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Lam L, Koopowitz S, Thompson A, Smith G, Tan S, Gupta A, Kovoor J, Harroud A, Bacchi S, Slee M. A systematic review of the symptomatic management of Lhermitte's phenomenon. J Clin Neurosci 2023; 116:32-36. [PMID: 37603922 DOI: 10.1016/j.jocn.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/20/2023] [Accepted: 08/16/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Lhermitte's phenomenon (LP) is a transient shock-like sensation that radiates down the spine into the extremities, usually with neck flexion. The potential efficacy and tolerability of various symptomatic therapies in the management of LP have not been systematically reviewed previously. METHOD A systematic review was conducted using PubMed, EMBASE, and the Cochrane Library from inception to August 2022 for peer-reviewed articles describing the treatment of patients with Lhermitte's phenomenon. The review adheres to the PRISMA guidelines and was registered on PROSPERO. RESULTS This systematic review included sixty-six articles, which included 450 patients with LP. Treatment of the underlying cause varied by aetiology. Whilst LP is most commonly considered in the context of structural pathology of the cervical cord, medication-induced LP was a common theme in the literature. The most common cause of medication-induced LP was platinum-based chemotherapy agents such as cisplatin and oxaliplatin. In medication-induced LP, symptoms typically resolved with cessation of the causative agent. Non-pharmacological treatment options were associated with mild-moderate symptomatic improvement. The most commonly used agents to treat patients with LP were carbamazepine and gabapentin, which resulted in variable degrees of symptomatic benefit. CONCLUSIONS No randomised studies currently exist to support the use of symptomatic therapies to treat LP. Observational data suggest that some therapies may yield a symptomatic benefit in the management of LP. However, this systematic review identified a significant paucity of evidence in the literature, which suggests that further controlled studies are needed to investigate the optimal management of this common neurologic phenomenon.
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Affiliation(s)
- Lydia Lam
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia; University of Adelaide, Adelaide, SA 5005, Australia.
| | | | | | - Georgia Smith
- Flinders University, Bedford Park, SA 5042, Australia
| | - Sheryn Tan
- University of Adelaide, Adelaide, SA 5005, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, SA 5005, Australia
| | - Joshua Kovoor
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia; University of Adelaide, Adelaide, SA 5005, Australia
| | - Adil Harroud
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec H3A 0G4, Canada
| | - Stephen Bacchi
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia; University of Adelaide, Adelaide, SA 5005, Australia; Flinders University, Bedford Park, SA 5042, Australia
| | - Mark Slee
- Flinders University, Bedford Park, SA 5042, Australia
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Oxaliplatin-Induced Lhermitte's Sign in Gastric Cancer. Case Rep Oncol Med 2020; 2020:8826657. [PMID: 32670652 PMCID: PMC7333045 DOI: 10.1155/2020/8826657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/01/2020] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
A 64-year-old Japanese man with no significant medical history presented with epigastric discomfort of 2-weeks' duration. He was diagnosed with metastatic HER2-positive gastric cancer. Chemotherapy with capecitabine, oxaliplatin, and trastuzumab was initiated. During the eighth cycle, he suddenly complained of electric shock-like pain in both legs upon neck flexion, consistent with Lhermitte's sign. Oxaliplatin was discontinued, and Lhermitte's sign resolved after 3 months. Neurotoxicity is commonly observed in platinum-based chemotherapy, but Lhermitte's sign is rare. This is the first report of oxaliplatin-induced Lhermitte's sign in a gastric cancer patient.
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Youssef B, Shank J, Reddy JP, Pinnix CC, Farha G, Akhtari M, Allen PK, Fanale MA, Garcia JA, Horace PH, Milgrom S, Smith GL, Nieto Y, Arzu I, Wang H, Fowler N, Rodriguez MA, Dabaja B. Incidence and predictors of Lhermitte's sign among patients receiving mediastinal radiation for lymphoma. Radiat Oncol 2015; 10:206. [PMID: 26407853 PMCID: PMC4582821 DOI: 10.1186/s13014-015-0504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 09/09/2015] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To prospectively examine the risk of developing Lhermitte's sign (LS) in patients with lymphoma treated with modern-era chemotherapy followed by consolidation intensity-modulated radiation therapy. METHODS We prospectively interviewed all patients with lymphoma who received irradiation to the mediastinum from July 2011 through April 2014. We extracted patient, disease, and treatment-related variables from the medical records of those patients and dosimetric variables from treatment-planning systems and analyzed these factors to identify potential predictors of LS with Pearson chi-square tests. RESULTS During the study period 106 patients received mediastinal radiation for lymphoma, and 31 (29 %) developed LS. No correlations were found between LS and any of the variables examined, including total radiation dose, maximum point dose to the spinal cord, volume receiving 105 % of the dose, and volumes receiving 5 or 15 Gy. CONCLUSION In this group of patients, treatment with chemotherapy followed by intensity-modulated radiation therapy led to 29 % developing LS; this symptom was independent of radiation dose and seemed to be an idiosyncratic reaction. This relatively high incidence could have resulted from prospective use of a structured interview.
