Merck Manual

Please confirm that you are a health care professional

honeypot link

Numbness

By

Michael C. Levin

, MD, College of Medicine, University of Saskatchewan

Last full review/revision Aug 2021| Content last modified Aug 2021
Click here for Patient Education
Topic Resources

"Numbness" can be used by patients to describe various symptoms, including loss of sensation, abnormal sensations, and weakness or paralysis. However, numbness is actually loss of sensation, either partial (hypesthesia) or complete (anesthesia).

Numbness may involve the three major sensory modalities to the same or different degrees:

  • Light touch

  • Pain and temperature sensation

  • Position and vibration sensation

Numbness is often accompanied by abnormal sensations of tingling (pins-and-needles) unrelated to a sensory stimulus (paresthesias). Other manifestations (eg, pain, extremity weakness, nonsensory cranial nerve dysfunction) may also be present depending on the cause.

Adverse effects of chronic numbness include

  • Difficulty walking and driving

  • Increased risk of falls

In addition, infections, diabetic foot ulcers, and injuries may not be recognized, leading to delayed treatment.

Pathophysiology of Numbness

Anatomy

Sensory processing areas within the brain connect with cranial nerves or spinal cord sensory pathways. Sensory fibers exiting the spinal cord join just outside the cord to form dorsal nerve roots (except for C1—see figure Spinal nerve Spinal nerve "Numbness" can be used by patients to describe various symptoms, including loss of sensation, abnormal sensations, and weakness or paralysis. However, numbness is actually loss of sensation... read more ). These 30 dorsal sensory roots join with corresponding motor ventral roots to form spinal nerves. Branches of the cervical and lumbosacral spinal nerves join more distally to form plexuses and then branch into nerve trunks. The intercostal nerves do not form plexuses; these nerves correspond to their segment of origin in the spinal cord. The term peripheral nerve refers to the part of the nerve distal to the nerve root and plexus.

Spinal nerve

Spinal nerve

Nerve roots from the most distal spinal cord segments descend within the spinal column below the end of the spinal cord, forming the cauda equina. The cauda equina supplies sensation to the legs, pubic, perineal, and sacral areas (saddle area).

The spinal cord is divided into functional segments (levels) that correspond approximately to the attachments of the pairs of spinal nerve roots. The area of skin supplied mostly by a particular spinal nerve is the dermatome corresponding to that spinal segment (see figure Sensory dermatomes Sensory dermatomes "Numbness" can be used by patients to describe various symptoms, including loss of sensation, abnormal sensations, and weakness or paralysis. However, numbness is actually loss of sensation... read more ).

Sensory dermatomes

Sensory dermatomes

Mechanisms

Numbness can occur from dysfunction anywhere along the pathway from the sensory receptors up to and including the cerebral cortex. Common mechanisms include the following:

Etiology of Numbness

Evaluation of Numbness

Because so many disorders can cause numbness, a sequential evaluation is done.

  • First, the distribution of numbness is used to localize the part of the nervous system that is involved.

  • Then, other clinical features—particularly rate of onset, associated neurologic symptoms and signs, and symmetry—further narrow the differential diagnosis and thus guide further questions and tests to diagnose specific causative disorders.

Although in practice certain elements of the history are typically asked selectively (eg, patients with a typical stroke syndrome are not usually asked at length about risk factors for polyneuropathy and vice versa), many of the potentially relevant components of the history are presented here for informational purposes.

History

History of present illness should include using an open-ended question to ask patients to describe numbness. Symptom onset, duration, and time course should be ascertained. Most important are

  • The location of numbness

  • Associated neurologic symptoms (eg, paresis, dysesthesias, sphincter dysfunction such as incontinence or retention, dysphasia, visual loss, diplopia, dysphagia, cognitive decline)

Possible precipitating causes (eg, compression of an extremity, trauma, recent intoxication, sleeping in an awkward position, symptoms of infection) are sought.

