Lhermitte's Sign

Original Editor - Shristi Maharjan

Top Contributors - Shristi Maharjan and Kim Jackson  

Introduction[edit | edit source]

Lhermitte's sign is termed "Lhermitte's Phenomenon" or the "Barber Chair Phenomenon" described as a transient electric shock-like sensation extending exclusively down the spine and/or extremities upon flexion of the neck. Often, it is a sequel to neurological disease.[1] Upon the flexion of the nape, electric shock-like trigger or paresthesia [2],radiates down the spine, often into the upper and lower extremities, and sometimes to the trunk.[3] The sensation is rapid and brief. Hence, it only lasts for a short time. [4] It results as a stimulus to irritated/injured nerves or the spinal cord. It causes a similar kind of sensation/irritation as hitting the elbow.[5] Lhermitte's sign can be categorized as a symptom because it is generally explained by patients. [6] And is commonly one of the symptoms that patients diagnosed with multiple sclerosis mention during the assessment.[7]

History[edit | edit source]

Marie and Chatelin first described Lhermitte's sign in 1917. Beriel and Devic first discussed the reference to the symptom of multiple sclerosis (MS) in 1918. Later in 1924, Lhermitte et al. described it in detail in a patient with MS and electric dysesthesias. [3] "Jacques Jean Lhermitte, a forefather of modern clinical neurology, was a French neurologist famously recognized for his eponymously named 'Lhermitte’s sign.'" [8]

Pathophysiology[edit | edit source]

Causes[edit | edit source]

There are several conditions that exhibits the Lhermitte's sign:

  1. Disease/Condition[3]
  2. Radiation[3]
  3. Chemotherapy
    • High dose
    • Nitric Oxide Toxicity
    • Oxaliplatin-Induced[11]
  4. Parasitic[3]
    • Parasitic invasion of Spinal Cord
    • Herpes Zoster Infection

Review[edit | edit source]

In the patients undergoing radiotherapy, Lhermitte's sign is most likely to be seen in younger patients than the older patients. [12] Thus, patient age can be considered as one of the important factor. [10]

The development of Lhermitte's Sign in patients of younger age, with no available history of trauma to the head and neck or history of undergoing radiation, is of great diagnostic importance.[13]

Prognosis[edit | edit source]

In Radiogenic-Lhermitte's sign, the Lhermitte's phenomenon manifests three months following the radiotherapy and eventually recovers within six months time frame. However, few cases may persist for more than a year with severe symptoms. [14] It depends on the increased metabolic activity of the spinal cord due to the altered conduction along the demyelinated spinal cord.[15][14]

The administration of carbamazepine shows to alleviate the symptom. [16] The sensation is sharp and rapid and is rarely intolerable. Move over it exhibits that symptom mitigates following six to eight neck flexions.[13]

Conclusion[edit | edit source]

Lhermitte's sign is most common in multiple sclerosis and subacute combined degeneration, albeit seen in other cases as well. [13]

Limitation[edit | edit source]

Only a handful of studies with a large number of patients are available on Lhermitte's sign. Further research in same is required to corroborate its specificity and sensitivity.

References[edit | edit source]

  1. Teoli D, Rocha Cabrero F, Ghassemzadeh S. Lhermitte Sign. 2021 Jun 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29630289.
  2. Koehler PJ. Lhermitte, Jean. Encyclopedia of the Neurological Sciences (Second Edition) 2014, Page 884
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Khare S, Seth D. Lhermitte's sign: the current status. Annals of Indian Academy of Neurology. 2015 Apr;18(2):154.
  4. Pearce JM. Lhermitte's sign. Journal of neurology, neurosurgery, and psychiatry. 1994 Jul;57(7):846.
  5. Eske Jamie, Hammond Nancy, MD. What is Lhermitte's sign? MedicalNewsToday. March 17 2021
  6. Garcia-Moreno JM, Izquierdo G. Lhermitte's sign. Neurologia (Barcelona, Spain). 2002 Mar 1;17(3):143-50.
  7. Brown Tracy, Melinosky Christopher. Lhermitte’s Sign: What Is It? How Do You Treat It? WebMD. July 23 2020
  8. Chu DT, Hautecoeur P, Santoro JD. Jacques Jean Lhermitte and Lhermitte’s sign. Multiple Sclerosis Journal. 2020 Apr;26(4):501-4.
  9. Teive HA, Haratz S, Zavala J, Munhoz RP, Scola RH, Werneck LC. Lhermitte's sign and vitamin B12 deficiency: case report. Sao Paulo Medical Journal. 2009;127:171-3.
  10. 10.0 10.1 Pak D, Vineberg K, Feng F, Ten Haken RK, Eisbruch A. Lhermitte sign after chemo-IMRT of head-and-neck cancer: incidence, doses, and potential mechanisms. International Journal of Radiation Oncology* Biology* Physics. 2012 Aug 1;83(5):1528-33.
  11. Amaraneni A, Seth A, Itawi EA, Chandana SR. Oxaliplatin-induced Lhermitte sign. A case report and review of literature. Clinical colorectal cancer. 2014 Dec 1;13(4):257-9.
  12. Mul VE, de Jong JM, Murrer LH, van den Ende PL, Houben RM, Lacko M, Lambin P, Baumert BG. Lhermitte sign and myelopathy after irradiation of the cervical spinal cord in radiotherapy treatment of head and neck cancer. Strahlentherapie und Onkologie. 2012 Jan 1;188(1):71-6.
  13. 13.0 13.1 13.2 Kanchandani R, Howe JG. Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature. Journal of Neurology, Neurosurgery & Psychiatry. 1982 Apr 1;45(4):308-12.
  14. 14.0 14.1 Ésik O, Csere T, Stefanits K, Lengyel Z, Sáfrány G, Vönöczky K, Lengyel E, Nemeskéri C, Repa I, Trón L. A review on radiogenic Lhermitte’s sign. Pathology Oncology Research. 2003 Jun;9(2):115-20.
  15. Ésik O, Csere T, Stefanits K, Szakáll S, Lengyel Z, Sáfrány G, Vönöczky K, Lengyel E, Olajos J, Bajzik G, Trón L. Increased metabolic activity in the spinal cord of patients with long-standing Lhermitte’s sign. Strahlentherapie und Onkologie. 2003 Oct;179(10):690-3.
  16. Ekbom K. Carbamazepine: a symptomatic treatment of the paresthesiae associated with Lhermitte's sign. Annals of Indian Academy of Neurology. 2017 Apr 1;20(2).