{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,20]],"date-time":"2026-04-20T22:06:16Z","timestamp":1776722776455,"version":"3.51.2"},"reference-count":30,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"13","license":[{"start":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T00:00:00Z","timestamp":1774828800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,3,30]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Vitamin B-12 deficiency can cause serious hematological and neurological complications. While most cases are chronic, acute presentations may occur. In autoimmune diseases, pernicious anemia is a common cause of vitamin B-12 deficiency. The authors present a case of acute vitamin B-12 deficiency following nitrous oxide anesthesia in a patient with Graves\u2019 disease, highlighting the impact of preexisting autoimmune conditions on perioperative management.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>A 44-year-old African American male with Graves\u2019 disease presented with symptoms of an L5\u2013S1 disc herniation and underwent an uncomplicated lumbar discectomy under nitrous oxide anesthesia with immediate symptom relief. In the early postoperative period, he developed gastrointestinal symptoms, a spastic myelopathy, and gait instability. Workup revealed severe vitamin B-12 deficiency, and his symptoms resolved with replacement therapy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>The acute presentation of vitamin B-12 deficiency is rare but can lead to serious and potentially irreversible neurological consequences if not recognized. Unexpected acute symptoms in the perioperative period require prompt evaluation. Awareness of past medical history and perioperative exposures can help identify the cause. Early recognition and treatment enable favorable outcomes in vitamin B-12 deficiency.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE25785\">https:\/\/thejns.org\/doi\/10.3171\/CASE25785<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case25785","type":"journal-article","created":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T10:04:48Z","timestamp":1775642688000},"source":"Crossref","is-referenced-by-count":1,"title":["The acute presentation of nitrous oxide\u2013induced vitamin B-12 deficiency in a postoperative lumbar discectomy patient: illustrative case"],"prefix":"10.3171","volume":"11","author":[{"given":"Anushka","family":"Acharya","sequence":"first","affiliation":[{"name":"Division of Neurosurgery, Howard University College of Medicine, Washington, DC"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Damirez","family":"Fossett","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, Howard University Hospital, Washington, DC"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"1","key":"bib1","series-title":"Adv Nutr","first-page":"54","article-title":"Vitamin B-12","volume":"3","author":"Allen","year":"2012","unstructured":"Allen LH.Vitamin B-12. Adv Nutr. 2012;3(1):54-55. doi:10.3945\/an.111.001370"},{"key":"bib2","article-title":"Vitamin","author":"Ankar","unstructured":"Ankar AKumar A.Vitamin B12 deficiency. In: StatPearls. StatPearls Publishing; 2025."},{"issue":"6","key":"bib3","series-title":"PLoS One","first-page":"e100379","article-title":"Vitamin B12 status in metformin treated patients: systematic review","volume":"9","author":"Liu","year":"2014","unstructured":"Liu QLi SQuan HLi J.Vitamin B12 status in metformin treated patients: systematic review. PLoS One. 2014;9(6):e100379. doi:10.1371\/journal.pone.0100379"},{"issue":"4","key":"bib4","series-title":"Adv Nutr","first-page":"511S","article-title":"Proton pump inhibitors, H2-receptor antagonists, metformin, and vitamin B-12 deficiency: clinical Implications","volume":"9","author":"Miller","year":"2018","unstructured":"Miller JW.Proton pump inhibitors, H2-receptor antagonists, metformin, and vitamin B-12 deficiency: clinical Implications. Adv Nutr. 2018;9(4):511S-518S. doi:10.1093\/advances\/nmy023"},{"key":"bib5","article-title":"Hyperthyroidism","author":"Mathew","unstructured":"Mathew PKaur JRawla P.Hyperthyroidism. In: StatPearls. StatPearls Publishing; 2025."