Practice Patterns - when do you consult neurology

[heybrother]

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?
-How about tarsal tunnel and reported weakness?
-Do all tarsal tunnel cases get an MRI?
-Muscle imbalance? A patient presents with a foot deformity caused by complete loss of peroneal strength.
-Spasticity after stroke with difficulty being braced
-You suspect CRPS - do you consult neurology and if so, when
-A patient develops new numbness,, nerve pain, or the classic tingling in toes. Who gets a consult for this? A healthy 30 year? A diabetic? An older 60 year old guy?
-Do you ever order labs to investigate neuropathy?
-Do you dose gabapentin on your own or ask others to do it?
-Will you prescribe lyrica?
-If you prescribe gabapentin/lyrica do you try to pass the future prescribing back to their PCP?
-How comfortable do you feel prescribing gabapentin etc taking into account that your EHR is going to show you interactions with all their other psych, anti-depressants, etc
-How about an anti-depressant that has indications for neuropathy?
-What does your face look like when a patient tells you they have peripheral neuropathy? Does the mask hide your pain?
-Do you think there's any podiatry mumbo-jumbo that works? Topical nerve creams, compounded gabapentin products.
-How about capsaicin and lidocaine
-There are apparently prescription capsaicin products - have you ever used them?
-Expensive neuropathy vitamins like Metanx - have you ever prescribed them? Did the patient think they did anything?
-Will you operate on tarsal tunnel? Do you believe in opening all the compartments ie. chasing laterally
-A patient reports burning, tingling, numbness, odd sensations, feels like wood etc - is one of these more treatable than the others?
-Are you a nerve surgeon with a diploma on the wall?
-Who is your #1 referrals ie. vascular/cardiology, neurology, orthopedics, family medicine
-Do you think neurology appreciates your referrals ie. are you sending them real cases or just pain/neuropathy you want to get rid of?
-Who should have to manage peripheral neuropathy?

I think I've asked some of these before but I just wanted them again in the same thread.

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[deleted285117]

I got a referral just today from a neurologist... to treat peripheral neuropathy. I thought it was comical. Kinda sad too.

Overall I enjoy treating neuropathy, would rather do that than nails. I always start off with OTC Metanx dopplegangers for much cheaper on Amazon (Benfotiamine, Methylcobalamin, L-methylfolate) and/or ALA before I initiate Gabapentin. I avoid Lyrica. I dont mind overseeing gabapentin Rx for patients, I just monitor CMP. I also recommend copper supplements for gastric bypass pts.

I havent written for an antidepressant in a longggg time.

The only topical I recommend is CBD, but even then I tell pts its hit or miss (realistically its mostly a miss). I also tell them avoid the gas station CBD.

I consult neuro for suspected neurologic balance disorders... or for a patient that wants all the worthless workup for their unknown source neuropathy, that in the end wont change the treatment plan anyway and theyll get the “idiopathic” stamp. I feel EMG/NCV are a waste.

CRPS goes to PT + pain mngmnt.

LS Radiculopathy referral to Physiatry or pain mngmnt. I do however recommend them Hokas, Oofos and/or Grav Defyers.

Other then neuroma I dont do nerve surgery, too volatile. And even then, I do Kobygard DTIL release first before I do neurectomy.

 

[Pronation]

