Idiopathic neuropathy

[podfam3008]

Can any of you tell me how you work up idiopathic neuropathy? What labs do you order? What is your treatment?

***List your algorithm***

I usually rule out superficial neuritis secondary to arthritis/spurring (via tinels), rule out lumbar issues, rule out DM, rule out neuroma (mulders click), rule out radiculopathy in their history. Check sharp dull, swmf, vibratory sensation. If I can't find a cause, I refer to Neurology for NCV/EMG, and allow them to start patients on nerve pain medication if needed. A lot of times they send them right back. Same with PCP's. I don't manage Gabapentin or Lyrica often. Occasionally, I will refer to pain clinic.

I was curious what everyone else was doing. Is there any good literature with a good algorithm? I see it more and more everyday, and it's frustrating because I feel like I can't help these people completely. Would appreciate everyone's thoughts and reasoning behind them/literature, etc.

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[msuDPM]

Can any of you tell me how you work up idiopathic neuropathy? What labs do you order? What is your treatment?

***List your algorithm***

I usually rule out superficial neuritis secondary to arthritis/spurring (via tinels), rule out lumbar issues, rule out DM, rule out neuroma (mulders click), rule out radiculopathy in their history. Check sharp dull, swmf, vibratory sensation. If I can't find a cause, I refer to Neurology for NCV/EMG, and allow them to start patients on nerve pain medication if needed. A lot of times they send them right back. Same with PCP's. I don't manage Gabapentin or Lyrica often. Occasionally, I will refer to pain clinic.

I was curious what everyone else was doing. Is there any good literature with a good algorithm? I see it more and more everyday, and it's frustrating because I feel like I can't help these people completely. Would appreciate everyone's thoughts and reasoning behind them/literature, etc.

Rule out foot and ankle MSK reasons for their pain and then send them back to their PCP for them to do their job.

Fin.

 

[deleted285117]

Depending on how much patient wants to investigate (since tx doesnt change much regardless): I check TSH, Folic acid/B12, Thiamine, ESR, CRP as first line. Further testing PRN for any other symptoms (ex add HLA-B27 if s/s autoimmune arthritis, lumbar XR if older and hx back pain, etc...). Check for Tinels like you mentioned.

I hold off on EMG/NCV usually, but will order that or other testing if symptoms worsen or spread to upper extrem.

I start fat-soluble B vits +/- ALA or Copper (Copper esp if hx gastric bypass). Add Gabapentin for painful neuropathy if above dont help.

 

[air bud]

I check ZERO labs and put on gabapentin. Gabapentin just works. Why send to Neuro? They are just going to end up doing the same thing but running up the bill ordering all sorts of ****. Gabapentin 300mg TID. Level 4 visit there you go. Come back 3 weeks later, titrate and another level 4 for medication management. Patients love it. If someone is a train wreck then I will send to PCP for management. I literally just saw a guy. On a statin is all. Just had labs not diabetic. Complains if burning tingling b/l feet worse at night. Some back pain no shooting pains. Ask - hx of chemo/rada, long-term exposure to chemicals (farming, military, oilfields), other familial neurological disease? No good here's gabapentin.

Use search function we had a pretty good thread on this maybe 5 or 6 months ago

Edit: to expand - Idiopathic - I take it literally ....I don't know why you have burning and tingling in your feet. But I know how likely make it better. If you are 40 - I am sending you to Neuro for a work up of some neurological disease. If you are 60 plus - not sending to nuero - if something bad was going on it would have already presented itself. Also, my guy today had intact protective sensation - I don't care. He said burning/tingling in his feet, worse at night wakes him up. Good pulses, no claudication symptoms, no smoker. Boom getting gaba.

Also Nuero consult is a 2.5 hour drive...

 

[podfam3008]

I check ZERO labs and put on gabapentin. Gabapentin just works. Why send to Neuro? They are just going to end up doing the same thing but running up the bill ordering all sorts of ****. Gabapentin 300mg TID. Level 4 visit there you go. Come back 3 weeks later, titrate and another level 4 for medication management. Patients love it. If someone is a train wreck then I will send to PCP for management. I literally just saw a guy. On a statin is all. Just had labs not diabetic. Complains if burning tingling b/l feet worse at night. Some back pain no shooting pains. Ask - hx of chemo/rada, long-term exposure to chemicals (farming, military, oilfields), other familial neurological disease? No good here's gabapentin.

Use search function we had a pretty good thread on this maybe 5 or 6 months ago

Thanks everyone!! Yes I did try searching, couldn't find the thread. If someone can find it, please link it here. Thanks!