Review of systems should identify symptoms of causative disorders. Some examples are

  • Back and/or neck pain: Osteoarthritis- or rheumatoid arthritis–associated herniated disk or spinal cord compression

  • Fever and/or rash: Infectious neuropathy, infectious radiculopathy, brain infection, or rheumatic disorders

  • Headache: Brain tumor, stroke, or encephalopathy

  • Joint pain: Rheumatic disorders

  • Undernutrition: Vitamin B12 deficiency

  • Excessive intake of high-mercury seafood: Toxic polyneuropathy

Past medical history should identify known conditions that can cause numbness, particularly the following:

  • Diabetes or chronic kidney disease: Polyneuropathy

  • Infections such as HIV, syphilis, or Lyme disease: Infectious peripheral neuropathy or brain infection

  • Coronary artery disease, atrial fibrillation, atherosclerosis, or smoking: Stroke

  • Cancer (particularly lung cancer): Paraneoplastic anti-Hu subacute sensory or motor neuropathy

  • Osteoarthritis or RA: Radiculopathy

Family history should include information about any familial neurologic disorders. Drug and social history should include use of all drugs and substances and occupational exposures to toxins. For example, B6 (pyridoxine) supplements, when taken in excess, can cause a crippling loss of body sensations.

Physical examination

A complete neurologic examination Introduction to the Neurologic Examination The neurologic examination begins with careful observation of the patient entering the examination area and continues during history taking. The patient should be assisted as little as possible... read more is done, emphasizing the location and neurologic territories of deficits in reflex, motor, and sensory function. In general, reflex testing is the most objective examination, and sensory testing is the most subjective; often, the area of sensory loss cannot be precisely defined.

Red flags

The following findings are of particular concern:

  • Sudden onset (eg, within minutes or hours) of numbness

  • Sudden or rapid onset (eg, within hours or days) of weakness

  • Dyspnea

  • Signs of cauda equina or conus medullaris syndrome (eg, saddle anesthesia, incontinence, loss of anal wink reflex)

  • Bilateral neurologic deficits below a spinal segment

  • Loss of sensation on both the face and body (on the same side or opposite side)

Interpretation of findings

The anatomic pattern of symptoms suggests the location of the lesion but is often not specific. In general,

  • Numbness of part of one limb: Peripheral nervous system lesion

  • Unilateral numbness of both limbs (with or without the trunk): Brain lesion

  • Bilateral numbness below a specific dermatomal level: Transverse myelopathy (a spinal cord lesion)

  • Bilateral numbness not corresponding to a specific dermatomal level: Polyneuropathy, multiple mononeuropathy, or a patchy spinal cord or brain disorder

More specific localizing patterns include the following:

  • Stocking-glove distribution: When motor signs are minimal or absent, usually an axonal polyneuropathy; when accompanied by weakness and spasticity (eg, hyperreflexia, increased tone, extensor plantar response), sometimes cervical spondylosis or a demyelinating polyneuropathy or demyelinating lesion of the spinal cord

  • Single dermatomal distribution: Nerve root lesion (radiculopathy)

  • Single extremity with more than one nerve or nerve root affected: Plexus lesion (plexopathy)

  • Multiple related or unrelated peripheral nerves: Multiple mononeuropathy

  • Loss of sensation affecting position and vibration disproportionately: Dysfunction of the dorsal columns or a demyelinating peripheral neuropathy

  • Saddle area distribution: Conus medullaris syndrome or compression of the cauda equina (cauda equina syndrome)

  • Crossed face-body distribution (ie, face and body affected on different sides): Lower brain stem lesion

  • Ipsilateral face and body distribution: Upper brain stem, thalamic, or cortical lesion

  • Bilateral numbness in a cape-like distribution over the neck and shoulders: Central cervical spinal cord abnormality, typically a syrinx

Findings that indicate involvement of multiple anatomic areas (eg, both brain and spinal cord lesions) suggest more than one lesion (eg, multiple sclerosis, metastatic tumors, multifocal degenerative brain or spinal cord disorders) or more than one causative disorder.

The rate of symptom onset helps suggest likely pathophysiology:

  • Nearly instantaneous (usually seconds, occasionally minutes): Ischemic or traumatic

  • Hours to days: Infectious or toxic-metabolic

  • Days to weeks: Infectious, toxic-metabolic, or immune-mediated

  • Weeks to months: Neoplastic, or degenerative, or occasionally infectious due to chronic central nervous system (CNS) infection (eg, fungal infection)

Degree of symmetry also provides clues.

