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Initial clinical assessment should include a thorough neurological examination documenting: Sensory testing for vibration sense (using a 128 Hz tuning fork) and proprioception Assessment of gait and coordination (Romberg's test) Evaluation of reflexes and muscle tone Cognitive screening if indicated Fundoscopy if visual symptoms are present History of nitrous oxide exposure (recreational or occupational) Laboratory investigations recommended in UK practice include: Serum B12 level whilst the standard first-line test, interpretation requires caution

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Cyano B12 in particular should be avoided, especially in patients with pernicious anemia and/or with high homocysteine