Lhermitte Sign


Article Author:
Dac Teoli
Franklyn Rocha Cabrero


Article Editor:
Sassan Ghassemzadeh


Editors In Chief:
Stephen Leslie
Karim Hamawy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/31/2019 10:03:49 AM

Introduction

Lhermitte’s sign (also known as Lhermitte’s phenomenon and the barber chair phenomenon) describes a transient sensation of an electric shock extending down the spine and/or extremities upon flexion of the neck, often a sequela of neurologic disease. It was first described by Marie and Chatelin in 1917, was erroneously credited to Babinski and Dubois, and eventually correclty credited to Jean Jaque Lhermitte through the seminal paper Les douleurs à type de décharge électrique consécutives à la flexion céphalique dans la sclérose en plaques: Un cas de forme sensitive de la sclérose multiple (1924) by Lhermitte et al. and Gutre. Lhermitte described it in multiple sclerosis and spinal cord diseases, he further hypothesized it was a result of irritation and inflammation of the cord, likely in the posterior and lateral columns.[1]

Lhermitte's sign is classsified as one of the paroxysmal pain syndromes of multiple sclerosis. Multiple sclerosis is a chronic, predominantly immune-mediated disease of the central nervous system, and one of the most common causes of neurological disability in young adults globally. The new Mc Donald's criteria 2017 there is a clinical and radiographical dissemination of time and space of symptoms, with presence of at least one lesion in at least two out of four CNS areas: Periventricular, cortical or juxtacortical, infratentorial and spinal cord. Additional radiographical and labororatory criteria include: new T2 and/or Gd-enhancing lesion on follow-up MRI, with reference to a baseline scan, irrespective of the timing of the baseline MRI, simultaneous presence of asymptomatic Gd-enhancing and nonenhancing lesions at any time, patients fulfilling disemmination of time and space, presence of OB in CSF. Common initial clinical symptoms include: mononuclear painful visual loss, spinal cord hemiparesis, mono/paraparesis, hypoesthesia, dysesthesia, paraesthesia, urinary and/or sphincter dysfunction, diplopia, oscillopsy, vertigo, gait ataxia, dysmetria, intentional/postural tremor, facial paresis, faciobrachial–crural hemiparesis, faciobrachial–crural hemihypoesthesia, affecting multiple organ systems of the patient. [2]

Lhermitte's sign or symptom should not to be confused with Uhthoff phenomenon, another often-noted objective finding in multiple sclerosis patient, which is characterized by heat sensitivity after prolonged heat exposure, saunas and hot tubs. Although sometimes bothersome or even frightening, to patients, these events do not prove to be a true advancement of disease conditions (such as in multiple sclerosis) or lead to further injury to the central nervous system (CNS). [3][4][5]

Etiology

Lhermitte's sign it is not a disease, as a paroxysmal multiple sclerosis-induced neuropathic pain syndrome, it is thought to develop as a direct or indirect demyelinating lesions in the brain and spinal cord. Specifically, it activates ascending spinothalamic tracts at the cervical level that have been sensitized by demyelination. This view is supported by an MRI study of plaque formations in the cervical spine, which were present in 95% of those with a history of Lhermitte’s sign compared with 52% of those who did not report the sign. [6]

Other etiologies besides MS, includes tumor progression causing spinal cord compression, radiculopathy, cervical spondylitis, transverse myelitis, subcute combined degeneration of the cord, radiation myelopathy, chemoradiation, among others. It seems to be preferentially present in patient with cervical demyelinating lesions and abnormal nerve conduction studies. It is not a sensitive or specific sign for any of the disorders mentioned. Neck flexion irritates demyelinated tracts in the posterior column, causing the electric sensation experience by patients. [7][8] [9]