-What is an appropriate indication for ordering NC/EMG? - Positive tinel at CPN, DPN, SPN, or tarsal tunnel
-Is neurology referral necessary if clinical findings support tarsal tunnel? Sometimes if a bigger picture is needed
-Do you perform NC/EMG to "confirm" tarsal tunnel? Sometimes if concerned about more proximal pathology
-How about tarsal tunnel and reported weakness? EMG
-Do all tarsal tunnel cases get an MRI? Rarely
-Muscle imbalance? A patient presents with a foot deformity caused by complete loss of peroneal strength. Neuro consult
-Spasticity after stroke with difficulty being braced Neuro consult
-You suspect CRPS - do you consult neurology and if so, when I send to a pain management doc with CRPS experience for a sympathetic block etc
-A patient develops new numbness,, nerve pain, or the classic tingling in toes. Who gets a consult for this? A healthy 30 year? A diabetic? An older 60 year old guy? If unilateral, all get a neuro consult
-Do you ever order labs to investigate neuropathy? No
-Do you dose gabapentin on your own or ask others to do it? I'll start it and tell patient that PCP would need to medically manage long term
-Will you prescribe lyrica? Yes
-If you prescribe gabapentin/lyrica do you try to pass the future prescribing back to their PCP? Absolutely
-How comfortable do you feel prescribing gabapentin etc taking into account that your EHR is going to show you interactions with all their other psych, anti-depressants, etc Defer to PCP if bunch of interactions
-How about an anti-depressant that has indications for neuropathy? Defer to neuro/pain management/pcp
-What does your face look like when a patient tells you they have peripheral neuropathy? Does the mask hide your pain? My face shows great pleasure as I reach for the nail nippers
-Do you think there's any podiatry mumbo-jumbo that works? Topical nerve creams, compounded gabapentin products.No
-How about capsaicin and lidocaine No
-There are apparently prescription capsaicin products - have you ever used them? No
-Expensive neuropathy vitamins like Metanx - have you ever prescribed them? Did the patient think they did anything? Hocus pocus
-Will you operate on tarsal tunnel? Do you believe in opening all the compartments ie. chasing laterally Yes if strong tinel and/or EMG findings. Yes, I make a long incision starting 3cm proximal to the medial mal and extend down to the in step. Excise the septum at the porta pedis, also plantar fasciectomy.
-A patient reports burning, tingling, numbness, odd sensations, feels like wood etc - is one of these more treatable than the others? Burning/tingling seems to do better than profound numbness.
-Are you a nerve surgeon with a diploma on the wall? Cringeworthy
-Who is your #1 referrals ie. vascular/cardiology, neurology, orthopedics, family medicine Vascular by far
-Do you think neurology appreciates your referrals ie. are you sending them real cases or just pain/neuropathy you want to get rid of? I try not to send them silly diabetic neuropathy EMG consults
-Who should have to manage peripheral neuropathy? PCP or pain management

I get the feeling that you hate nerve stuff.

 

[heybrother]

I tease/joke a little too much and I probably came across as negative. I'm actually more tolerant of all this since these visits all became level 4s. 😎 I'm playing the hand I'm dealt. I wrote terbinafine twice in residency and gabapentin zero times. I have a lot more people seeking these prescriptions now than I did. I now regularly write both. Love it, hate it - might as well try to be good at my job. The washingtonpost does a series on medical mysteries and there's always a DPM who told someone with a progressive neurologic condition they just needed orthotics so I'm always curious what others think we should be doing. As far as tarsal tunnel, I sadly saw more people seeking a 2nd opinion after failed tarsal tunnel than I did new onset tarsal tunnel cases. Last of all went to a small, close minded podiatry residency so I want to hear what other people think/are doing, etc.

 

[DYK343]

For neuro cases (Charcot marie tooth as an example) I really never get anything viable from the consult. Half the time it returns idiopathic neuropathy when its clearly CMT. I still send them as its kinda a must. But always seems like a waste of time at least where I currently practice.

My experience neurologists dont believe in tarsal tunnel or they believe its extrodinarily rare. I dont think its that common but I see it once every 3-4 months. I dont treat tarsal tunnel beyond injections and or orthotics/shoe changes (Hokas are my go to as stated above). I send surgical tarsal tunnels to another DPM or MD who is crazy enough to do a tarsal tunnel release. Usually its the new guy 1st year out of residency who takes on those cases. Some larger academic centers have peripheral nerve surgeons. I dont even touch mortons neuromas surgically anymore. Not for me. Bad bad bad. How many times have you seen that mid 50s mildly obese female with incisions between every metatarsal both feet as well as a couple on the bottom? Seems like a weekly occurence in my office.

CRPS - neuro, pain mangement, physical therapy, honestly IMO there is not much a DPM can do for them exept diagnose and get them to where they need to be. But then again anything nerve I try to send out. Knock on wood I have not had a CRPS case from my own post op yet (saw some in residency) but I know it will happen someday.

I dont have great success with gabapentin, lyrica, or OTC vitamins. I have tried to Rx Metanyx multiple times but not covered and my patients dont usually buy it. Its probably not going to work but when patients are desparate I mention it as an option. I usually tell them to try a vit B complex.

Capsaican is mace. They rub their feet then rub their eyes 20min later and you will hear about it. Used it in a homeless clinic as a student. Thats the only time. It does help. But its just not worth it. Its inevitable that they will get it in their eyes or some mucosal surface at some point.

