Lhermitte Sign Test

What is Lhermitte's sign?

Lhermitte's sign, also known as the barber chair phenomenon or Lhermitte's phenomenon, is an electric shock-like sensation that travels down the spine and may extend into the arms and legs. Neck movements trigger this sensation, especially when the head is flexed forward.

What problems can Lhermitte's sign cause?

This can cause intense bursts of pain that are startling and uncomfortable. Although the sensation usually lasts only a few seconds, it can be disruptive. Patients often describe it as an electric shock or a buzz that runs down the back, sometimes reaching the extremities. If it occurs frequently or is triggered by joint movements, this symptom can impact daily activities and quality of life.

What is this sign indicative of?

Lhermitte's sign is indicative of dysfunction in the cervical spinal cord, associated with demyelinating disorders such as multiple sclerosis (MS). It can also suggest other conditions affecting the upper cervical spinal cord, such as cervical spinal cord tumors, cervical spondylosis, subacute combined degeneration of the spinal cord, or spinal cord compression. Additionally, it can occur as a result of neck trauma, certain neurological diseases, or as a side effect of early delayed radiation injury.

What is multiple sclerosis (MS)?

Multiple sclerosis is a chronic, immune-mediated neurological disease that affects the central nervous system, the brain and spinal cord. It involves the immune system attacking the myelin sheath, the protective covering of nerve fibers, leading to inflammation and subsequent damage. This damage disrupts the normal flow of electrical impulses along the nerves.

MS' relation to Lhermitte's sign

Lhermitte's Sign is commonly associated with MS. In MS, immune-mediated damage to the myelin sheath, particularly in the cervical spine, leads to the development of Lhermitte's Sign. This happens because damaged nerves in the spinal cord become overly sensitive, especially with movements like flexing the neck forward. Patients with MS may experience Lhermitte's Sign as one of their many symptoms, and its presence can be an indicator of demyelination in the cervical spinal cord.

Complications MS may lead to

MS can lead to a variety of complications, both neurological and systemic. It can cause neurological symptoms, such as muscle weakness, spasticity, coordination problems, visual disturbances, and cognitive impairment. It can cause neuropathic pain, including the pain experienced during Lhermitte's sign, due to the damaged nerves sending abnormal pain signals to the brain. Muscle weakness, spasticity, and balance problems can result in mobility issues, making walking and other physical activities challenging.

Furthermore, continuous demyelination and inflammation can lead to progressive spinal cord damage, which can worsen symptoms and disability. It can also affect the autonomic nerves that control bladder and bowel function, leading to incontinence or retention.

Chronic fatigue is a common and debilitating symptom in MS, significantly affecting the patient's ability to perform daily activities. This fatigue, compounded with the chronic nature of MS and its unpredictable course, can lead to psychological complications such as depression and anxiety.

What is the Lhermitte Sign Test?

The Lhermitte Sign Test is a diagnostic procedure used to trigger Lhermitte's sign, an electrical sensation running down the spine and limbs when the head is moved forward. Named after the French neurologist Jacques Jean Lhermitte, this test helps identify issues related to the cervical cord and associated neurological symptoms in conditions like MS.

How is this test conducted?

The test for Lhermitte's sign is extremely straightforward, and it doesn't require any special equipment. It involves just one movement from a seated or standing position. Here's a detailed procedure:

1. Explain the procedure to the patient to ensure they are comfortable and understand what to expect.
2. Ensure the patient is seated or standing in a stable position.
3. Observe the patient's baseline posture and any spontaneous symptoms they may report.
4. Instruct the patient to slowly bend their neck forward, bringing their chin towards their chest. Monitor the patient closely for any signs of discomfort or the onset of symptoms.
5. Ask the patient to describe any sensations they experience during the neck flexion. Specifically, inquire about the presence of an electric shock-like sensation, its intensity, duration, and affected areas (spine, arms, legs, etc.).

How are the results interpreted?

A positive Lhermitte Sign Test indicates an electric shock-like sensation down the spine with neck flexion, suggesting cervical spinal cord issues. It is common in multiple sclerosis and other conditions like cervical spondylosis and cord tumors. Further investigation with cervical spine MRI and vitamin B12 tests may be needed.

On the other hand, a negative test means no electric shock-like sensation upon neck flexion, suggesting no significant cervical spinal cord issues. Still, it doesn't rule out multiple sclerosis or other neurological conditions—further tests and evaluation are needed for a complete diagnosis.

Next steps after conducting this test

After conducting the initial test, take an approach to manage the patient's condition effectively. The following steps outline the key actions to ensure thorough evaluation, appropriate treatment, and ongoing support for the patient.

1. Explain the test results and reassure the patient about Lhermitte's sign. Provide materials on managing it, including strategies to avoid triggers and reduce symptoms.
2. Conduct further diagnostic testing. Schedule a cervical spine MRI and conduct blood tests for vitamin B12 levels. If needed, refer the patient for EMG and nerve conduction studies.
3. Refer to specialists as needed: a neurologist for evaluation, a physical therapist for posture and muscle relaxation, and a pain specialist for pain management.
4. Develop a treatment plan and a long-term management plan that includes lifestyle changes, mechanical devices, therapies, and appropriate medications based on the patient's condition.
5. Schedule regular appointments to monitor progress and adjust treatment. Encourage symptom tracking and maintain open communication for concerns.

How to use our Lhermitte Sign Test template

For easier integration with your clinical practice, here's how to use our template:

Step 1: Download the Template

Begin by accessing or downloading the Lhermitte Sign Test template from our resource library on the Carepatron app or on our website. Ensure that you have a printed or digital copy ready for use during patient consultations.

Step 2: Explain the procedure and fill out the details

Before conducting the test, explain the procedure to the patient, including what Lhermitte's sign is and why the test is being performed. Fill out the patient's information on the template.

Step 3: Conduct the Lhermitte's Sign Test

Perform the Lhermitte's Sign Test by instructing the patient to flex their neck forward. Observe for any electric shock-like sensations experienced by the patient.

Step 4: Record the results

Document the results of the neck flexion test on the template. Tick whether the test was positive or negative based on your observation, and note the intensity and other subjective details in the additional notes.