Epidemiology

Epidemiological studies of the incidence and prevalence of Lhermitte's sign (LS) are scant. One prospective study showed that the incidence of LS, by self report, was about 16% in almost 700 patient. [10] An old study reported that that LS was experienced by 33.3% out of 114 patients of MS; and in 16%, it was reported to have been occurred in the first episode of MS.[11] [5] One study compared the prevalence in patient with MS and Neuromyelitis Optica (NMO). They found that the prevalence of LS among MS patients (4.3%) was significantly lower than NMO patients (20.5%) (P < 0.0001). 5.9% of the MS and 12.5% of the NMO patients had a positive family history of Lhermitte’s sign. It was observed that a higher proportion of patients with NMO rather than MS experienced the sign (20.5% vs. 4.3%). [12]. The overall prevalence of LS range from 9-41 % [13][6]. Although this symptom is typically self-limiting with spontaneous resolution after some weeks, its frequency and intensity may be troublesome in some patients. [14] The incidence and prevalence of the sign on rarer causes, including Vitamin B12, Behcet's disease, SSRI discontinuation syndrome, among others has not been studied in the population. There are no available statistics regarding the incidence or prevalence of Lhermitte's sign in today's global population. [15][16]

Pathophysiology

Lhermitte's sign pathophysiology is related to demyelination of dorsal columns of the cervical spine, associated with radiographical demyelinating lesion and electrodiagnostic abnormalities on nerve conduction. It is also associated with compressive myelopathy with reported affect on the dorsal columns of the caudal medulla. As mentioned before it is thought to transiently activate neuropathic pain pathways. Most recent theory is that it implicates glutamatergic signalling and microglial cell activation in the CNS. In the case of Lhermitte's sign, it is thought to result from ectopic firing and hyperexcitability of demyelinated sensory neurones (in cervical regions of spinal cord), involving ascending spinothalamic nociceptive signal transduction and impaired function of inhibitory GABAergic interneurons. Other proposed molecular mechanisms include downstream activated microglia that enhance pro-inflammatory cytokine signalling, activation of proteins like bradykinin with B1 and B2 receptors, upregulation of Wnt signalling, CREB phosphorylation and other transcription factors in the CNS that augment hyperexcitability and pain. [9] [17]

History and Physical

Neck movements, tiredness, stress, and heat can trigger Lhermitte’s sign. Patients often describe Lhermitte's sign as an electric shock of pain that runs from the head down to the back, and through the arms and legs. It often happens when they bend their head down and touch their chin to their chest or when an examiner elicits it.[7]

Evaluation

Although there are no routine laboratory, radiological, or other tests to assess or manage Lhermitte's sign, there has been some prospective studies linking its presence to radiographic and electrodiagnostic findings. One study showed a correlation between the clinical sign and the presence of a demyelinating lesion on cervical MRI and conduction delay of median and tibial somatosensory evoked potentials (SSEP), which was clinically significant. [10] This suggests that patients that have this physical exam finding, are more likely to have a cervical spine lesion and abnormal upper and lower extremity nerve conduction due to demyelination.[7]

Treatment / Management

There is no randomized or double blinded studies level I evidence based treatment for LS, usually it is benign and self-resolves, rarely patients may have severe pain and discomfort. Few reports and anectodal evidence show that carbamazepine[18], oxcarbazepine, gabapentin, may be beneficial in some patients. [19] Inhibition of pro-inflammatory cytokine signalling, augmentation of inhibitory cytokine signalling and blockade of chemokine receptor-mediated inflammatory cell recruitment to the CNS, have potential as future strategies for improving relief of MS-associated neuropathic pain, including Lhermitte's. [9]

Additionally, there are case series using extracranial picotesla range pulsed electromagnetic fields (EMFs), that effectively treated patients with Lhermitte's sign. One theory is that the reduction of axonal excitability occurs through the modulation of ionic membrane permeability. Second theory involves modulating pain control systems through neurotransmitter activity and pineal melatonin functions, as discussed earlier. [20][21][20]

Differential Diagnosis

The differential diagnosis of Lhermitte sign, besides MS, has been reported in the literature and includes: tumor progression causing spinal cord compression, radiculopathy, cervical spondylitis, transverse myelitis, subcute combined degeneration of the cord, radiation myelopathy, parasitic invasion of the cord, Arnold-Chiari Malformation, high dose chemoradiation (cisplatin), Trauma, Arachnoiditis, Herpes Zoster toxicity, Syringomyelia,  Behcet's disease, vitamin B12 deficiency, nitric oxide toxicity, systemic lupus erythematous, and post-dural puncture headache.[22][23][24][23]

Radiation Oncology

Lhermitte's sign has been noted as a potential side effect of radiation oncology therapies, specifically as an early delayed radiation injury. These often occur within 4 months of radiation therapy.[25][23]

Medical Oncology

Cisplatin or docetaxel neurotoxicity has been tied to Lhermitte's sign.[23]

Prognosis

Lhermitte's sign or syndrome is not a disease process itself, and it is usually intermittent in nature, only elicited under neck flexion. The prognosis of the disease process underlying the Lhermitte's sign is variable as abovementioned.