 

[ldsrmdude]

I’ll pretty much echo what others have said here, but it seems me and @Pronation have pretty similar practice styles. In residency I had a PM&R doc nearby who had a big interest in tarsal tunnel and EMG who we collaborated on some research so we sent a ton of referrals. In practice, I haven’t had much success with getting useful info or NCV results for tarsal tunnel. If I had someone I trusted doing them or interpreting them, I’d do it more. I do a few tarsal tunnel cases a year. I try to be pretty selective about who I do it on and have good results. Actually I ran into a respiratory tech at the hospital last weekend that I did one on probably 3-4 years ago. She still tells me how happy she is with the surgery even several years later. I do a long incision but don’t spend much time tracking down all the branches, mostly just release anything that could cause compression and close. I think it’s a good surgery to do on the right patient. I’ve seen docs do it on basically every patient with heel pain and that’s a recipe for disaster.
If I see a patient in the office I think may have tarsal tunnel (positive Tinels and history lines up with tarsal tunnel), I’ll usually inject if there’s no obvious mass that I can palpate or other obvious cause. If most of their pain goes away, I’ll usually leave it at that. If they do well initially but their pain comes back after a few weeks/months, then if it’s a patient I think would be a good candidate for surgery and I’m pretty sure of diagnosis, we may talk about it. If not, I’ll send for an EMG/NCV, consider physical therapy although I haven’t had a lot of success with that, or refer to neuro if I think there are more issues at play (peripheral neuropathy, radiculopathy, etc).
I’ve never done a revision tarsal tunnel release in practice. I’ve had a few patients come to me for second opinions or asking me to revise, and that’s just a mess I don’t want to get involved in. They usually get a pain management referral because I’m not sure I can offer them anything unless the surgery was obviously inadequate (super small incision, pain is at porta pedis and incision doesn’t extend that far, etc).

I’ll just add I’ve had some results with topical compounded medications but it’s inconsistent and nobody wants to pay for it so I rarely offer it. Most of the time I see a patient with peripheral neuropathy, they either already are on gabapentin or have tried it in the past. If not, I’ll start it and usually have them see their PCP if they want to keep taking it.

Also agree that a lot of neuro consults don’t yield much but if I’m doing it, it’s usually either because I don’t know what’s causing their pain but am suspicious it’s not directly related to the foot or I’m doing it to cover myself in cases of pes cavus, CMT, etc.

 

[air bud]

Love gabapentin, rx it all the time. I think probably 90 percent success rate honestly. If only at night 300mg nightly. If day time and worse at night I start 300 AM 300 afternoon 300-600 evening. Never do lyrica. Mild success with duloxetine when gaba hasn't worked. Have had success with adding it to gaba, I know there is a paper out there that talks about using together. Just today had a DM neuro dude come in and his PCP told him he had to live with the paresthesias in his feet...never done metanyx or whatever it is or any OTC meds. Never really check B12. Always ask about history of brain injury or siezure. Probably should be better about other psych meds. Always educated people on gaba and how it works. If numbness and not burning/tingling then its working. Also, I have had very good success with patients with intact protective sensation but all the classic signs of idiopathic neuropathy. Feel like feet swollen but they are not, feels like rubber band around forefoot. Dude comes in with chronic forefoot pain only, intact protective sensation and I can not elicit pain on physical exam - getting gabapenting and works every time.

Never have prescribed an antidpressant.

Somewhat happy with neuroma excisions. Never gotten an MRI or NCV. Don't do acohol sclerosing.

Done 4 or 5 tarsal tunnel mild success, won't do anymore. Might order an NCV for it just because will make visit easier to a referring doc. Make them go 5 or 6 hours away to nerve specialist person since nobody near me( well now nearest pod is 2.5 hours anyways..) that I would trust to do them.

Neuro consult under these scenarios:
-Less that 50 with idiopathic neuropathy. --- Just today, 38 y/o with mother dead of MS, he has had bilateral carpal tunnel with moderate sucess 2 years ago, feeling like walking on lumps and pebbles b/l feet, worse with standing which he does all day. Has tried every shoe out there, none work. Pain on palpation of all intermet spaces including DPN/1st. tinel over tarsal tunnel. Negative over fibular head and dorsal foot. On exam just really hard for patient to relax. Often will put people on gaba so at least gives neuro something else to work with on initial visit. Didn't with this dude since operates heavy machinery.

