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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?
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 way...how 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 weakness...bet 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 life...health, 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

Posted by Cathy on May 08, 1999 at 10:31:57
My decision to have a gastric stapling was not one that I made out of convenience or ease.  It was thought through and advised by my doctor.
A series of other diet options and yes, pills were tried first.  Within the last 6 months I have been diagnosed with hypothyroid and I feel that explains
the difficulty that I have always had in trying to control my weight.  My
family has a very strong tendency to being large.  That does not matter.
What matters is how I can control my current health problem.  I have 4 beautiful children ranging in ages from 16 to 1.  I have workded hard for them and will continue to do so.  Because I am "fat" does not imply that I do not have the
ability to work hard. I appreciate all the information that you gave me concerning the B-12 situation, you opened my eyes and made me ask further questions, so I feel that I have found some truly useful information. But please do not have the thinking that because someone is large that they have no self restraint or self discipline.  I know that being large does not take away from the individuals worth.  There is no difference in the value of someone who is large and someone who is not.  If you were large then you should already know that.  I am sorry.  Thanks again for your help.

Posted by Jody, PA-C on May 08, 1999 at 20:57:20
OOOOPS!   Didn't mean to "imply" any such things.  I apologize for miscommunicating.  Just trying to be encouraging...v/r Very Respectfully...Jody

Posted by CCF MD mdf on May 09, 1999 at 08:49:15
I don't know how to comment on the "seizures." The first thing that must be established is that you really have epileptic seizures versus something else that looks like seizures. B12 isn't something I'd think of associated with that.
Reversal of gastric stapling may not do much to change things. Your questions are very good and sensible, but your best bet is to ask them directly of your doctor(s), or see a neurologist for a second opinion and get this information.
If you wish, you may request an appointment at 800 223-2273 ext 4-5559 (neurology appointments). If your primary question is about seizures, request the seizure specialists - we have some of the best around (I am not one of them). I hope this helps. CCF MD mdf.
Posted by wendy on June 13, 1999 at 11:42:31
     I am 23 years old and I am experiencing something which I think
is Lhermitte's sign.  I have gone to a neurologist and he tells me not
to worry about it.  The reason I am worried is because my father had
MS.  I have recently read articles on the connection of Lhermitte's
sign and vitamin B12 deficiency.  I haven't eaten meat in about 4 years.
Since I am only 23 is it more likely that I have MS than a B12 deficiency?
I am also feeling a numbing sensation in my toes. I had two MRIs done two years ago on my brain and lower back.  They both came out negative.  Is there anything else I can do to find out what is causing this feeling?

Posted by CCF Neuro[P] MD, RPS on June 13, 1999 at 14:34:22
Dear Wendy:
It is sometimes difficult to make a diagnosis when a disease is in the early stages.  This is not to say that you have MS or vitamin B 12 deficiency.  Numbness in the toes can be from a number of things.  Although most of the things are things like diabetes, lumbar stenosis, vertebral degeneration, disc bulging, trauma, circulatory problems, etc.  As you can see the range is vast.  However, when you think that you might be experiencing Lhermitte's and you have a family history of MS, and you add that you are a vegetarian there might be a connection.  If you are a strict vegetarian that includes diary products, there might be a chance of becoming vitamin B 12 deficient.  The toe numbness might be anything from shoes being too tight to ....  I don't think it would be unreasonable to see you neurologist to get some blood work for the possibility of vitamin B12 deficiency.  Do you take vitamins?  Most of the time when there is not a GI co-problem the taking of oral vitamins is enough to keep the vitamin B 12 level up.  Anyway, a quick talk and exam will ease your mind.
Sorry I couldn't be more specific.
CCF Neuro MD  

Posted by wendy on June 14, 1999 at 20:00:29
Thank you for your quick response.  I am not sure if what I am feeling
is Lhermitte's sign.  Everything I read about it describes it as painful.
What I am feeling is not pain.  Whenever I bend my neck down, I feel a
vibration in my lower back and in my right hand which lasts for about 1
second.  Does this sound like Lhermitte's sign?  When I described what I
felt to the neurologist I went to, he said it wasn't Lhermitte's sign, but
he didn't tell me what else it could have been.  He described Lhermitte's
sign as "a wool sweater scratching the upper back."  Have you heard of
what I am describing to you in any of your patients?  

Posted by CCF Neuro[P] MD, RPS on June 15, 1999 at 11:36:38
Dear Wendy:
I think I would agree with your neurologist and what you are feeling is not Lhermitte's sign (which by definition is painful).  It is difficult for me to tell you what is going on.  The nerves to you hands and arm exit the neck portion of the spine.  When you flex your neck (bend down) you change the position of your vertebrae, discs, and exit points of the nerves.  This change in position might be moving the nerves within the neural foramen (exit points from the spine) to cause the quick vibratory sense.  This would be only a guess.
CCF Neuro[P] MD

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