How to make a good peripheral neuropathy referral

Small fibre neuropathy

• Purely sensory: numbness, pain and tingling
• Slow or no progression
• Examination and nerve conduction studies can be normal
• Currently no evidence that any treatment can reverse or slow progression
• Can do a skin biopsy to confirm the diagnosis but doesn't change management, so don't offer this as standard
• Treat neuropathic pain and monitor HbA1c, B12 and immunglobulins annually
• Neurology input or follow-up not needed

Metabolic neuropathy

• Predominantly sensory and mostly spinothalamic (pain and temperature)
• Slowly progressive (years) or triggered by chemotherapy. Exception is nitrous oxide induced/functional B12 deficiency
• Nerve conduction studies show axonal sensory-motor neuropathy
• Need to test and monitor HbA1c, B12 levels and immunoglobulin profile. Treat B vitamin deficiency (B1, B6 and B12) and diabetes if present
• May need to see a neurologist if the problem is due to critical/functional B12 deficiency

Diabetic neuropathy

• Patients with suspected diabetic neuropathy do not need to be referred to the Neurology clinic
• Please ensure bloods for neuropathy screen have been done to include:
  • HbA1C
  • B12
  • Folate
  • TFTs
  • Vasculitis screen
  • Anti-neuronal antibodies
  • HIV
  • Hep B and C
  • Syphilis serology
  • FBC
  • UEs
  • LFTs
• If results are normal/negative, the preferrence is to not suggest anything further other than symptomatic management
• You could request nerve conduction studies directly from the Neurophysiology department via your local secondary care provider, but this would likely not change management

Inflammatory neuropathy

• Usually motor and sensory including large fibre/posterior column involvement (joint position sense). It can be just motor (multi-focal motor neuropathy) or just sensory (neuronopathy)
• Usually start with distal paraesthesia (tingling in hands and feet)
• Rapidly progressive:
  • A few days (Guillain Barre syndrome, GBS)
  • Up to three months (chronic inflammatory demyelinating polyradiculoneuropathy, CIDP)
• Need to contact the Neurology team urgently. GBS will likely need to go to ED
• Nerve conduction studies will be abnormal. May show 'demyelinating neuropathy'

Vasculitic neuropathy

• Usually 'patchy' and 'stepwise' onset with big nerves being picked off overnight
• Most commonly seen in the context of established systemic vasculitis (inflammation of the blood vessels)
• Can be a painful, rapidly progressive, 'length dependent neuropathy' (starting in the feet and working up to the knees and then affecting the hands)
• Often needs urgent treatment - contact the patients usual team (renal/rheumatology) or the Neurology team urgently

Inherited neuropathy

• Evident from childhood. Ask about early development:
  • Were you walking at about 12 months?
  • Were you good at sports?
• Pes cavus: a high lateral arch of the foot and 'hammer toes'
• May be a family history; not all inherited neuropathies are dominantly inherited
• Nerve conductions studies will be abnormal. The commonest type, Charcot Marie Tooth disease type 1 (CMT1) is demyelinating
• Should be referred to neurology – please include details of any relatives that are already diagnosed and any known genetic mutations

Motor neurone disease

• Purely motor, no sensory loss (beware patients who also have a diabetic neuropathy)
• Prominent wasting and fasciculations – look at the anatomical snuffbox and the tongue
• Note if there is not weakness or wasting and the patient can both see and feel the fasciculations themself it could be benign fasciculation syndrome – the patient would still need nerve conductions studies but should be reassured
• The nerve conduction studies (actually the electromyogram; EMG) should be abnormal. Rarely they need to be repeated after three to six months if the clinical suspiscion is high
• All patients should also have an MRI scan of their neck unless contraindicated
• Contact neurology urgently and we will fast-track the nerve conductions studies and OPD appointment if they confirm the diagnosis