AANEM Connect

67F Patient referred for right hand weakness and numbness/pain over the past year.  She reports it started in digit 5, now numb in digit 4 also. She is having progressive difficulty with gripping things, bending her fingers and thumb, but also weakness with extending her wrist and thumb. She has a histroy of stroke with right sided residual deficits a few years ago, but those were improving until the last year. Her exam is notable for 4/5 RUE  shoulder abduction, elbow flexion, elbow extension. 3/5 RUE wrist extension, finger extension, DIP flexion, thumb opposition, and 2nd/5th digit abduction. 5/5 throughout the LUE. Decreased sensation in right ring and pinky fingers. 3+ reflex throughout the RUE. Has a positive Tinel's at the elbow but also positive Spurling and Adson+Roos test (she really reported symptoms with any movement of that arm).

NCS notable for absent right ulnar SNAP with robust median, radial and contralateral ulnar signals. Very low amplitude right ulnar CMAP (0.2 mV) and slowing across the elbow (59 m/s to 48 m/s) without conduction block.  Also slowing of the right median SNAP at D2 (4.4 ms), with normal right median CMAP.

EMG with neuropathic changes in FDIH, OP, EIP (p waves, fibs, large polyphasic units with markedly reduced recruitment, with most spontaneous activity at FDIH). Normal biceps, triceps. 

The lesion seems to be post ganglionic, and with pattern of numbness and weakness, the most parsimonious location would be inferior trunk. No trauma, no cancer history. However, she also has slowing across the elbow, so considered seperate severe ulnar neuropathy and a cervical (C8?) radiculopathy. 

I sent for an MRI brachial plexus with contrast, which returned as essentially normal. Then got an MRI C-spine with findings of "Severe right foraminal zone stenosis C6-C7 due to uncinate osteoarthropathy and moderate degenerative disc disease.  Tiny right paramedian disc protrusion C5-C6. There is no central canal compromise at any level". Nothing notable at C7/T1.  I've referred her to both a hand surgeon to discuss her ulnar elbow, and a spine neurosurgeon for her neck. 

Any suggestions on interpretation of localization in this patient? Things that would have helped electrodiagnostically to point in the right direction for management? Looking back I probably should have done a MABC. 

Thanks!