 

[air bud]

Practice Patterns - when do you consult neurology

When do you consult neurology? What do you consult neurology for? I'll throw some possible examples/scenarios -What is an appropriate indication for ordering NC/EMG? -Is neurology referral necessary if clinical findings support tarsal tunnel? -Do you perform NC/EMG to "confirm" tarsal tunnel...

forums.studentdoctor.net

 

[Feli]

Idiopathic means the physician is an idiot, right?
I get that word and itatrogenic and idiosyncratic and stuff all confused. Etiology and embryology and ecology and such also stump me. Dunno.

But yes, figure out the most common cause or make a best WAG from their history and just start therapy (topical, PO, PT, nutritional, etc) to get them feeling better... exact cause of the neuropathy isn't all too important unless it's fixable... and it rarely is (herniated disc, bona fide vitamin deficiency, etc).
"How many neurologists does it take to fix a light bulb?
The light bulb cannot be fixed, but if you get a veeery good neurologist, they might tell you exactly where the filament is broken." 😝

If you are in MSG or just want to turf, send the patients who don't respond to your basic tx to neuro/pain/PMR/endo as appropriate (or neurosurg if it's likely back pain etiology and they are a surg candidate). If the pt really demands answers, do ENFD or send them for EMG/NCV or injections or whatever. Those really don't change the treatment, though. Like others, I mostly use gabapent, duloxetine, PT sessions, lidocaine crm, multivit if they are not already, etc. Rarely do I do pregabalin, amitript, capsaicin, fancy testing, expensive supplements, etc.

 

[CutsWithFury]

Ask basic questions. History of lower back pain/ confirmed lower back pathology?, history of radiation/chemotherapy? Alcohol Abuse?, Diabetes? etc

I don't bother ordering labs

Only thing I do is order EMG/ECV to which will pick up gross abnormalities.

If EMG/NCV negative then refer back to medicine or if patient is adamant refer to neurology and they can do a more focused work up (labs or other neuro testing such as small fiber neuropathy biopsy).

But honestly I refer the referral note from PCP first and try and divert the patient as quickly as possible. I really choose to not treat neuropathy. PCPs think because the patient claims they have neuropathy that they need their feet checked. When in reality it is the symptoms of neuropathic pain which is bothering them. I see this countless times which means PCPs really have no desire to do any work up for direct management of it.

 

[dtrack22]

Only thing I do is order EMG/ECV to which will pick up gross abnormalities.

I hardly ever order EMG/NCVS any more. They come back mentioning tarsal tunnel and then everyone tells the patient they have tarsal tunnel. Tarsal tunnel surgeries never work. I hate tarsal tunnel. Maybe one of those fellowship trained micro-nerve Podiatric surgeons can move to my area and cut on these people? Triple nerve releases anyone?

 

[DYK343]

I hardly ever order EMG/NCVS any more. They come back mentioning tarsal tunnel and then everyone tells the patient they have tarsal tunnel. Tarsal tunnel surgeries never work. I hate tarsal tunnel. Maybe one of those fellowship trained micro-nerve Podiatric surgeons can move to my area and cut on these people? Triple nerve releases anyone?

I'm with you. I gave up all nerve surgery. I flat out tell patients I will only make them worse they need to go to someone with better results than me. They like that I admit that.

...What I dont admit is that the other surgeon is still going to have the same crappy results

 

[dtrack22]

Patient today told me his neuropathy symptoms have improved since he recently started taking viagra. Makes sense, it’s a vasodilator. I’m gonna start offering it to all of my neuropathy referrals.

 

[deleted1097413]

Patient today told me his neuropathy symptoms have improved since he recently started taking viagra. Makes sense, it’s a vasodilator. I’m gonna start offering it to all of my neuropathy referrals.

Fix the neuropathy and save a ton of marriages.. win-win.

 

[heybrother]

Fix the neuropathy and save a ton of marriages.. win-win.

I was going to post a link to the old SNL skit where young women being groped by an older man say "Thanks Viagra" but the link doesn't work.

 

[nikkisorous]

I hardly ever order EMG/NCVS any more. They come back mentioning tarsal tunnel and then everyone tells the patient they have tarsal tunnel. Tarsal tunnel surgeries never work. I hate tarsal tunnel. Maybe one of those fellowship trained micro-nerve Podiatric surgeons can move to my area and cut on these people? Triple nerve releases anyone?

This, lol.

My preference for symptomatic management is amitriptyline (if they're a good candidate), otherwise gabapentin.

 

[Redsting]

I've started doing cymbalta on some that don't respond well to Gaba due to poor results or bad side effects. It does great. Amitriptyline is the same idea.
I do less and less EMG, I offer it so patients know its out there. But other than tell me its coming from the back, what am I going to do with it? Also a couple people told me it was $1300. I had someone who was with the VA hunting for increase in their % disability and I sent them to a neuro who's read comes back 100/100 times "polyneuropathy".