SIERRA NEVADA MEDICAL ASSOCIATES, INC. (IPA)
UTILIZATION GUIDELINES
PRIMARY CARE MANAGEMENT GUIDELINES
NEUROLOGY
The Primary Care Physician should:
1.
Initiate diagnosis and treatment of all headaches, neuropathies, central nervous
system disorders, myofascial syndromes and psychophysiological diseases.
2.
Diagnose and treat tension and migraine headaches. Imaging of the head
should not be necessary for such patients. When patients have altered mental
status, neurological findings, change in headache pattern, or sudden onset of
severe headaches with no previous history, neurological consultation and/or
brain imaging may be appropriate. Early neurological consultation may be more
cost-effective, since patients with normal neurological examinations have little
likelihood of abnormal imaging.
3.
Evaluate and treat soft tissue pain syndromes. Avoid excessive radiological and
electrohysiologic studies in patients who lack dermatonal, radicular, or peripheral
nerve distribution and who have no evidence of an underlying inflammatory
metabolic disease.
a)
Treatment should consist of appropriate exercise, anti-inflammatory
medications, pain modulators, analgesics, muscle relaxants, and/or
injection of trigger points and tender points. Avoid use of narcotic
derivatives in chronic pain syndromes if possible. Patients with chronic
pain will often need management of depression.
b)
Limited physical therapy may be helpful with 1-2 visits for instruction in
proper exercise technique, and 1-2 follow up visits to assure proper
performance of exercises. Consider consultation for clarification of
diagnosis or if lack of improvement.
4.
Diagnose and treat syncope and seizures. If epilepsy is a consideration, the
patient should have a sleep-deprived EEG ordered by the primary care physician
and read by a neurologist. If a seizure disorder is diagnosed, the primary care
physician should provide anticonvulsant treatment. If seizures are recurrent or
refractory to treatment, neurology consultation would be appropriate. Once the
course has stabilized, follow up by the primary care physician would be
appropriate.
5.
Manage degenerative neurological disorders with respect to their general
medical care. For confirmation of such diagnoses, neurological consultation may
be appropriate.
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6.
Strokes and TIAs should be managed by the PCP although brief consultation by
a neurologist may be appropriate. If a classic ischemic attack is associated with
a carotid lesion for which surgery would be appropriate, referral to an appropriate
surgeon is indicated.
7.
Evaluate neuropathies and radiculopathies with appropriate radiological,
laboratory, and electrophysiological studies. Consider consultation if no
improvement or uncertain diagnosis after 6 to 8 weeks of conservative treatment
or if there is a progressive neurological defect.
8.
Lumbar spinal stenosis may be treated conservatively if mild or patient is not a
surgical candidate. Most myelopathies should be referred.
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