笑气中毒导致脊髓病变的临床分析
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摘要
目的 探讨笑气中毒致脊髓病变的临床表现、血清学以及影像学的特点,以提高临床对笑气中毒致脊髓亚急性联合变性的认识。方法 回顾性分析2017年10月-2018年12月中国医科大学附属第一医院神经内科收治的12例确诊笑气中毒致脊髓病变患者的临床资料,总结其临床症状严重程度与血红蛋白、血清维生素B12和同型半胱氨酸水平以及影像学表现的特点,并分析吸食笑气时间(以6 m为界)与磁共振成像的关系。结果 12例患者平均发病年龄为(23. 75±4. 52)岁,均有不同程度的神经系统受损表现,血红蛋白降低者3例(25. 00%),血清维生素B12降低者7例(58. 33%),血清同型半胱氨酸升高者12例(100%);磁共振成像示脊髓侧索、后索T2加权高信号7例(58. 33%);吸食笑气时间≥6 m者6例(50. 00%),<6 m者6例(50. 00%)。结论 笑气中毒致脊髓亚急性联合变性多见于健康年轻人,血清同型半胱氨酸升高较血红蛋白和血清维生素B12水平下降对该病诊断更有意义;磁共振成像与否可能与吸食笑气时间长短有关。
Objective To explore the diverse presentations,ancillary tests and neuroimaging in patients with nitrous oxide-induced myelopathy. Methods Twelve patients with N_2O-induced SCD were included in this study. The severity of neurological impairment with laboratory data including serum vitamin B12 levels,hemoglobin,and homocysterine were analyzed,and images of spinal cord on magnetic resonance imaging( MRI) were evaluated. Results The average age of disease onset was( 23. 75 ± 4. 52). For most of the patients,sensory symptoms,often times as initial symptoms,occurred earlier than motor symptoms. There were only three patients( 25%) with decreased hemoglobin. Decreased serum vitamin B12 levels was detected in seven patients( 58. 33%). Elevated serum levels of homocysterine were found in all of our patients( 100%). Spinal cord lesions on MRI were observed in seven patients( 58. 33%). A half of the patients spent time abusing N_2O over six months,and the other was within six months. Conclusion The nitrous oxide-induced myelopathy always occurred in young. The elevated serum homocysterine is more effective than the decreased serum hemoglobin and vitamin B12.The occurrence rate of MRI may be associated with the time of abused N_2O.
Objective To explore the diverse presentations,ancillary tests and neuroimaging in patients with nitrous oxide-induced myelopathy. Methods Twelve patients with N_2O-induced SCD were included in this study. The severity of neurological impairment with laboratory data including serum vitamin B12 levels,hemoglobin,and homocysterine were analyzed,and images of spinal cord on magnetic resonance imaging( MRI) were evaluated. Results The average age of disease onset was( 23. 75 ± 4. 52). For most of the patients,sensory symptoms,often times as initial symptoms,occurred earlier than motor symptoms. There were only three patients( 25%) with decreased hemoglobin. Decreased serum vitamin B12 levels was detected in seven patients( 58. 33%). Elevated serum levels of homocysterine were found in all of our patients( 100%). Spinal cord lesions on MRI were observed in seven patients( 58. 33%). A half of the patients spent time abusing N_2O over six months,and the other was within six months. Conclusion The nitrous oxide-induced myelopathy always occurred in young. The elevated serum homocysterine is more effective than the decreased serum hemoglobin and vitamin B12.The occurrence rate of MRI may be associated with the time of abused N_2O.
引文
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[15]Myles PS,Chan MT,Leslie K,et al.Effect of nitrous oxide on plasma homocystine and folate in patients undergoing major surgery[J].Br JAnaesth,2008,100(6):780-786.
[16]Carmel R.Current concepts in cobalamin deficiency[J].Annu Rev Med,2000,51:357-375.
[17]Hemmer B,Glocker FX,Schumacher M,et al.Subacute combined degeneration:clinical,electrophysiological,and magnetic resonance imaging findings[J].J Neurol Neurosurg Psychiatry,1998,65(5):822-827.
[18]Hunt A,Harrington D,Robinson S.Vitamin B12 deficiency[J].BMJ,2014,349:5226.
[19]Sun HY,Lee JW,Park KS,et al.Spine MR imaging features of subacute combined degeneration patients[J].Eur Spine J,2014,23(5):1052-1058.
