Nitrous oxide-induced myeloneuropathy: a case series

Devan Mair; Alvar Paris; Safiya A Zaloum; Laura M White; Katherine C Dodd; Christina Englezou; Farhin Patel; Siraj Abualnaja; James B Lilleker; David Gosal; Tom Hayton; Di Liang; Holger Allroggen; Mark Pucci; Stephen Keddie; Alastair J Noyce

doi:10.1136/jnnp-2023-331131

Nitrous oxide-induced myeloneuropathy: a case series

Devan Mair, Alvar Paris, Safiya A Zaloum, Laura M White, Katherine C Dodd, Christina Englezou, Farhin Patel, Siraj Abualnaja, James B Lilleker, David Gosal, Tom Hayton, Di Liang, Holger Allroggen, Mark Pucci, Stephen Keddie, Alastair J Noyce

Research output: Contribution to journal › Article › peer-review

Abstract

BACKGROUND: Nitrous oxide (N2O) is the second most common recreational drug used by 16- to 24-year-olds in the UK. Neurological symptoms can occur in some people that use N2O recreationally, but most information comes from small case series.

METHODS: We describe 119 patients with N2O-myeloneuropathy seen at NHS teaching hospitals in three of the UK's largest cities: London, Birmingham and Manchester. This work summarises the clinical and investigative findings in the largest case series to date.

RESULTS: Paraesthesia was the presenting complaint in 85% of cases, with the lower limbs more commonly affected than the upper limbs. Gait ataxia was common, and bladder and bowel disturbance were frequent additional symptoms. The mid-cervical region of the spinal cord (C3-C5) was most often affected on MRI T2-weighted imaging. The number of N2O canisters consumed per week correlated with methylmalonic acid levels in the blood as a measure of functional B12 deficiency (rho (ρ)=0.44, p=0.04).

CONCLUSIONS: Preventable neurological harm from N2O abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of N2O has led to an apparent rise in cases of N2O-myeloneuropathy in several areas of the UK. Our results highlight the range of clinical manifestations in a large group of patients to improve awareness of risk, aid early recognition, and promote timely treatment.

Original language	English
Pages (from-to)	681-688
Number of pages	8
Journal	Journal of neurology, neurosurgery, and psychiatry
Volume	94
Issue number	9
Early online date	30 May 2023
DOIs	https://doi.org/10.1136/jnnp-2023-331131
Publication status	Published - 1 Sept 2023

Keywords

B12 deficiency
clinical neurology
myelopathy
neuropathy

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Mair, D., Paris, A., Zaloum, S. A., White, L. M., Dodd, K. C., Englezou, C., Patel, F., Abualnaja, S., Lilleker, J. B., Gosal, D., Hayton, T., Liang, D., Allroggen, H., Pucci, M., Keddie, S., & Noyce, A. J. (2023). Nitrous oxide-induced myeloneuropathy: a case series. Journal of neurology, neurosurgery, and psychiatry, 94(9), 681-688. https://doi.org/10.1136/jnnp-2023-331131

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title = "Nitrous oxide-induced myeloneuropathy: a case series",

abstract = "BACKGROUND: Nitrous oxide (N2O) is the second most common recreational drug used by 16- to 24-year-olds in the UK. Neurological symptoms can occur in some people that use N2O recreationally, but most information comes from small case series.METHODS: We describe 119 patients with N2O-myeloneuropathy seen at NHS teaching hospitals in three of the UK's largest cities: London, Birmingham and Manchester. This work summarises the clinical and investigative findings in the largest case series to date.RESULTS: Paraesthesia was the presenting complaint in 85% of cases, with the lower limbs more commonly affected than the upper limbs. Gait ataxia was common, and bladder and bowel disturbance were frequent additional symptoms. The mid-cervical region of the spinal cord (C3-C5) was most often affected on MRI T2-weighted imaging. The number of N2O canisters consumed per week correlated with methylmalonic acid levels in the blood as a measure of functional B12 deficiency (rho (ρ)=0.44, p=0.04).CONCLUSIONS: Preventable neurological harm from N2O abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of N2O has led to an apparent rise in cases of N2O-myeloneuropathy in several areas of the UK. Our results highlight the range of clinical manifestations in a large group of patients to improve awareness of risk, aid early recognition, and promote timely treatment.",