Complications

There are no known complications related to Lhermitte's sign, as it is not a disease itself. However, it is also occasionally reported as a facet of a discontinuation syndrome related to certain medications. Psychotropic medications such as SSRIs and SNRIs, specifically paroxetine and venlafaxine have been shown to have an association. When being on these medications for some length of time, and then suddenly halting to drastically reducing dosages, some patients enforce experiencing symptoms similar to Lhermitte's sign. Regarding SSRI withdrawal symptoms, fluoxetine, given the extended length of its half-life, can be given at a single small dosage, and as a result, avoid Lhermitte's sign and other similar symptoms.[22] On the other hand, paroxetine withdrawal has been reported in the literature as causing reversible Lhermitte's sign, this is thought to be related to the drug's short half-life. [24]

In dentistry, there have been studies which found Lhermitte's sign associated with nitrous oxide abusers (believed to be tied back to depleting vitamin B12).  It is also occasionally reported as a facet of a discontinuation syndrome related to certain medications. Psychotropic medications such as SSRIs and SNRIs, specifically paroxetine and venlafaxine have been shown to have an association. When being on these medications for some length of time, and then suddenly halting to drastically reducing dosages, some patients enforce experiencing symptoms similar to Lhermitte's sign. In dentistry, there have been studies which found Lhermitte's sign associated with nitrous oxide abusers (believed to be tied back to depleting vitamin B12).

Consultations

In the case of multiple sclerosis, an experienced neurologist should be consulted if demyelinating disorders are suspected

Deterrence and Patient Education

No active intervention is required by healthcare providers beyond an explanation and reassurance; the syndrome usually resolves spontaneously over a period of months to a year, under rare cases it can be treated with neuropathic pain medication if refractory and recurrent.[26]

Pearls and Other Issues

  • Lhermitte's sign generally occurs with pathologies involving the cervical spinal cord but is not specific to etiology.
  • It often occurs in patients with multiple sclerosis, cervical spondylotic myelopathy, chemotherapy, radiation myelopathy, and B12 deficiency, among others.
  • Increased spinal cord metabolic activity and positive positron emission tomography (PET) imaging have been described in association with Lhermitte's sign.
  • The incidence and prevalence of Lhermitte symptom are difficult to estimate. 
  • A patient can experience Lhermitte's sign intermittently. It does not have to always happen with the same degree of neck flexion. It may be infrequent or occur with slight to dramatic movement of the head or neck.
  • Delayed onset Lhermitte’s sign has been reported following head and/or neck trauma. This occurs several months following injury, without associated neurological symptoms or pain, and typically resolving within 12 months.
  • As a misnomer, Lhermitte's "sign" is not truly a sign at all, at least in the traditional sense of medical terminology. Rather, it is a symptom.[27][28][26][28]

Enhancing Healthcare Team Outcomes

Multiple sclerosis is a chronic disease which can sometimes follow an unpredictable trajectory. It is best to enhance patient outcomes by integrating a team-based approach, including nurses, physician assistants, and physicians should be used in managing patients who live with multiple sclerosis. Consider speaking to the patient about implementing new physicians and services to their overall care, such a palliative medicine, as such resources can offer a new range of support to the family and the patient. [Level V]


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Lhermitte Sign - Questions

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A patient who recently completed a standard course of radiation treatment for tonsil cancer (stage T2N2M0) presents to the physician because of tingling in his arms and fingers when he bends his neck. What is the best treatment in this case?



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A 35-year-old female with multiple sclerosis comes in the office for follow up care with his neurologist. She is complaining of difficulties ambulating that has worsened in the last 6 weeks, she now needs a piece of durable medical equipment to go to work and is unable to do her routine power yoga at night. She is not compliant with her medications. On exam, she has bilateral clonus of her lower extremities, bladder spasticity, and changes of mood and memory. Which of the following statements is true regarding a known elicited physical exam finding in some patients with this diagnosis?



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A 30-year-old female with a past medical history of multiple sclerosis and anxiety presents for a follow-up visit to the hospital. During the physical examination, the clinician performs the maneuver as depicted in the image. Which of the following drugs, if left suddenly, may cause electrical shock-like pain upon performing this maneuver?