[20]姜明,胡洪涛,闰欣,等.亚急性联合变性病程不同时期MRI上病灶出现率及临床表现的差别[J].中风与神经疾病杂志,2013,30(3):222-225.
[21]Scalabrino G.Cobalamin(vitamin B12)in subacute combined degeneration and beyond:traditional interpretations and novel theories[J].Exp Neurology,2005,192(2):463-479.
[22]Murata S,Naritomi H,Sawada T.MRI in subacute combined degeneration[J].Neuroradiology,1994,36(5):408-409.
[2]Hathout L,El-Saden S.Nitrous oxide-induced B12 deficiency myelopathy:Perspectives on the clinical biochemistry of vitamin B12[J].JNeurol Sci,2011,301(1/2):1-8.
[3]Kaar SJ,Ferris J,Waldron J,et al.The rise of nitrous oxide abuse.An international survey of contemporary nitrous oxide use[J].J Psyehopharmacol,2016,30(4):395-401.
[4]姜季委,石碧川,周雅萍,等.笑气中毒致脊髓亚急性联合变性2例报告[J].中风与神经疾病杂志,2018,35(4):352-354.
[5]Healton EB,Savage DG,Brust JC,et al.Neurologic aspects of cobalamin deficiency[J].Medicine(Baitimore),1991,70(4):229-245.
[6]Becker DE,Rosenberg M.Nitrous oxide and the inhalation anesthetics[J].Anesth Prog,2008,55(4):124-130.
[7]Morris N,Lynch K,Greenberg SA.Severe motor neuropathy or neuronopathy due to nitrous oxide toxicity after correction of Vitamin B12deficiency[J].Muscle Nerve,2015,51(4):614-616.
[8]Middleton JA,Roffers JA.Peripheral neuropathy due to recreational use of nitrous oxide presenting after an ankle sprain with foot drop[J].Orthopedics,2018,41(3):e432-e433.
[9]于文慧,李德雨,席天阳,等.“笑气”中毒导致神经系统损害4例并文献复习[J].中风与神经疾病杂志,2018,25(5):556-561.
[10]王丽,范其江,董明睿,等.滥用笑气中毒致神经系统损害一例[J].中国现代神经疾病杂志,2016,16(8):533-537.
[11]李晓艳,李远方,贾佳,等.笑气滥用的神经系统损害(附1例报道并文献复习)[J].卒中与神经疾病,2018,25(2):173-178.
[12]Cao J,Su ZY,Xu SB,et al.Subacute combined degeneration:A retrospective study of 68 cases with short-term follow-up[J].Eur Neurol,2018,79(5/6):247-255.
[13]Li J,Ren M,Dong A,et al.A retrospective study of 23 cases with subacute combined degeneration[J].Int J Neurosci,2016,126(10):872-877.
[14]Graber JJ,Sherman FT,Kaufmann H,et al.Vitamin B12-responsive severe leukoencephalopathy and autonomic dysfunction in a patient with“normal”serum B12 levels[J].J Neurol Neurosurg Psychiatry,2010,81(12):1369-1371.
[15]Myles PS,Chan MT,Leslie K,et al.Effect of nitrous oxide on plasma homocystine and folate in patients undergoing major surgery[J].Br JAnaesth,2008,100(6):780-786.
[16]Carmel R.Current concepts in cobalamin deficiency[J].Annu Rev Med,2000,51:357-375.
[17]Hemmer B,Glocker FX,Schumacher M,et al.Subacute combined degeneration:clinical,electrophysiological,and magnetic resonance imaging findings[J].J Neurol Neurosurg Psychiatry,1998,65(5):822-827.
[18]Hunt A,Harrington D,Robinson S.Vitamin B12 deficiency[J].BMJ,2014,349:5226.
[19]Sun HY,Lee JW,Park KS,et al.Spine MR imaging features of subacute combined degeneration patients[J].Eur Spine J,2014,23(5):1052-1058.
[20]姜明,胡洪涛,闰欣,等.亚急性联合变性病程不同时期MRI上病灶出现率及临床表现的差别[J].中风与神经疾病杂志,2013,30(3):222-225.
[21]Scalabrino G.Cobalamin(vitamin B12)in subacute combined degeneration and beyond:traditional interpretations and novel theories[J].Exp Neurology,2005,192(2):463-479.
[22]Murata S,Naritomi H,Sawada T.MRI in subacute combined degeneration[J].Neuroradiology,1994,36(5):408-409.