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Affiliation(s)
- Bassem Youssef
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - JoAnn Shank
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Jay P Reddy
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Chelsea C Pinnix
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - George Farha
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Mani Akhtari
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA. .,Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.
| | - Pamela K Allen
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Michelle A Fanale
- Departments of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - John A Garcia
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Patricia H Horace
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Sarah Milgrom
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Grace Li Smith
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Yago Nieto
- Departments of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Isadora Arzu
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - He Wang
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Nathan Fowler
- Departments of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Maria Alma Rodriguez
- Departments of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Bouthaina Dabaja
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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Amaraneni A, Seth A, Itawi EA, Chandana SR. Oxaliplatin-induced Lhermitte sign. A case report and review of literature. Clin Colorectal Cancer 2014; 13:257-9. [PMID: 25442817 DOI: 10.1016/j.clcc.2014.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 08/14/2014] [Accepted: 09/10/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Akshay Amaraneni
- Department of Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, MI
| | - Abhishek Seth
- Department of Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, MI
| | - Edward A Itawi
- Division of Colorectal Surgery, Bronson Methodist Hospital, Kalamazoo, MI
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Hafner J, Kumar K, Mulligan S, Ng K. Multifocal central nervous system demyelination and Lhermitte's phenomenon secondary to combination chemotherapy for chronic lymphocytic leukaemia. J Neurol Sci 2014; 338:218-9. [PMID: 24468536 DOI: 10.1016/j.jns.2013.12.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 12/19/2013] [Indexed: 11/29/2022]
Abstract
The CRF regime (cyclophosphamide, rituximab and fludarabine) is used for the treatment of chronic lymphocytic leukaemia. We report a case of diffuse CNS demyelination following treatment with CRF, presenting with Lhermitte's phenomenon, and imaging and neurophysiological evidence of demyelination. Fludarabine is the most likely causative agent, although CNS demyelination has not been previously described in low dose therapy.
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Affiliation(s)
- J Hafner
- Department of Neurology and Clinical Neurophysiology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; The University of Sydney, NSW 2006, Australia
| | - K Kumar
- Department of Neurology and Clinical Neurophysiology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; The University of Sydney, NSW 2006, Australia
| | - S Mulligan
- Department of Haematology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; The University of Sydney, NSW 2006, Australia
| | - K Ng
- Department of Neurology and Clinical Neurophysiology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; The University of Sydney, NSW 2006, Australia.
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Gemici C. Lhermitte's sign: Review with special emphasis in oncology practice. Crit Rev Oncol Hematol 2009; 74:79-86. [PMID: 19493683 DOI: 10.1016/j.critrevonc.2009.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 04/03/2009] [Accepted: 04/30/2009] [Indexed: 10/20/2022] Open
Abstract
Lhermitte's sign (LS) is characterized by electric shock like sensation, spreading along the spine in a cervico-caudal direction and also into both arms and legs, which is felt upon forward flexion of the neck. It is a myelopathy resulting from damage to sensory axons at the dorsal columns of the cervical or thoracic spinal cord and a well-known clinical sign in neurology practice. Patients with cancer may present with LS due to various causes either related to the tumor itself or to its treatment. Spinal cord tumors, radiotherapy and chemotherapy are possible causes of LS observed in oncology practice. While LS is observed with a frequency of 3.6-13% in large patient groups receiving radiotherapy for head and neck and thoracic malignancies, the true incidence of chemotherapy and spinal cord tumor induced LS is unknown with only few reported cases in the literature. In the present article, various pathologies causing Lhermitte's sign are reviewed with special emphasis on the implications of this sign in oncology practice.
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Affiliation(s)
- Cengiz Gemici
- Dr. Lutfi Kirdar Kartal Education and Research Hospital, Department of Oncology, Umraniye, Istanbul, Turkey.
