{"id":24964,"date":"2025-07-31T11:21:07","date_gmt":"2025-07-31T10:21:07","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=24964"},"modified":"2025-08-04T09:34:38","modified_gmt":"2025-08-04T08:34:38","slug":"vitamin-b12-neurological-symptoms","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/haematology\/vitamin-b12-deficiency\/vitamin-b12-neurological-symptoms\/","title":{"rendered":"Vitamin B12 &amp; Neurological symptoms"},"content":{"rendered":"\n<ul class=\"wp-block-list\">\n<li>Neurological symptoms may be the only manifestation of&nbsp;B12&nbsp;deficiency<\/li>\n\n\n\n<li>Symptoms can include lower limb sensory symptoms, suggestive of either a spinal cord lesion (subacute combined degeneration or peripheral neuropathy) or visual (optic neuropathy).&nbsp; <strong><em>See below about Nitrous Oxide use<\/em><\/strong><\/li>\n\n\n\n<li>People with&nbsp;B12&nbsp;related sensory symptoms may especially have problems with proprioception and vibration loss<\/li>\n\n\n\n<li>Sensory symptoms are common in the normal population and modestly reduced&nbsp;B12&nbsp;levels (e.g. 120 to 180pg\/mL) are often \u2018false positives\u2019 (i.e. there is no connection between the symptoms and result)<\/li>\n\n\n\n<li>People with mild or intermittent lower limb sensory symptoms, retained ankle reflexes or normal vibration sense at the toes are unlikely to have a&nbsp;B12&nbsp;deficiency related neurological syndrome. Most such people, especially if symptoms are variable and intermittent, can be managed conservatively<\/li>\n\n\n\n<li>For people with mild sensory symptoms not responding to IM treatment it is unlikely that the symptoms were due to&nbsp;B12&nbsp;deficiency. Consider alternative explanations and discontinue alternate day IM treatment after 2 weeks. Maintenance may then be via the oral route unless there is a specific indication to give IM such as pernicious anaemia \/ malabsorption<\/li>\n\n\n\n<li>B12 related neurological syndromes may occur with normal haematological indices (thus a normal&nbsp;B12&nbsp;result may be a \u2018false negative\u2019 result) although this is rare<\/li>\n\n\n\n<li><strong><em>If there is combined&nbsp;B12&nbsp;and folate deficiency always start&nbsp;B12 intramuscular injections&nbsp;24 hours ahead of folate replacement<\/em><\/strong>.<\/li>\n\n\n\n<li>B12&nbsp;neurological symptoms typically take several months to improve and may not recover completely even with replacement. We suggest waiting at least 3 months for a clinical response<\/li>\n<\/ul>\n\n\n\n<p><strong><u>Nitrous Oxide use<\/u><\/strong><\/p>\n\n\n\n<p>People presenting with lower limb sensory symptoms, suggestive of either a spinal cord lesion (subacute combined degeneration or peripheral neuropathy) or visual (optic neuropathy) should be asked about Nitrous Oxide (NO) use.&nbsp; B12 levels will be NORMAL if checked in cases of Nitrous Oxide misuse.<\/p>\n\n\n\n<p style=\"text-decoration:underline\">Subacute degeneration of the cord is a medical emergency \u2013 please arrange same day emergency assessment in secondary care.<\/p>\n\n\n\n<p><strong>C.M &amp; A.K. 01-08-25<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\"><strong>Who to refer:<\/strong><\/h4>\n\n\n\n<p>Symptoms suggestive of either a spinal cord lesion (subacute combined degeneration or peripheral neuropathy) or visual (optic neuropathy) need same day specialist emergency assessment.<\/p>\n\n\n\n<p>Please seek specialist advice if symptoms are severe, there is diagnostic uncertainty, and a neurology opinion is required to help determine the cause.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p><\/p>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Nitrous Oxide use People presenting with lower limb sensory symptoms, suggestive of either a spinal cord lesion (subacute combined degeneration or peripheral neuropathy) or visual (optic neuropathy) should be asked about Nitrous Oxide (NO) use.&nbsp; B12 levels will be NORMAL if checked in cases of Nitrous Oxide misuse. Subacute degeneration of the cord is a<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":24957,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[1301],"class_list":["post-24964","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-vitamin-b12-neurological-symptoms"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"heatherlevy","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/heatherlevy\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/haematology\/https-apps-nhslothian-scot-refhelp-vitamin-b12-deficiency\/https-apps-nhslothian-scot-refhelp-vitamin-b12-neurological-symptoms\/\" rel=\"tag\">Vitamin B12 Neurological symptoms<\/a>","rttpg_excerpt":"Nitrous Oxide use People presenting with lower limb sensory symptoms, suggestive of either a spinal cord lesion (subacute combined degeneration or peripheral neuropathy) or visual (optic neuropathy) should be asked about Nitrous Oxide (NO) use.&nbsp; B12 levels will be NORMAL if checked in cases of Nitrous Oxide misuse. Subacute degeneration of the cord is a","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/24964","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=24964"}],"version-history":[{"count":2,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/24964\/revisions"}],"predecessor-version":[{"id":24999,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/24964\/revisions\/24999"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/24957"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=24964"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=24964"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}