REMEMBERING PROF. V.S. DAVE BY HIS LECTURE ON PARESTHESIA IN THE EXTREMITIES

 

The Neurosurgery Department in King George’s Medical College was always amongst the best teaching units of our Ammeter. It was started by Prof. P.N. Tandon way back in 1961, when just a handful of Neurosurgery teaching units existed in India. Prof. P.N. Tandon later moved to All India Institute of Medical Sciences. As Neurosurgery was a part of the Department of Surgery, its Head of the Department Prof. S.C. Mishra then handpicked Prof. V.S. Dave from Mumbai to run the new Department in K.G.M.C. in 1967. Prof. Dave was the gentlest of souls I ever came across. He was so soft spoken that in my residency days, even in his rounds we, the resident team, could hardly hear him. Only when he had to discuss a finding on the Carotid Angiograms, which we residents used to perform on all head injury patients, could he be heard teaching his residents. He was invariably dressed in white and always wore a starched white apron and was extremely kind to patients and their relatives. Though Neurosurgery those days had very serious patients and was very busy, he and his 2^nd. In Command, Dr. D.K. Chabbra worked tirelessly without looking at watch. His dedication and his diligence were infectious and easily trickled down his team.

Prof. Dave and his team performed all kinds of Cranial and Spinal Surgery. Pitutary surgery, ICP Monitoring, Minimally Invasive Cranial and Spinal Neurosurgery, Brain Tumor Surgery, Spinal Tumor Surgery, Brain and Spinal Trauma Management, Surgery of CV Junction Anomalies, Neuro Vascular Surgery, Micro Neurosurgery, Pediatric Neurosurgery (Meningocele, Encephalocele, Hydrocephalus etc.) were all performed in the Neurosurgery Department. Skull base surgery was his speciality and he excelled in it. You have to appreciate that those were pre CT Scan and pre MRI days and a good clinical examination and a carotid angiogram were the only two means of arriving at a diagnosis.

Prof. Dave used to stay in Rana Pratap Marg near the Botanical Garden and could reach the sick patient’s bedside within 10 minutes of a telephone call. He was always available for everybody. Even when there was an anaesthetic accident in the Ophthalmology OR, a request from his Ophthalmology colleague was enough to find him by his side within minutes. Availability was his hallmark and he was accessible to the junior most member of the resident team. He had a special bond with Dr. D.K. Chabbra and the latter could interpret his gestures and facial expressions and do exactly as the Professor wished. I have introduced you to Prof. D.K. Chabbra in one of my previous blogs: https://surajitbrainwaves.blogspot.com/2020/06/remembering-prof-d-k-chabra-today.html

Prof. Dave’s son Ajay is an ophthalmologist of repute.

 

I have been able to salvage a lecture on Peripheral Neuropathy or Paresthesia in the extremities, which was delivered to our class by Prof. V.S. Dave. 

Paresthesia is the tingling sensation or numbness, or sensation similar to pins and needles, experienced in the extremities – arms and hands or thighs, legs and feet. Often, as pins and needles, it is simply a benign consequence of undue pressure being placed on the body parts in question, such as leaning on one arm or crossing your legs for a long time. It is resolved as quickly as it appears when you remove the offending pressure, causing only mild discomfort, but no pain.  

The very same sensation can occur without any obvious pressure being applied. This paresthesia may be severe, episodic or even chronic (never ending). If this happens and is coupled with other symptoms, like

·        Pain

·        Itchiness

·        Numbness

·        Muscle wasting

then the tingling might be an indication of nerve damage. Such damage is called peripheral neuropathy, affecting nerves that are far away from the brain and spinal cord, usually in the hands and feet.  There are three categories of causation.  

1. Diabetes

Many people who are diabetic, the elderly in particular, suffer from peripheral neuropathy. There are in excess of 100 different types of peripheral neuropathy. In time, the condition worsens when left untreated, resulting in reduced mobility and possibly even disability. The major cause of peripheral neuropathy, in around 30% of cases, is diabetes. Peripheral neuropathy is therefore considered to be the first sign of diabetes. 

Since peripheral neuropathy, the underlying cause of paresthesia, in 30% of cases is a sign of diabetes, it is very important that if your patient has a history of prolonged paresthesia monitor his/her blood sugar levels.   Some common Peripheral Neuropathies in Diabetes are;

·        Peripheral symmetric neuropathy: This affects the feet and hands and is the most common form of neuropathy.

·        Autonomic neuropathy: This affects the nerves that control involuntary functions of the body, such as digestion, urination, or heart rate.

·        Proximal neuropathy: This affects the muscles of the hips, thighs, or buttocks and is also known as diabetic amyotrophy.

·        Focal neuropathy: This affects a single nerve, usually in the head, torso, or leg.

