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 2nd. 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.
