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Re: Lhermitte's Sign - an episode or symptom?
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Re: Lhermitte's Sign - an episode or symptom?

Posted By Karen on May 06, 1999 at 10:57:03
I was diagnosed with probable MS 2 years ago. At the time, I had numbness in my leg and also Lhermitte's Sign. The episode lasted 6 weeks and then went away. My Neurologist said that I should consider various treatments should I have another episode. Last week I've been experiencing Lhermitte's Sign- only. Is this considered an "episode" - or rather just a symptom of MS? Does it mean I'm relapsing?

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Posted By CCF MD mdf on May 06, 1999 at 11:32:41
Lhermitte's sign is not specific to MS.
As you probably know, it refers to a shock-like sensation that travels down your spine upon flexing the neck. It can arise in any disorder affecting cervical spinal cord, such as disc compression or even vitamin B12 deficiency.
Since you have not been having the symptom and you have experienced a recurrence, I recommend a visit to your neurologist as soon as you can get in. If the prior diagnosis was "possible MS" then I don't know what data was missing but this time you may be able to get enough information to clarify the diagnosis. If this indeed turns out to be MS, you want to know as early as possible because there are now treatments available which can slow down the progression.
This forum can't substitute for medical advice in an evaluation by your doctor. I hope this helps. CCF MD mdf.

Posted By Cathy on May 07, 1999 at 00:08:23
I have never heard of Lhermitte's sign, however the doctor mentioned that it could occur with a vitamin B-12 deficency.  My neuro told me that my B-12 level is too low and I am currently taking an over the counter B-12.  Can you tell me the exact symptoms of a B-12 deficency?  I have been have other symptoms and just wonder if it is possible they may be linked to the B-12 problem.  Thank you. (My other symptoms are mild jerking or twitching of my hands especially my left hand  most noticable when I am doing fine motor things.  Occasional jeking of legs and neck or head.  Also spiking of my most recent EEG and sleep apnea, and daytime fatigue and backaches which feel like my back is going out on me)Again thanks...

Posted By Jody Lublanezki, PA-C on May 07, 1999 at 01:15:42
Chronic B-12 deficiency can cause a "demyelination" of nerve.  Myelin is the sheath that covers some nerves and enable them to transmit impulses much faster than non-myelinated nerve fibers. Hmmm, an illustration ... 'snap' a rubber band on your wrist.  There is an immediate sensation of the pain of the snap...but there is a brief 'residue' of burning sensation after the snap is well over with.  That residual of burning pain is the slower non-myelinated nerve fibers conducting the pain that was so rapidly transmitted by the myelinated fibers.
So, that contrasts the two types of nerve fibers.  Now what about how the B-12? A deficiency can lead to demylination of longer nerves, and slow impulses.  Either weakness and decreased muscle tone results...or painful stimuli even 'lingers' a little longer before completing transmission.  Tiredness & fatigue of a muscle can seem much more pronounced if the nerve fibers become less myelinated.
By the about HOW B-12 becomes deficient in the first place? All stomach disorders contribute, but basically it is a malabsorption problem of the stomach.  Got H.pylori?  The bacteria that causes gastroesophageal-reflux disease and peptic/duodenal ulcers?  These boogers in the stomach lining cause B-12 deficiency.  People who take H2-blockers (like famotidine, cimetidine, ranitidine...won't say brand-names here) or Proton-Pump Inhibitors (like omeprazole, lansoprazole), not temporarily...but for YEARS develop the deficiency.  It's as if part of the stomach is removed...and gastrectomy will most certainly cause malabsorption difficulties.  People who take too many laxatives can get this kind of problem also.
Anyway, B-12 is needed to maintain myelin sheaths of nerve cells.  One of my tests in elderly patients is to get them to stand from sitting with their hands out in front of them so they can't use anything but their most powerful proximal muscles in the thighs/hips/buttocks to get 'em up. If there is any tiny sign of they have B-12/Folate deficiency.  Usually a CBC helps screen. If the Mean Corpuscular Volume (MCV) is elevated this is a clue.
Hope this illuminates....Jody  

Posted By Cathy on May 07, 1999 at 15:18:58
     Thanks this makes understanding the importance of B-12 easier for me.
I would also like to ask you my having a gastric stapling for weigh control(which failed) in 1986 could have something to do with this.  My neuro says that taking a high dose (500mg) of dilantin inteferes withe the absorption of B-12 also.  I also take Folic Acid, synthroid, and zoloft.  He did not tell me that I had a B-12 deficency, only that it was low. Do you think that taking
an over the counter B-12 will be strong enough to get my levels to normal?  Thank you so much for your information.

