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Peripheral Neuropathy- Under Review

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Checked: 19-08-2025 by Rob Adams Next Review: 19-08-2027

Overview

Clinical Knowledge Summaries has the following pages:

Sensory neuropathy | CKS | NICE (1)- includes information on causes, assessment and initial investigations for peripheral neuropathy
Neuropathic pain - drug treatment | CKS | NICE

The patient.info website has a professional article on:

Diabetic Neuropathy

The Macmillan cancer support website also has information:

Peripheral Neuropathy caused by cancer or its treatment

Who to Refer

If the cause of peripheral neuropathy can be identified, then patients can often be managed in primary care.

Consider advice and guidance or referral for patients with red flags or where there is diagnostic uncertainty or patients are not responding to treatment.

Red Flags

The following factors may indicate need for more rapid assessment or advice (1):

Younger onset can be associated with hereditary neuropathies, as well as nutritional deficiency or toxic exposures (such as heavy metals)
Rapid progression is atypical (such as progression of sensory symptoms from toes to knees, and/or gait difficulties within 6 months of symptom onset).
Paraneoplastic causes tend to be of acute onset.
Acute/subacute progression may be associated with toxic exposures or infectious causes.

Before Referral

A good history and examination can lead to clues regarding possible causes of peripheral neuropathy.

In particular ask about alcohol and review drug history.

Investigations

Investigations in primary care should include the following bloods (1):

HbA1C or fasting glucose.
Vitamin B12
Serum protein electrophoresis - paraproteinaemias are responsible for approximately 10% of peripheral neuropathies.

Additional investigations may be considered depending on history and examination including:

U and E
LFT
TFT
Coeliac serology
Early inflammatory arthritis screening
Infectious diseases screening - HIV, EBV, Herpes simplex, Varicella zoster, Hepatitis C, Lyme disease

Nerve Conduction Studies

Nerve conduction studies may be indicated in the following circumstances - see the Neurophysiology page for further details:

Polyneuropathy of unknown cause - allowing classification into axonal or demyelinating types.
Mononeuropathy that cannot be localised clinically (e.g. CTS and cervical spondylosis +/- radiculopathy).

Referral

Referral should be considered to the relevant specialty if there is diagnostic uncertainty or symptoms are not controlled by management in primary care.

Referral options include:

Neurology - advice and guidance or referral via eRS
Diabetes clinic - via eRS for patient with diabetic neuropathy.
Pain Clinic - via eRS - see Pain Clinic guidelines.
Oncology - for neuropathy associated with cancer or cancer treatment.

Resources

References

(1) Sensory neuropathy | CKS | NICE

Patient information:

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