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    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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A 45-year-old female with a past medical history of thyroid disease and type I diabetes has a history of numbness and tingling that started about 8 months ago in the right lower extremity. In the last 3 weeks, she also has noted the numbness has progressively worsened and now her numbness is up to her right thigh. She also complains of tightness around her abdomen and midback. She went to the beach for a tan and noticed she had some balance difficulties towards the right, and fell without head trauma. She was scared and came to the clinic this morning. On neck flexion, she feels an electrical shock down her spine and her right arm and leg with some vibration/pinprick deficits in the right lower extremity with some deficits of proprioception of the great toe. If this symptom causes severe pain, what is the best treatment of choice?



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A 55-year-old African American male presents to the emergency department complaining of generalized weakness, double vision, tingling in the hands bilaterally, and tongue numbness. He states that it started 2 days ago after smoking tobacco. On exam patient is sweating profusely, has a left-sided weakness, decreased sensation to light touch, vibration and sensation on both upper and lower extremities, +3 in patellar and biceps reflex, wide-based gait, and a positive Romberg sign. The patient also reports experiencing a shock-like sensation on neck flexion. Given the most likely etiology, which diagnostic modality would be the best to confirm this physical exam finding?



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Lhermitte sign is described as which of the following types of sensations?



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A 36-year-old female presents to the clinic for a scheduled appointment. She has a history of depression exacerbated six months ago with the death of her father, as well as a recent severe purulent cellulitis which required a brief hospitalization for intravenous antibiotics. The patient takes venlafaxine on an outpatient-basis but did not mention it to the clinicians treating her cellulitis. Her recovery was uneventful. Today, in the clinic, the patient requests a trial of stopping venlafaxine. The patient mentions that when her neighbor stopped taking this medication, she had terrible sensations of electricity coursing down her spine. In order to avoid this phenomenon, the physician wishes to prescribe a single dose of the appropriate medication as a bridge. Which of the following is the strongest contraindication to prescribing the appropriate medication to avoid Lhermitte sign in this patient?



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Lhermitte Sign - References

References

The Relationship Between Preoperative Clinical Presentation and Quantitative Magnetic Resonance Imaging Features in Patients With Degenerative Cervical Myelopathy., Nouri A,Tetreault L,Dalzell K,Zamorano JJ,Fehlings MG,, Neurosurgery, 2017 Jan 1     [PubMed]
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[Lhermitte's sign in three oncological patients]., Porta-Etessam J,Martínez-Salio A,Berbel A,Balsalobre-Aznar J,Esteban J,Benito-León J,Ruiz J,, Revista de neurologia, 2000 Apr 1-15     [PubMed]
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Al-Araji AH,Oger J, Reappraisal of Lhermitte's sign in multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2005 Aug     [PubMed]
Khan N,Smith MT, Multiple sclerosis-induced neuropathic pain: pharmacological management and pathophysiological insights from rodent EAE models. Inflammopharmacology. 2014 Feb     [PubMed]
Beckmann Y,Özakbaş S,Bülbül NG,Kösehasanoğulları G,Seçil Y,Bulut O,İncesu TK,Tokuçoğlu F,Ertekin C, Reassessment of Lhermitte's sign in multiple sclerosis. Acta neurologica Belgica. 2015 Dec     [PubMed]
Kanchandani R,Howe JG, Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature. Journal of neurology, neurosurgery, and psychiatry. 1982 Apr     [PubMed]
Etemadifar M,Mehrbod N,Dehghani L,Golabbakhsh A,Fereidan-Esfahani M,Akbari M,Nasr Z, Prevalence of Lhermitte's sign in multiple sclerosis versus neuromyelitis optica. Iranian journal of neurology. 2014     [PubMed]
Solaro C,Brichetto G,Amato MP,Cocco E,Colombo B,D'Aleo G,Gasperini C,Ghezzi A,Martinelli V,Milanese C,Patti F,Trojano M,Verdun E,Mancardi GL, The prevalence of pain in multiple sclerosis: a multicenter cross-sectional study. Neurology. 2004 Sep 14     [PubMed]
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Truini A,Galeotti F,Cruccu G, Treating pain in multiple sclerosis. Expert opinion on pharmacotherapy. 2011 Oct     [PubMed]

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