-CMT - mainly because I think right thing to do even though often family history and clear clinical signs.


-Neuropathic with known etiology but just terrible neuropathy, has failed all meds and really frustrated.

Holy crap the second I think CRPS (only seen 2x so far) they are going to Neuro, PT, pain management. Don't mess with that stuff take it seriously.

In regards to stuff like blue emu oil and other OTC supplements, whether CBD or whatever, I tell patients this: If you think it works, and you can afford it, and I don't think its going to hurt you ---- sure go ahead and take it. I believe in the placebo effect.

Edit - all neuroma patients get powersteps pinnacle PLUS - the one with met pad. And yes, I did say I put patients with intact peripheral sensation but "wierd" feelings in the bilateral feet with no physical pain reproducible on gabapentin with very good results. Please note I am not a medical doctor I just like this medication

 

[CutsWithFury]

If it sounds neuropathic I refer to physiatry for EMG. If EMG demonstrates some kind of neuropathy then I refer to neurology. If EMG negative then I resume regular MSK work up. If it appears to be tarsal tunnel or neuroma then I defer surgery at all costs. I will do steroid injection, shoegear modification and for some people will refer to physical therapy.

I only prescribe gabapentin post-operatively for my big elective and non elective surgeries for multi-modal pain control in addition to narcotic with +/- NSAIDs (depending on case)

I really try to block all neuropathy patients from getting scheduled as best I can but PCPs are really clever. They will just put "foot pain" in the consult now to trick me and my office staff. Well played medicine

 

[air bud]

Can anyone clue me in on why Hokas may help tarsal tunnel symptoms?

 

[DYK343]

Can anyone clue me in on why Hokas may help tarsal tunnel symptoms?

The same way orthotics help tarsal tunnel...... placebo

 

[619]

I only prescribe gabapentin post-operatively for my big elective

First time hearing using Gabapentin for routine post-op pain control protocol. Do you give them the rx immediately after surgery together with usual pain meds or you wait till first post-op visit to see how their pain level is before adding Gabapentin. Just curious

I order a Popliteal block for all my big cases. Patients love it and for the most part don't even use any pain meds.

 

[CutsWithFury]

First time hearing using Gabapentin for routine post-op pain control protocol. Do you give them the rx immediately after surgery together with usual pain meds or you wait till first post-op visit to see how their pain level is before adding Gabapentin. Just curious

I order a Popliteal block for all my big cases. Patients love it and for the most part don't even use any pain meds.

Post op pain protocol for osseous procedures is oxycodone 5 mg, gabapentin 400 mg, tylenol, +/- flexeril (depends on patient), NO NSAIDs.

Post op pain protocol for soft tissue procedures is oxycodone 5 mg, gabapentin 400 mg, tylenol, +/- flexeril (depends on patient), NSAIDs.

 

[air bud]

First time hearing using Gabapentin for routine post-op pain control protocol. Do you give them the rx immediately after surgery together with usual pain meds or you wait till first post-op visit to see how their pain level is before adding Gabapentin. Just curious

I order a Popliteal block for all my big cases. Patients love it and for the most part don't even use any pain meds.

Oh yeah. I give gaba any time doing peroneal tendons or anything lateal column where may have some sural nerve issues due to soft tissue edema. Also anytime doing any midfoot stuff like 2nd or 3rd TMT fusions. Same concept. soft tissue edema and temporary impingement of nerve.

Again, I am not a medical doctor, I just like this medication.

Other times I guess give send in rx and say fill it if have burning tingling post op. Would like to do more with toradol for 2 or 3 days after surgery but don't.

I get popblocks on midfoot and proximal. Even lapidus these days I do.

 

[Pronation]

First time hearing using Gabapentin for routine post-op pain control protocol. Do you give them the rx immediately after surgery together with usual pain meds or you wait till first post-op visit to see how their pain level is before adding Gabapentin. Just curious

I order a Popliteal block for all my big cases. Patients love it and for the most part don't even use any pain meds.