Posted By CCF MD mdf on May 07, 1999 at 22:30:52
Vitamin B12 deficiency is not anything to fool around with. The neurologic consequences usually include impairment of peripheral nerve function (and actual permanent damage) as well as a syndrome called "subacute combined degeneration" in which damage to the spinal cord occurs. It is a metabolic problem - B12 and folate are necessary cofactors in certain biochemical reactions and neural tissue needs this in order to work properly. Untreated, B12 deficiency can lead to permanent damage.
Symptoms may include numbness in the feet, incoordination of hands or feet, and others. It's hard to catalog all the symptoms because they are variable. The discipline of neurologists is to judge where in the nervous system a symptom or set of symptoms is coming from, then figure out what it might be. The Lhermitte sign is an example. It localizes a problem to the cervical spinal cord, and then we use other clues (history, exam, lab tests, MRI, etc) to narrow down the exact culprit.
I have focused on neurologic symptoms. An internist or hematologist can tell you about B12 anemia, in which you have too few red cells and they are too big (megaloblastic anemia). That is the reference to the "MCV" in the complete blood count (CBC) that was mentioned. The more common sort of anemia which comes from iron deficiency is different - there the cells tend to be too small. The term "pernicious anemia" refers to B12 deficiency anemia.
The dietary absorption of vitamin B12 is complex. It's not just a matter of swallowing a bunch of it (dietary or supplemental) and letting the guts do the work. There is something called "intrinsic factor" which is made in certain cells in the stomach that must be present in order for B12 to be absorbed at a point in the very end of the small intestine (the ileum). Why so complicated? Beats me.
It takes many years for the effects of B12 deficiency to become apparent. If you had a gastric stapling 13 years ago, you might not be making adequate intrinsic factor, and your ileum is therefore not absorbing it. Soldiers with wartime injuries to stomach and intestines also ended up getting B12 deficiency. But it took them more than 10 years usually, because the body's stores take about that long to run out.
If your B12 level is low, and you have had a gastric stapling, you need formal evaluation for B12. The first blood tests include the B12 level itself in the blood, plus methylmalonic acid and homocysteine (the pattern can help with the diagnosis). You may need a Schilling test (not something a neurologist does - see your internist).
Let your doctor advise you on whether dietary supplement of B12 will be adequate. It may not, and you may need injections. There is a common protocol for B12 injections. If your problem is impairment of absorption, then dietary supplementation of B12 is likely not to be enough.
By the way, with some vitamins, it is possible to get toxicity from too much (such as vit A). With vit B12, there is no known syndrome resulting from too much. So it's safe to take it, and not safe to be without it. But let your doctor be your guide.
Sorry about the longwinded response. I hope this helps. CCF MD mdf.

Posted By Cathy on May 08, 1999 at 00:01:03
Thank you very much for your information.  If you have the time please answer a few more for me.  My seizure disorder started in January 1005 after the birth of my 3rd child.  I was treated between and then had a reoccurance of them after a c-section delivery of my 4th child.  Is it possible that my whole seizure disorder could be caused by a B-12 deficency?  EEG spiking? Slightly jerking of hands, legs and occasionaly head?  Sleep Apnea and daytime fatigue?  Depression?
Would recovery be possible if had had the gastric stapling reversed?  I was never told that the stapling had any side effects.  I never lost weight except for a slight amount and now I am hypothyroid.  Is this fatal?  I have 4 children, 2 teenagers and a 4 year old and a 1 year old, I want to be the one raising them.  Excuse me, for a minute there I panicked.  I have got a grip now and would like to ask one more question.  Could this be why I sometimes have trouble getting my hands to do exactly what I want them to do?  Thank you.  i will call my Family Doctor and schedule and appointment to discuss my concerns with and ask for further lab work.  Thank you so much.

Posted By Jody, PA-C on May 08, 1999 at 01:41:23
Cathy...CCF MD expands even more on this complex stuff that's really tough to put into easily understood E-Mails versus the textbooks. He mentioned the "years" to get into such a fix...likely will take years to back out too unfortunately. Get with the Docs...Oral supplements might not be enough...but may well suffice too.  I don't think anything short of magic will get this situation corrected in a "few days" of some therapy though.  So, the stomach got stapled to decrease it's volume I suppose.  I'd guess that would amount to a "approximate" partial gastrectomy...must've costed a bundle!  Sorry to hear it failed though. That weight-loss thing ain't easy either, I know...I used to haul around 275 lbs myself.  IT TOOK DIET AND EXERCISE TO BRING DOWN TO 180. Diet & Exercise are the ONLY safe, tried & found to be true solutions.  I could give you a bath in diet-pills & such nonsense...without the D&E it's all worthless. A piece of bland advice...but it IS true. All the good things in, happiness, large incomes, nice home, decent family...YOU name your own goals...they will all take precious time and lots & lots of effort.  More than you have to give-up sometimes. But ALL those good things are well worth the sweat...the aches...the investments of personal energies.  Work at living a happy, healthy, secure life.   v/r...Jody

Follow Ups:

Lhermitte's Sign - an episode or symptom? Cathy 5/08/1999

Re: Lhermitte's Sign - an episode or symptom? Jody, PA-C 5/08/1999

Lhermitte's Sign - an episode or symptom? CCF MD mdf 5/09/1999

Re: Lhermitte's Sign - an episode or symptom? wendy 6/13/1999

Lhermitte's Sign - an episode or symptom? CCF Neuro[P] MD, RPS 6/13/1999

Re: Lhermitte's Sign - an episode or symptom? wendy 6/14/1999

Lhermitte's Sign - an episode or symptom? CCF Neuro[P] MD, RPS 6/15/1999

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