Reasoning GP · Algorithm · 1-page summary
Tingling, numbness and paraesthesia in adults
For: adults with new or persistent tingling, numbness or paraesthesia in primary care. Not for: children. Detailed management of carpal tunnel, sciatica, cauda equina and neuropathic pain → use those protocols.
Core rule: localise first. Upper motor neurone (UMN) signs, bilateral symptoms or rapid progression = a central or compressive cause until proven otherwise. Never label it peripheral neuropathy without a neurological examination.
0Stop — call 999 now — any one feature is enough
- Saddle anaesthesia, or new bladder, bowel or sexual dysfunction or urinary retention, with or without bilateral leg tingling or weakness (cauda equina, cord compression) → 999 emergency MRI spine the same day.
- Sudden one-sided face, arm or leg tingling or numbness, even without weakness: FAST and check glucose. Persisting → 999 stroke pathway.
- Ascending tingling with weakness and areflexia (Guillain-Barré) plus breathlessness, weak cough, or swallowing or speech difficulty → 999
- Do not wait for an FVC threshold or nerve studies in suspected Guillain-Barré.
1Triage by tempo and pattern
| Pattern | Action |
|---|---|
| Sudden, resolved | One-sided (TIA): offer aspirin 300 mg unless contraindicated (anticoagulated or bleeding risk → specialist advice) → Specialist ≤24 h; no driving |
| Rapidly ascending | Guillain-Barré → Same-day hospital (999 if bulbar or respiratory) |
| Sensory level | Cord compression → 999. Rapid bilateral weakness, can't walk safely → Same-day hospital |
| Progressive, UMN | Motor involvement or UMN signs → Neurology ≤2 weeks + MRI spine |
| Chronic, distal | First-line bloods, treat the cause → Routine |
2Screen — one row is enough
- Fever + back pain + deficit, or autonomic instability → Same-day
- Foot ulcer + fever, sepsis, ischaemia, deep infection, gangrene → Same-day. Warm, swollen foot (Charcot) → Foot service ≤1 working day
- Lhermitte's, absent ankle jerks + upgoing plantars, sensory ataxia → B12 now; Urgent neurology
- Low B12 + ataxia or cognitive change → bloods, then IM hydroxocobalamin urgently. Never folic acid alone.
- Weight loss, sweats, nodes → Urgent neurology; NG12 pathway if cancer suggested
- Asymmetric, painful, stepwise (vasculitis) → ESR, CRP; Urgent neurology
3Assess — once blocks 0–2 are answered
☐ Touch, pinprick, vibration, joint position ☐ Power, reflexes, plantars, clonus, Romberg, gait ☐ Sensory level, Spurling's, SLR ☐ Feet, pulses; monofilament in diabetes ☐ Postural BP if autonomic
☐ HbA1c, B12 + folate, TSH, FBC, U&E, ESR, AUDIT-C; coeliac if indicated ☐ Electrophoresis + light chains if unexplained. Not routinely: tumour markers, antineuronal antibodies, MRI without localising signs.
4Classify — the pattern localises the lesion
- Stocking-and-glove — diabetes, alcohol, B12, CKD, thyroid, paraprotein, drugs, nitrous oxide.
- Single nerve — entrapment: median (nocturnal, eased by shaking), ulnar, radial, peroneal, meralgia.
- Dermatomal + neck or back pain → radiculopathy; weakness, gait change, brisk reflexes → MRI.
- Hands and feet together — absent reflexes = polyneuropathy; any UMN sign = cord → urgent neurology + MRI spine.
- Perioral + both hands → hyperventilation; check calcium.
- Uncertain — say so, document the signs at each visit; progression → escalate investigation or referral.
5Treat today — the cause first
- Painful neuropathy: offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin (CG173); none for painless numbness; no gabapentinoids for sciatica (NG59). Driving warning; taper.
- B12 deficiency + neurology: hydroxocobalamin 1 mg IM alternate days until no further improvement, then every 2 months.
- Carpal tunnel: neutral night splint first; a single steroid injection is an option.
- Alcohol: safe reduction, thiamine; Wernicke's risk → parenteral thiamine before or with glucose; never delay hypoglycaemia treatment. Isoniazid → co-prescribe pyridoxine. Doses: NICE/SPC, BNF, local formulary.
6Refer routinely
- Unexplained, small-fibre or hereditary neuropathy → neurology.
- Carpal tunnel: severe → hand surgery; wasting, or not improved after a single injection → Urgent hand surgery
- Radiculopathy: progressive weakness, or cervical pain after 6 weeks → spinal surgery.
- Loss of protective sensation → podiatry. Paraprotein → Urgent haematology
7Never reassure by
- Calling it neuropathy without a full neurological examination.
- The absence of weakness in sudden one-sided tingling.
- A B12 within the range when suspicion is high (consider MMA).
- A painless warm, swollen diabetic foot.
- Normal nerve studies when the pain is burning (small fibre).
- Anaemia corrected by folic acid while the neuropathy progresses.
8Safety-net — say it, then document it
999 “Call 999 for new numbness between the legs or around the bottom, any new bladder or bowel change, breathlessness, a weak cough or trouble swallowing, or sudden one-sided numbness, face droop, arm weakness or speech change.” Same day “New weakness in both legs, numbness spreading quickly upwards, or you can't walk safely — go to hospital today. Any foot wound, blister, colour change, warmth or swelling — get it seen today.”
Follow-up: bloods reviewed within 1 week; review 2–4 weeks after starting or changing medication, 4–8 weeks for response. Neuropathy affecting pedal control → patient must tell the DVLA; document it.
✓Safe to leave primary care only if — all five, documented
No block 0–2 feature
Power, reflexes, plantars, sensation and gait recorded
Pattern localised, or uncertainty stated
Bloods sent; result review and follow-up dated
Foot check, safety-net and driving advice given
Summary of the full Reasoning GP tingling and paraesthesia algorithm, which holds the detail, examination, investigations and evidence. Sources: NICE NG127, NG128, NG19, NG239, NG59, NG220, NG12 (updated April 2026), CG173; BSSH/GIRFT carpal tunnel pathway; DVLA. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.