Initial Workup and Treatment for Paresthesias
The initial workup for paresthesias should include a focused neurological examination, laboratory testing for common metabolic causes, and appropriate imaging based on suspected etiology, with treatment directed at the underlying cause. 1, 2, 3
Clinical Assessment
History
- Onset pattern: acute vs. gradual
- Distribution: "stocking and glove" vs. dermatomal vs. asymmetric
- Associated symptoms: weakness, pain, autonomic symptoms
- Aggravating/relieving factors
- Medical history: diabetes, alcohol use, toxic exposures, trauma, prior surgeries
- Medication review: chemotherapeutics and other neurotoxic drugs
Physical Examination
- Comprehensive neurological assessment:
- Sensory testing (light touch, pinprick, vibration, proprioception)
- Motor strength testing
- Deep tendon reflexes
- Cranial nerve examination
- Coordination testing
- Musculoskeletal evaluation for potential compression sites
Diagnostic Testing
First-line Laboratory Tests
- Complete blood count
- Comprehensive metabolic panel
- Fasting blood glucose/HbA1c
- Vitamin B12 level
- Thyroid-stimulating hormone
- Serum protein electrophoresis with immunofixation 2
Imaging
- Avoid routine imaging in cases of suspected peripheral neuropathy
- Consider targeted imaging when:
- Focal neurological deficits are present
- Structural lesions are suspected
- Symptoms suggest central nervous system involvement 3
Specialized Testing
- Nerve conduction studies/electromyography to determine:
- Axonal vs. demyelinating pattern
- Focal vs. generalized involvement
- Severity of nerve damage 3
- Consider referral to neurology for:
- Rapidly progressive symptoms
- Asymmetric or focal deficits
- Significant motor involvement
- Unclear etiology after initial workup 2
Treatment Approach
Treat Underlying Cause
- Manage diabetes and other metabolic disorders
- Discontinue offending medications or toxins
- Correct nutritional deficiencies
- Address compression neuropathies (splinting, surgery)
- Treat inflammatory/immune-mediated conditions
Symptomatic Management
- Neuropathic pain medications:
- First-line: Gabapentinoids (gabapentin, pregabalin)
- Second-line: Tricyclic antidepressants, SNRIs
- Third-line: Topical agents (lidocaine, capsaicin)
- Physical therapy for weakness or functional limitations
- Occupational therapy for adaptive techniques
Common Pitfalls to Avoid
- Assuming all paresthesias are peripheral in origin (consider central causes)
- Missing multifocal or asymmetric patterns that suggest specific etiologies
- Overlooking potentially reversible causes (B12 deficiency, hypothyroidism)
- Inadequate follow-up for progressive symptoms
- Focusing solely on symptomatic treatment without addressing underlying cause
Clinical Pearls
- Paresthesias in a "stocking and glove" distribution typically suggest a length-dependent peripheral neuropathy
- Asymmetric or focal symptoms may indicate compression, radiculopathy, or mononeuropathy
- Bilateral symptoms with upper motor neuron signs warrant evaluation for central causes
- Up to 46% of peripheral neuropathies remain idiopathic despite thorough evaluation 2
- Early identification and treatment of underlying causes improves long-term outcomes