation of the midline, paraspinals, and trapezius and rhomboid region will often identify tight knots or fascial bands indicative of cervical spine pathology. Axial loading of the c-spine, particularly in slight extension, may produce pain or paresthesias into the neck, shoulders, or arms. Gross motor strength and sensibility should, of course, always be tested with root levels in mind. Perhaps the most commonly forsaken portion of the physical exam is deep tendon reflexes. Hyporeflexia is indicative of radiculopathy while hyperreflexia is concerning for a central, myelopathic condition.

Particularly in the patient in whom the provocative testing for carpal tunnel syndrome is negative or equivocal, the cervical spine should be scrutinized as the probable cause of symptoms.

Radiographic assessment of the cervical spine is not necessarily indicated early on, even in the presence of physical findings. It should, however, be considered when a patient fails to respond to basic conservative measures.

Treatment

Basic measures for treating carpal tunnel include nighttime splinting, avoidance of aggravating activities, and possible consideration of NSAIDs or injection. It has been my experience that these measures are widely and appropriately utilized. The mistake that is commonly made is to declare these treatments a failure, when in fact the failure has been a failure to treat the cervical component. Referral to physical therapy for cervical spine traction, stretching, and strengthening is critical for addressing the more proximal component of this "double crush" of the nerve.