cervical or lumbar radiculopathy in adults - NICE guidance - suspected neurological conditions - recognition and referral

Last edited 05/2019

Sensory symptoms including tingling or numbness in adults

Summary points from NICE guidance relating to numbness and weakness in adults are:

Numbness and weakness

• assess sudden-onset transient unilateral numbness in adults as per possible stroke/TIA
  
  
• refer immediately adults with rapidly progressive (within hours to days) symmetrical numbness and weakness or imbalance to have a neurological assessment

Sensory disturbances

Refer urgently adults with recurrent, brief (less than 2 minutes), fixed-pattern disturbances of sensation to have an assessment for epilepsy.

Refer adults with persistent, distally predominant altered sensation in the limbs, and brisk deep tendon reflexes, to have an assessment for possible brain or spine disease.

Suspect migraine with aura in adults who have sensory symptoms that occur with or without headache and:

• are fully reversible and
• develop over at least 5minutes and
• last between 5 and 60 minutes.

For adults with persistent, distally predominant ('stocking' or 'glove and stocking') altered sensation in the limbs and depressed deep tendon reflexes:

• be alert to the possibility of peripheral neuropathy and consider checking:
  
  
  • vitamin B12 deficiency
    
    
  • thyroid function
    
    
  • for evidence of coeliac disease
    
    
  • renal function blood glucose
    
    
  • ESR (erythrocyte sedimentation rate)
    
    
  • alcohol consumption, using a tool such as AUDIT (Alcohol Use Disorders Identification Test)

Numbness and tingling as part of a functional neurological disorder

• be aware that, for adults who have been diagnosed with a functional neurological disorder by a specialist, recurrent numbness and tingling might be part of the disorder and the person might not need re-referral if there are no new neurological signs. New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed
  
  
• advise adults with tingling and a diagnosis of functional neurological disorder that the tingling might fluctuate and evolve over time and could increase at times of stress

Carpal tunnel syndrome

• refer in line with local pathways if symptoms of carpal tunnel syndrome are severe or persistent after initial management.

Numbness, tingling or pain in the outer thigh

• reassure adults with unilateral or bilateral numbness, tingling or pain in the distribution of the lateral cutaneous nerve of the thigh (meralgia paraesthetica) that the condition is benign and might improve spontaneously. Consider referring for pain management only if the symptoms are severe

Cervical or lumbar radiculopathy

• do not routinely refer adults with symptoms of cervical radiculopathy that have remained stable for 6 weeks or more unless:
  
  
  • pain is not controlled with analgesics or
    
    
  • the symptoms are disabling or
    
    
  • one of the following factors is present:
    
    
    • age under 20
      
      
    • gait disturbance
      
      
    • clumsy or weak hands or legs
      
      
    • brisk deep tendon reflexes (triceps and lower limbs)
      
      
    • extensor plantar responses
      
      
    • new-onset disturbance of bladder or bowel function

Do not routinely refer adults with symptoms of lumbar radiculopathy that have remained stable for 6 weeks or more unless pain is not controlled with analgesics or symptoms are disabling.

Tingling or sensory disturbances on waking from sleep

Do not routinely refer adults with recurrent episodes of tingling or sensory disturbance in the limbs that are present on waking from sleep and last less than 10 minutes (1)

Reference:

• NICE (May 2019). Suspected neurological conditions: recognition and referral