When should I consider referring a patient with peripheral neuropathy to a specialist?

Consider referring a patient with peripheral neuropathy to a specialist if:

• There is no identifiable cause after initial investigations including vitamin B12 deficiency, thyroid function, coeliac disease, renal function, blood glucose, ESR, and alcohol use assessment.
• The patient has rapidly progressive (within hours to days) symmetrical numbness and weakness or imbalance, requiring urgent neurological assessment.
• There are persistent, distally predominant altered sensations in the limbs with brisk deep tendon reflexes, suggesting possible brain or spine disease.
• Symptoms are severe, significantly limit daily activities, or if treatment options available in primary care have been exhausted and symptoms remain significant.
• There is poor control of neuropathic pain despite maximum tolerated doses of medication, or if treatment is poorly tolerated and alternative management is needed.
• In children, if tingling is accompanied by other peripheral nervous system symptoms such as weakness, bladder or bowel dysfunction, or if episodic symptoms are not associated with nerve compression.

Referral is typically to a neurologist or specialist pain service depending on the clinical context and severity of symptoms.

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