The Evaluation of Distal Symmetric Polyneuropathy

Callaghan, Brian C.; Kerber, Kevin A.; Smith, Andrea L.; Fendrick, A. Mark; Feldman, Eva L.

doi:10.1001/archneurol.2011.1735

Cited by 21 publications

(28 citation statements)

References 23 publications

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“…Overall, neurologists indicate they would order many tests, including thyroid (92%) and rheumatologic studies (ranging from 21% to 75% over a variety of tests). 4 Unfortunately, the cost of evaluations can be prohibitive, and physicians often order high-cost, low-yield tests rather than low-cost, high-yield studies. 5 Despite the recent AAN recommendations and the publication of several clinical approaches to the evaluation of neuropathy, clinicians continue to order a wide variety of laboratory tests.…”

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confidence: 99%

Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

et al. 2013

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SummaryPeripheral neuropathy is a common disorder, often prompting an extensive initial laboratory evaluation. The initial evaluation is particularly challenging to primary care physicians and neurologists because of the broad differential diagnosis. Although screening thyroid and rheumatologic tests are frequently ordered, the diagnostic yield of these tests is unclear. Data from our institution were collected on patient demographics, clinical characteristics including warning signs suggestive of a diagnosis other than distal symmetric polyneuropathy, history of thyroid or rheumatologic disease, and laboratory tests ordered. Thyroid and rheumatologic screening tests are commonly ordered in the evaluation of peripheral neuropathy. Our findings suggest a low aggregate value of these tests based on low yield and infrequent changes in the suspected etiology or management of these patients. P eripheral neuropathy encompasses a heterogeneous group of disorders, including distal symmetric polyneuropathy, multiple mononeuropathies, and demyelinating neuropathies, among many others. Peripheral neuropathy is a prevalent condition affecting approximately 2% of the general population and as many as 8% of those over the age of 55.1,2 Distal symmetric polyneuropathy (DSP) is the most frequently encountered form of peripheral neuropathy, typically presenting symmetrically in the feet with pain, *These authors contributed equally to this work.

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confidence: 99%

Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

et al. 2013

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“…Specifically, in our prior survey, neurologists indicated they would order fewer MRIs of the neuroaxis than internists (12.9% vs 19.8%) given the same distal symmetric polyneuropathy vignette, whereas in this study we found the opposite. 5 Possible explanations include that peripheral neuropathy patients with a neurologist are more likely to have a separate indication for an MRI, the real-world practice of neurologists does not match their ideal intentions, the evaluation of neuropathy is different in Medicare vs non-Medicare populations, or neurology survey respondents were more likely to be lower MRI test utilizers. On the other hand, both studies demonstrated higher overall test utilization, including electrodiagnostic utilization, by neurologists.…”

Section: Test Utilizationmentioning

confidence: 99%

“…3 Identifying these high-impact tests in the evaluation of peripheral neuropathy is particularly important because it is a highly prevalent disease encountered by many provider types. [4][5][6][7] However, the optimal diagnostic testing algorithm for this condition is unknown. While peripheral neuropathy comprises many different subtypes that may affect what constitutes appropriate testing, the vast majority of patients have a distal symmetric polyneuropathy.…”

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confidence: 99%

“…3 Given the limited available evidence, it is not surprising that a survey found that physicians order many costly tests at the time of peripheral neuropathy diagnosis and also have substantial variation in evaluation patterns. 5 Interestingly, high-cost, low-yield tests such as MRIs of the neuroaxis are frequently ordered (23.2%), whereas low-cost, high-yield tests like glucose tolerance tests are rarely ordered (1%). 9 Furthermore, neurologists report that they would order more tests than internists when presented with the same clinical vignettes of distal symmetric polyneuropathy.…”

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confidence: 99%

“…9 Furthermore, neurologists report that they would order more tests than internists when presented with the same clinical vignettes of distal symmetric polyneuropathy. 5 Specifically, neurologists reported the increased utilization of laboratory and electrodiagnostic testing, but not MRIs of the brain or spinal cord, which internists indicated that they would order more often. However, the actual utilization of diagnostic testing and expenditures in patients with peripheral neuropathy who see a neurologist compared to those who see other provider types is unknown.…”

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Expenditures in the elderly with peripheral neuropathy

et al. 2013

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SummaryTo optimize care in the evaluation of peripheral neuropathy, we sought to define which tests drive expenditures and the role of the provider type. We investigated test utilization and expenditures by provider type in those with incident neuropathy in a nationally representative elderly, Medicare population. Multivariable logistic regression was used to determine predictors of MRI and electrodiagnostic utilization. MRIs of the neuroaxis and electrodiagnostic tests accounted for 88% of total expenditures. Mean and aggregate diagnostic expenditures were higher in those who saw a neurologist. Patients who saw a neurologist were more likely to receive an MRI and an electrodiagnostic test. MRIs and electrodiagnostic tests are the main contributors to expenditures in the evaluation of peripheral neuropathy, and should be the focus of future efficiency efforts.

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Distal Symmetric Polyneuropathy

Callaghan

Price

Feldman

2015

JAMA

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228

163

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Importance Peripheral neuropathy is a highly prevalent and morbid condition affecting 2–7% of the population. Patients frequently suffer from pain and are at risk of falls, ulcerations, and amputations. We aimed to review recent diagnostic and therapeutic advances in peripheral neuropathy in distal symmetric polyneuropathy, the most common subtype of peripheral neuropathy. Observations and Advances Current evidence supports limited routine laboratory testing in patients with distal symmetric polyneuropathy. Patients without a known cause should have a complete blood count, comprehensive metabolic panel, B12, serum protein electrophoresis with immunofixation, fasting glucose, and a glucose tolerance test. The presence of atypical features such as asymmetry, non-length-dependence, motor predominance, acute or subacute onset, and/or prominent autonomic involvement should prompt a consultation with a neurologist or neuromuscular specialist. Electrodiagnostic tests and magnetic resonance imaging of the neuroaxis are the main drivers of the cost of the diagnostic evaluation, but evidence supporting their use is lacking. Strong evidence supports the use of tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, and voltage-gated calcium channel ligands in the treatment of neuropathic pain. More intensive glucose control substantially reduces the incidence of distal symmetric polyneuropathy in patients with type 1 diabetes, but does not in type 2 diabetes. Conclusions and Relevance The opportunity exists to improve guideline concordant testing in distal symmetric polyneuropathy patients. Moreover, the role of electrodiagnostic tests needs to be further defined, and interventions to reduce magnetic resonance imaging use in this population are needed. Even though several efficacious medications exist for neuropathic pain treatment, pain is still under-recognized and undertreated. New disease modifying medications are needed to prevent and treat peripheral neuropathy, particularly in type 2 diabetes.

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The Evaluation of Distal Symmetric Polyneuropathy

Cited by 21 publications

References 23 publications

Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

Expenditures in the elderly with peripheral neuropathy

Distal Symmetric Polyneuropathy

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