Citation

Keddie S, Adams A, Kelso ARC, Turner B, Schmierer K, Gnanapavan S, Malaspina A, Giovannoni G, Basnett I, Noyce AJ. J. Neurol. 2018; 265(5): 1089-1095.

Affiliation

Barts and The London School of Medicine, Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, WC1N 1PJ, UK. a.noyce@qmul.ac.uk.

Copyright

(Copyright © 2018, Holtzbrinck Springer Nature Publishing Group)

DOI

10.1007/s00415-018-8801-3

PMID

29502317

Abstract

BACKGROUND: Whilst the dangers of 'legal highs' have been widely publicised in the media, very few cases of the neurological syndrome associated with the inhalation of nitrous oxide (N₂O) have been reported. Here we set out to raise awareness of subacute degeneration of the spinal cord arising from recreational N₂O use so that formal surveillance programs and public health interventions can be designed.

METHODS: Case series documenting the clinical and investigational features of ten consecutive cases of subacute degeneration of the spinal cord presenting to a hospital with a tertiary neurosciences service in East London.

RESULTS: Sensory disturbance in the lower (± upper) limbs was the commonest presenting feature, along with gait abnormalities and sensory ataxia. MRI imaging of the spine showed the characteristic features of dorsal column hyperintensity on T₂weighted sequences. Serum B₁₂levels may be normal because subacute degeneration of the spinal cord in this situation is triggered by functional rather than absolute B₁₂deficiency.

DISCUSSION: A high index of suspicion is required to prompt appropriate investigation, make the diagnosis and commence treatment early. This is the largest reported series of patients with subacute degeneration of the spinal cord induced by recreational use of N₂O. However, the number of patients admitted to hospital likely represents the 'tip of the iceberg', with many less severe presentations remaining undetected. After raising awareness, attention should focus on measuring the extent of the problem, the groups affected, and devising ways to prevent potentially long-term neurological damage.

Language: en

Keywords

Hydroxocobalamin; Myelopathy; Subacute degeneration of the spinal cord; Vitamin B12