Recognizing the symptoms of spinal cord compression can lead to prompt treatment and a more positive prognosis, but what if symptoms of cord compression in the cervical spine are really being caused by an underlying vitamin B12 deficiency?
- Neck pain
- severe headaches focused in the occipital region (the base of the skull)
- muscle weakness
- numbness and paraesthesia in the limbs and extremities
- problems walking (gait disturbance)
- loss of fine motor skills
- bowel and/or bladder dysfunction
B12 Deficiency: Causes and Effects
Many of these symptoms can also reflect an underlying B12 deficiency which has the effect of demyelinating the nerves. This loss of myelin means that the nerve fibers are no longer properly insulated and are less efficient at, or in some cases incapable of, transmitting nerve impulses. Vitamin B12 deficiency can occur due to low intake of the nutrient, autoimmune disease affecting absorption of utilization of the vitamin, parasitic infection, gastrointestinal surgery, malabsorption genetic disorders affecting certain enzymes and even the use of certain anaesthetic drugs like nitrous oxide.
Demyelinating diseases such as Multiple Sclerosis create similar symptoms to those listed above but administration of B12 and/or cervical spine surgery are not able to halt the demyelination as the disease occurs when the body attacks itself. In cases of RA, however, demyelination may be triggered, rarely, by medications prescribed for the autoimmune condition, such as tumor-necrosis factor alpha-blocking agents. The small number of patients experiencing these symptoms tend to do so shortly after beginning a course of such drugs and are usually seen to experience a full resolution of the demyelination symptoms after the drug is stopped. In rare cases the symptoms start later and do not resolve even after the medications are stopped.
Diagnosing B12 Deficiency
Symptoms that physicians and patients should look for when considering if headaches, pain and paraesthesia are related to RA, cervical spine degeneration and/or vitamin B12 deficiency include neuropsychiatric symptoms. Patients’ behavior may change, concentration problems can develop, memory may falter and visual disturbances arise in some severe cases. Unfortunately, patients with RA are at risk of having B12 deficiency misdiagnosed as the anaemia caused by such deficiency can also be a result of methotrexate treatment. Those with macrocytosis are, therefore, recommended to have their B12 levels checked before a diagnosis is made. Iron deficiency may also mask this B12 deficiency and some patients suffering the effects of low levels of B12 may have low-normal or even normal blood test results but still be diagnosed with B12 deficiency following tests of their homocysteine and methylmalonic acid levels (both indices of B12 deficiency).
Treating Vitamin B12 Deficiency
Where symptoms are attributable to a deficiency of vitamin B12 the patient may receive either intramuscular injections of the vitamin or oral supplements if malabsorption is not a factor. Symptoms will take some time to reverse but prognosis is usually good, especially in younger patients (below the age of fifty) and where demyelination is not too extensive (less than seven vertebral segments). Unfortunately, those whose condition is not recognized quickly can reach a point where successful reversal of the loss of myelin becomes unlikely and some patients continue to suffer symptoms even after myelin is restored (which can also suggest another cause of the symptoms, such as nerve compression).
Ruling Out B12 Deficiency in Cases of RA
Patients will usually receive maintenance supplementation of vitamin B12 and undergo magnetic resonance imaging (MRI) to assess the degree of remyelination. MRI can also highlight other possible problems in the cervical spine connected to RA, including atlantoaxial subluxation and spinal cord compression which can occur when joint degeneration becomes severe. In these cases, neck surgery will usually be necessary in order to fuse the spine, restoring the correct position and stability and taking pressure off the spinal cord. Early MRI use can rule out such possible diagnoses and allow physicians to concentrate on bloodwork and other potential causes of neck pain, arm tingling, and headaches, such as vitamin B12 deficiency.
Vasiliki-Kalliopi Bournia, MD, Vasiliki Dania, MD, Stephanos Lachanis, MD, Maria Konsta, MD, Alexios Iliopoulos, MDDisclosures, J Clin Rheumatol. 2012;18(7):372-374.
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