  • Highly symmetric involvement: A systemic cause (eg, a metabolic, toxic, drug-related, infectious, or postinfectious cause; vitamin deficiency)

  • Clearly asymmetric involvement: A structural cause (eg, tumor, trauma, stroke, peripheral plexus or nerve compression, a focal or multifocal degenerative disorder)

After location of the lesion, rate of onset, and degree of symmetry have been determined, the list of potential specific diagnoses is much smaller, so that focusing on clinical features that differentiate among them is practical (see table Some Causes of Numbness Some Causes of Numbness "Numbness" can be used by patients to describe various symptoms, including loss of sensation, abnormal sensations, and weakness or paralysis. However, numbness is actually loss of sensation... read more ). For example, if initial evaluation suggests an axonal polyneuropathy, subsequent evaluation focuses on features of each of the many possible drugs, toxins, and disorders that can cause these polyneuropathies.

Testing

Testing is required unless the diagnosis is clinically obvious and conservative treatment is elected (eg, in some cases of carpal tunnel syndrome, for a herniated disk or traumatic neuropraxia). Test selection is based on anatomic location of the suspected cause:

  • Peripheral nerves or nerve roots: Nerve conduction studies and electromyography (electrodiagnostic testing)

  • Brain or spinal cord: MRI

Electrodiagnostic tests can help differentiate between neuropathies and plexopathies (lesions distal to the nerve root) and more proximal lesions (eg, radiculopathies) and between types of polyneuropathies (eg, axonal and demyelinating, hereditary and acquired).

If clinical findings suggest a structural lesion of the brain or spinal cord or a radiculopathy, MRI is usually indicated. CT is usually a second choice but may be particularly helpful if MRI is not available soon enough (eg, in emergencies).

After the lesion is localized, subsequent testing can focus on specific disorders (eg, metabolic, infectious, toxic, autoimmune, or other systemic disorders). For example, if findings indicate a polyneuropathy, subsequent tests typically include complete blood count (CBC), electrolytes, renal function tests, rapid plasma reagin test, and measurement of fasting plasma glucose, hemoglobin A1C, vitamin B12, folate, thyroid-stimulating hormone, and usually serum immunoelectrophoresis and serum protein electrophoresis (particularly if the neuropathy is painful). Serum immunoelectrophoresis and serum protein electrophoresis can help diagnose multiple myeloma and multiple sclerosis.

Treatment of Numbness

Treatment is directed at the disorder causing numbness.

Patients with insensitive feet, particularly if circulation is impaired, should take precautions to prevent and recognize injury. Socks and well-fitting shoes are needed when walking, and shoes must be inspected for hidden foreign material before wear. The feet should be inspected frequently for ulcers and signs of infection. Patients with insensitive hands or fingers must be alert when handling potentially hot or sharp objects.

Driving skill should be monitored.

Key Points

  • Use an open-ended question to ask patients to describe their numbness.

  • The anatomic pattern and time course of symptoms helps narrow the list of possible diagnoses.

  • If part of a limb is numb, suspect a peripheral nerve, plexus, or nerve root lesion.

  • If both limbs are numb on one side, with or without numbness of the trunk on the same side, suspect a brain lesion.

  • If patients have bilateral numbness below a specific spinal cord segment, particularly with motor and reflex deficits, suspect a transverse myelopathy.

  • If patients have bilateral numbness not corresponding to a spinal cord segment, suspect a polyneuropathy, multiple mononeuropathy, or a patchy spinal cord or brain lesion.

  • If numbness occurs in a stocking-glove distribution, suspect an axonal polyneuropathy.

  • If numbness occurs nearly instantaneously in the absence of trauma, suspect an acute ischemic event.

  • Consider doing electrodiagnostic studies for suspected peripheral nervous system causes and MRI for CNS causes.

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read

Test your knowledge

Seizure Disorders
A patient experiences a seizure in which tingling and numbness occur in her left leg. Dysfunction in which of the following lobes of the brain is most likely responsible for this finding?
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

Also of Interest

Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
TOP