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Esik 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. Pathol Oncol Res 2003; 9:115-20. [PMID: 12858217 DOI: 10.1007/bf03033755] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2003] [Accepted: 05/05/2003] [Indexed: 10/20/2022]
Abstract
Radiation myelopathy is a rare, but extremely serious side-effect of radiotherapy. Recovery from radiation-induced motor sequelae is rare, whereas, the regeneration of sensory losses is relatively frequent. Among the sensory radiogenic injuries of the spinal cord, Lhermitte's sign (LS) is most frequent. This review describes the clinical picture and diagnostic imaging signs of radiogenic LS. There have been only a few studies on large patient groups with radiogenic LS, demonstrating a rate of occurrence of 3.6-13%, relating mainly to mantle irradiation or the radiotherapy of head and neck tumors. These cases typically manifest themselves 3 months following radiotherapy and gradually disappear within 6 months. Only 3 LS cases have been described in the English literature with extraordinarily severe symptoms lasting for more than 1 year. MRI, a sensitive tool in the detection of demyelination, failed to reveal any pathological sign accompanying radiogenic LS. However, positron emission tomography demonstrated increased [18F]fluorodeoxyglucose accumulation and [15O]butanol perfusion, but a negligible [11C]methionine uptake in the irradiated spinal cord segments in patients with long-standing LS. These imaging data are suggestive of a close direct relationship between the regional perfusion and metabolism of the spinal cord, very much like the situation in the brain. We postulate that an altered, energy-demanding conduction along the demyelinated axons of patients with chronic radiogenic LS may explain the increased metabolism and perfusion.
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Affiliation(s)
- Olga Esik
- Department of Oncotherapy, Semmelweis University, H-1122 Budapest, Hungary.
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Abstract
Neurologic complications are common in children with cancer, but the literature dealing with this subject is sparse. Using a symptoms and signs approach, the most common causes for requesting a neurologic evaluation for this population are reviewed. The spectrum of neurologic symptoms in children with cancer differs from adults and requires the consulting neurologist to have a thorough knowledge of childhood cancer and its effects on the nervous system.
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Affiliation(s)
- N L Antunes
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Abstract
Radiotherapy remains the primary treatment of malignant epidural spinal cord compression. Therapeutic success depends on diagnosis before the development of neurological compromise and the prompt initiation of radiotherapy. Radiotherapy alone is effective in over 85% of cases of spinal cord compression that occur in highly radioresponsive tumors (multiple myeloma, germ cell or lymphoproliferative tumors). In the more common tumors, like breast, prostate, and lung cancer, response to radiotherapy is based on presenting neurologic deficits, extent of disease, duration of symptoms, and overall clinical status, including other sites of metastatic involvement. Surgery is recommended in addition to radiotherapy in selected cases, and further study is needed to better define the prognostic and neurological parameters for the surgical management of spinal cord compression. Improvements in outcome in the treatment of spinal cord compression will require approaches like combined modality therapy because of the limitations primarily imposed by the radiation tolerance of the spinal cord.
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Affiliation(s)
- N A Janjan
- Department of Radiotherapy, University of Texas, Houston, USA
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Fein DA, Marcus RB, Parsons JT, Mendenhall WM, Million RR. Lhermitte's sign: incidence and treatment variables influencing risk after irradiation of the cervical spinal cord. Int J Radiat Oncol Biol Phys 1993; 27:1029-33. [PMID: 8262823 DOI: 10.1016/0360-3016(93)90519-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Lhermitte's sign is a relatively infrequent sequela of irradiation of the cervical spinal cord. In this study, we sought to determine whether various treatment parameters influenced the likelihood of developing Lhermitte's sign. METHODS AND MATERIALS Between October 1964 and December 1987, 2901 patients with malignancies of the upper respiratory tract were treated at the University of Florida. The dose of radiation to the cervical spinal cord was calculated for those patients who had a minimum 1-year follow-up. A total of 1112 patients who received a minimum of 3000 cGy to at least 2 cm of cervical spinal cord were included in this analysis. RESULTS Forty patients (3.6%) developed Lhermitte's sign. The mean time to development of Lhermitte's sign after irradiation was 3 months, and the mean duration of symptoms was 6 months. No patient with Lhermitte's sign developed transverse myelitis. Several variables were examined in a univariate analysis, including total dose to the cervical spinal cord, length of cervical spinal cord irradiated, dose per fraction, continuous-course compared with split-course radiotherapy, and once-daily compared with twice-daily irradiation. Only two variables proved to be significant. Six (8%) of 75 patients who received > or = 5000 cGy to the cervical spinal cord developed Lhermitte's sign compared with 34 (3.3%) of 1037 patients who received < 5000 cGy (p = .04). For patients treated with once-daily fractionation, 28 (3.4%) of 821 patients who received < 200 cGy per fraction developed Lhermitte's sign compared with 6 (10%) of 58 patients who received > or = 200 cGy (p = .02). CONCLUSION An increased risk of developing Lhermitte's sign was demonstrated for patients who received either > or = 200 cGy per fraction (one fraction per day) or > or = 5000 cGy total dose to the cervical spinal cord.
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Affiliation(s)
- D A Fein
- Department of Radiation Oncology, University of Florida, College of Medicine, Gainesville 32610-0385
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