 

2. Idiopathic Cause 

In another 30% of cases of peripheral neuropathy, where the cause is not diabetes, no cause can be found, and they are thus labeled ‘idiopathic’. This may be the case more commonly in over the age of 60, and it progresses slowly. Patients often resort to over-the-counter pain medication for mild pain, but for severe pain, judicious use of NSAIDs and anti-depressants are prescribed. Therapeutic footwears can also be acquired which reduce symptoms.   

3. Unrelated causes

The remaining 40% of cases besides diabetic and idiopathic causes of peripheral neuropathy contain a wide variety of unrelated causes. However, the disease is very well-researched, and most of the time it is possible to diagnose the root cause of  paresthesia efficiently.   Besides paresthesia​, other nerve related condition are:

1.      Neuralgia: This is a potent stabbing or burning pain that occurs right along the nerve that has become damaged. It has many possible causes, such as shingles, diabetes, or multiple sclerosis.

2.      Radiculopathy: this is a disease of the spinal nerve roots. It can produce pain, numbness, and weakness at the spine area. 

3.      Carpal Tunnel: a syndrome of the hand’s median nerve, which has become compressed. It is located on your palm.  I have discussed Carpal Tunnel Syndrome in one of my previous blogs: https://surajitbrainwaves.blogspot.com/2022/04/carpel-tunnel-syndrome.html

4.      Mini Stroke (transient ischemic attack): unlike a stroke, which kills brain cells, this ITA, mini-stroke, does not. It does, however, cause similar symptoms to a stroke, and is the result of blood flow to the brain stopping for a period of time. This is considered a medical emergency that may well require urgent attention. I have a blog on Stroke and Mini Stroke: https://surajitbrainwaves.blogspot.com/2022/01/stroke-killer-mini-stroke-warning.html

5.      Spinal Cord Injury: This is a very serious type of injury, which may drastically alter your patient’s life condition and quality. It too will require urgent medical attention.  

6.      Other common causes include, but are not limited, to:

·        Cervical Spondylitis

·        Stroke (urgent)

·        Ulnar Nerve Palsy 

·        Panic Disorder

·        Intracerebral Hemorrhage (urgent) 

·        Guillain-Barre Syndrome (urgent) 

·        Stenosis of spinal canal

·        Spinal Bone Fracture

·        Alcohol Abuse / Alcoholism

·        Frostbite (urgent)

·        Vitamin Deficiency

 

 

Diagnoses

History: In order to be absolutely thorough, you will require a complete medical history of how the paresthesia or neuralgia started. Since medication is often considered a cause of tingling, history of any such medications, or vaccinations would be important. A detailed history of any infections or injuries the patient might have sustained may be vital.  A habit of asking a set of questions may be of help to avoid missing the diagnosis:

·        Numbness or tingling with no obvious cause

·        A pain in the neck, forearm or fingers

·        Unusually frequent urination

·        Numbness in legs which worsens on walking

·        History of a rash

·        History of dizziness, a muscle spasm, or something else unusual.

·        Weakness in limbs interfering with normal mobility

·        History of recent head, neck or back injury

·        Inability to control arms or leg movement

·        Lost bladder or bowel control

·        Feel confused and have lost consciousness for a

·        Speech is slurring

·        Vision is affected

Physical examination: A detailed examination of the patient, not restricting oneself to the effected limb, is vital. Which spinal levels are involved or which peripheral nerve is compressed and where is important to document. Any scar in the anatomical line of a nerve or any local tenderness should ne documented.

Investigations: Blood tests CBC, electrolyte levels, thyroid functions, toxicology screening and nerve conduction studies are required to establish the diagnosis. Perhaps a lumbar puncture and CSF examination may be needed. X-rays and angiograms, may clinch the diagnosis.   

 

Treatment

Treatments will be related to the diagnosis made of the cause of your paresthesia. If the peripheral nerve cells have not died they will regenerate and the patient will return to normal. For diabetes, good blood sugar control can slow down and reduce the progression of diabetic neuropathy. Those who, for example, have a vitamin deficiency can have their diet supplemented with more balance, which will also correct their peripheral neuropathy.    Maintaining an optimal weight by adhering to a regimen of diet and exercises and drastically cutting down alcohol and tobacco consumption will help. .If the cause of tingling is surgical like cervical spondylitis, carpel tunnel syndrome or other compression neuropathies then prompt surgery is indicated before muscle wasting sets in.

 

Thus ended Prof. Dave’s lecture on Paresthesia in the extremities. He would gently smile and quietly walk out of the lecture theatre with his Senior Residents and continue with his morning patient rounds. No fuss, no fanfare, always gentle and always held in very high esteem, Prof. Dave was a true Georgian role model. He was the senior most professor of Surgery in our Department but he refused to become the Head of the Department as he felt that would interfere with his true passion of teaching and training Neurosurgery residents and treating Neurosurgery patients. With no CT Scans, no MRIs, no neuroendoscope and with very primitive operating microscope, the Professor could do wonders by his sheer dedication to Neurosurgery and devotion to his professional duties.