keywords = "B12 deficiency, clinical neurology, myelopathy, neuropathy",

author = "Devan Mair and Alvar Paris and Zaloum, {Safiya A} and White, {Laura M} and Dodd, {Katherine C} and Christina Englezou and Farhin Patel and Siraj Abualnaja and Lilleker, {James B} and David Gosal and Tom Hayton and Di Liang and Holger Allroggen and Mark Pucci and Stephen Keddie and Noyce, {Alastair J}",

note = "{\textcopyright} Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.",

year = "2023",

month = sep,

day = "1",

doi = "10.1136/jnnp-2023-331131",

language = "English",

volume = "94",

pages = "681--688",

journal = "Journal of neurology, neurosurgery, and psychiatry",

issn = "0022-3050",

publisher = "BMJ ",

number = "9",

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TY - JOUR

T1 - Nitrous oxide-induced myeloneuropathy

T2 - a case series

AU - Mair, Devan

AU - Paris, Alvar

AU - Zaloum, Safiya A

AU - White, Laura M

AU - Dodd, Katherine C

AU - Englezou, Christina

AU - Patel, Farhin

AU - Abualnaja, Siraj

AU - Lilleker, James B

AU - Gosal, David

AU - Hayton, Tom

AU - Liang, Di

AU - Allroggen, Holger

AU - Pucci, Mark

AU - Keddie, Stephen

AU - Noyce, Alastair J

PY - 2023/9/1

Y1 - 2023/9/1

N2 - BACKGROUND: Nitrous oxide (N2O) is the second most common recreational drug used by 16- to 24-year-olds in the UK. Neurological symptoms can occur in some people that use N2O recreationally, but most information comes from small case series.METHODS: We describe 119 patients with N2O-myeloneuropathy seen at NHS teaching hospitals in three of the UK's largest cities: London, Birmingham and Manchester. This work summarises the clinical and investigative findings in the largest case series to date.RESULTS: Paraesthesia was the presenting complaint in 85% of cases, with the lower limbs more commonly affected than the upper limbs. Gait ataxia was common, and bladder and bowel disturbance were frequent additional symptoms. The mid-cervical region of the spinal cord (C3-C5) was most often affected on MRI T2-weighted imaging. The number of N2O canisters consumed per week correlated with methylmalonic acid levels in the blood as a measure of functional B12 deficiency (rho (ρ)=0.44, p=0.04).CONCLUSIONS: Preventable neurological harm from N2O abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of N2O has led to an apparent rise in cases of N2O-myeloneuropathy in several areas of the UK. Our results highlight the range of clinical manifestations in a large group of patients to improve awareness of risk, aid early recognition, and promote timely treatment.

AB - BACKGROUND: Nitrous oxide (N2O) is the second most common recreational drug used by 16- to 24-year-olds in the UK. Neurological symptoms can occur in some people that use N2O recreationally, but most information comes from small case series.METHODS: We describe 119 patients with N2O-myeloneuropathy seen at NHS teaching hospitals in three of the UK's largest cities: London, Birmingham and Manchester. This work summarises the clinical and investigative findings in the largest case series to date.RESULTS: Paraesthesia was the presenting complaint in 85% of cases, with the lower limbs more commonly affected than the upper limbs. Gait ataxia was common, and bladder and bowel disturbance were frequent additional symptoms. The mid-cervical region of the spinal cord (C3-C5) was most often affected on MRI T2-weighted imaging. The number of N2O canisters consumed per week correlated with methylmalonic acid levels in the blood as a measure of functional B12 deficiency (rho (ρ)=0.44, p=0.04).CONCLUSIONS: Preventable neurological harm from N2O abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of N2O has led to an apparent rise in cases of N2O-myeloneuropathy in several areas of the UK. Our results highlight the range of clinical manifestations in a large group of patients to improve awareness of risk, aid early recognition, and promote timely treatment.

KW - B12 deficiency

KW - clinical neurology

KW - myelopathy

KW - neuropathy

U2 - 10.1136/jnnp-2023-331131

DO - 10.1136/jnnp-2023-331131

M3 - Article

C2 - 37253616

SN - 0022-3050

VL - 94

SP - 681

EP - 688

JO - Journal of neurology, neurosurgery, and psychiatry

JF - Journal of neurology, neurosurgery, and psychiatry

IS - 9

ER -

Nitrous oxide-induced myeloneuropathy: a case series

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Keywords

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