Reasons why I hate pop blocks and try to avoid them as much as possible. I pretty much only use them for ankle cases at this point.
1) Middle of the night calls with uncontrolled rebound pain
2) Iatrogenic nerve injury with persistent numbness/paresthesias
3) Delays my damn cases half the time

 

[DYK343]

I always get nervous Rxing gabapentin + opioids due to their interactions but the literature on post op pain control is good so I should do more of it.

I had a patient tank in residency after Rxing muscle relaxant. Had her on opioids and she was having intractable leg pain secondary to Baumann. I gave her a muscle relaxant and she coded so I'm always sketch about doing that anymore.

Almost all my patients get a pop block. They do delay cases. I havent had too much issues with rebound pain but it exists.

 

[dtrack22]

They do delay cases. I havent had too much issues with rebound pain but it exists.

I have anesthesia do a lot of regional. They usually get done while the room is being turned over at my facility and so they usually don’t add much time but they certainly can. I think I would do a lot less if I had 5-6 cases and it was adding 20 minutes to every turnover. I have all of my block patients take narcotics and Tylenol, scheduled, after surgery until the block wears off. I’ve never seen rebound pain when the block wears off, but all of my patients have pain meds on board when that happens.

I’ve had a femoral block wear off in the middle of the night and I hadn’t taken any pain meds. Not because I was told not to or because I thought I was tough. I just fell asleep without taking a pill, because I was completely numb. 2am rolled around and I woke up feeling like my knee was going to explode out through my skin. Not fun and hard to get back on top off from a pain control standpoint.

 

[air bud]

Love gabapentin, rx it all the time. I think probably 90 percent success rate honestly. If only at night 300mg nightly. If day time and worse at night I start 300 AM 300 afternoon 300-600 evening. Never do lyrica. Mild success with duloxetine when gaba hasn't worked. Have had success with adding it to gaba, I know there is a paper out there that talks about using together. Just today had a DM neuro dude come in and his PCP told him he had to live with the paresthesias in his feet...never done metanyx or whatever it is or any OTC meds. Never really check B12. Always ask about history of brain injury or siezure. Probably should be better about other psych meds. Always educated people on gaba and how it works. If numbness and not burning/tingling then its working. Also, I have had very good success with patients with intact protective sensation but all the classic signs of idiopathic neuropathy. Feel like feet swollen but they are not, feels like rubber band around forefoot. Dude comes in with chronic forefoot pain only, intact protective sensation and I can not elicit pain on physical exam - getting gabapenting and works every time.

Never have prescribed an antidpressant.

Somewhat happy with neuroma excisions. Never gotten an MRI or NCV. Don't do acohol sclerosing.

Done 4 or 5 tarsal tunnel mild success, won't do anymore. Might order an NCV for it just because will make visit easier to a referring doc. Make them go 5 or 6 hours away to nerve specialist person since nobody near me( well now nearest pod is 2.5 hours anyways..) that I would trust to do them.

Neuro consult under these scenarios:
-Less that 50 with idiopathic neuropathy. --- Just today, 38 y/o with mother dead of MS, he has had bilateral carpal tunnel with moderate sucess 2 years ago, feeling like walking on lumps and pebbles b/l feet, worse with standing which he does all day. Has tried every shoe out there, none work. Pain on palpation of all intermet spaces including DPN/1st. tinel over tarsal tunnel. Negative over fibular head and dorsal foot. On exam just really hard for patient to relax. Often will put people on gaba so at least gives neuro something else to work with on initial visit. Didn't with this dude since operates heavy machinery.

-CMT - mainly because I think right thing to do even though often family history and clear clinical signs.


-Neuropathic with known etiology but just terrible neuropathy, has failed all meds and really frustrated.

Holy crap the second I think CRPS (only seen 2x so far) they are going to Neuro, PT, pain management. Don't mess with that stuff take it seriously.

In regards to stuff like blue emu oil and other OTC supplements, whether CBD or whatever, I tell patients this: If you think it works, and you can afford it, and I don't think its going to hurt you ---- sure go ahead and take it. I believe in the placebo effect.

Edit - all neuroma patients get powersteps pinnacle PLUS - the one with met pad. And yes, I did say I put patients with intact peripheral sensation but "wierd" feelings in the bilateral feet with no physical pain reproducible on gabapentin with very good results. Please note I am not a medical doctor I just like this medication

Update. Dude came back three weeks later. Life-changing. He can sleep, no more pain etc. Not always that simple. But sometimes it is. And to think PCP said you just have to deal with it