},{"issue":"2","key":"bib6","series-title":"Am J Med","first-page":"183.e1","article-title":"Prevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease","volume":"123","author":"Boelaert","year":"2010","unstructured":"Boelaert KNewby PRSimmonds MJPrevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease. Am J Med. 2010;123(2):183.e1-183.e9. doi:10.1016\/j.amjmed.2009.06.030"},{"issue":"4","key":"bib7","series-title":"J Inherit Metab Dis","first-page":"673","article-title":"Vitamin B12, folate, and the methionine remethylation cycle-biochemistry, pathways, and regulation","volume":"42","author":"Froese","year":"2019","unstructured":"Froese DSFowler BBaumgartner MR.Vitamin B12, folate, and the methionine remethylation cycle-biochemistry, pathways, and regulation. J Inherit Metab Dis. 2019;42(4):673-685. doi:10.1002\/jimd.12009"},{"issue":"7","key":"bib8","series-title":"Cureus","first-page":"e9088","article-title":"Nitrous oxide-induced vitamin B12 deficiency resulting in myelopathy","volume":"12","author":"Campdesuner","year":"2020","unstructured":"Campdesuner VTeklie YAlkayali TPierce DGeorge J.Nitrous oxide-induced vitamin B12 deficiency resulting in myelopathy. Cureus. 2020;12(7):e9088. doi:10.7759\/cureus.9088"},{"issue":"1","key":"bib9","series-title":"Best Pract Res Clin Endocrinol Metab","first-page":"101373","article-title":"Thyro-entero-gastric autoimmunity: pathophysiology and implications for patient management","volume":"34","author":"Lahner","year":"2020","unstructured":"Lahner EConti LCicone FThyro-entero-gastric autoimmunity: pathophysiology and implications for patient management. Best Pract Res Clin Endocrinol Metab. 2020;34(1):101373. doi:10.1016\/j.beem.2019.101373"},{"issue":"9","key":"bib10","series-title":"Eur J Neurol","first-page":"1239","article-title":"Increased incidence of Guillain-Barr\u00e9 syndrome after surgery","volume":"19","author":"Gensicke","year":"2012","unstructured":"Gensicke HDatta ANDill PSchindler CFischer D.Increased incidence of Guillain-Barr\u00e9 syndrome after surgery. Eur J Neurol. 2012;19(9):1239-1244. doi:10.1111\/j.1468-1331.2012.03730.x"},{"key":"bib11","article-title":"Nitrous oxide","author":"Knuf","unstructured":"Knuf KFinney D.Nitrous oxide. In: StatPearls. StatPearls Publishing; 2025."},{"issue":"11","key":"bib12","series-title":"Lancet Neurol","first-page":"949","article-title":"Vitamin B12, folic acid, and the nervous system","volume":"5","author":"Reynolds","year":"2006","unstructured":"Reynolds E.Vitamin B12, folic acid, and the nervous system. Lancet Neurol. 2006;5(11):949-960. doi:10.1016\/S1474-4422(06)70598-1"},{"key":"bib13","series-title":"Food Chem Toxicol","first-page":"112894","article-title":"Nitrous oxide abuse in the emergency practice, and review of toxicity mechanisms and potential markers","volume":"162","author":"Joncquel Chevalier-Curt","year":"2022","unstructured":"Joncquel Chevalier-Curt MGrzych GTard CNitrous oxide abuse in the emergency practice, and review of toxicity mechanisms and potential markers. Food Chem Toxicol. 2022;162:112894. doi:10.1016\/j.fct.2022.112894"},{"key":"bib14","series-title":"Clin Neurol Neurosurg","first-page":"163","article-title":"Subacute combined degeneration of the spinal cord following nitrous oxide anesthesia: a systematic review of cases","volume":"173","author":"Patel","year":"2018","unstructured":"Patel KKMejia Munne JCGunness VRNSubacute combined degeneration of the spinal cord following nitrous oxide anesthesia: a systematic review of cases. Clin Neurol Neurosurg. 2018;173:163-168. doi:10.1016\/j.clineuro.2018.08.016"},{"issue":"3","key":"bib15","series-title":"Oman Med J","first-page":"194","article-title":"The effect of vitamin B12 infusion on prevention of nitrous oxide-induced homocysteine increase: a double-blind randomized controlled trial","volume":"29","author":"Kiasari","year":"2014","unstructured":"Kiasari AZFirouzian ABaradari AGNia HSKiasari SHM.The effect of vitamin B12 infusion on prevention of nitrous oxide-induced homocysteine increase: a double-blind randomized controlled trial. Oman Med J. 2014;29(3):194-197. doi:10.5001\/omj.2014.48"},{"issue":"1","key":"bib1","series-title":"Adv Nutr","first-page":"54","article-title":"Vitamin B-12","volume":"3","author":"Allen","year":"2012","unstructured":"Allen LH.Vitamin B-12. Adv Nutr. 2012;3(1):54-55. doi:10.3945\/an.111.001370"},{"key":"bib2","article-title":"Vitamin","author":"Ankar","unstructured":"Ankar AKumar A.Vitamin B12 deficiency. In: StatPearls. 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StatPearls Publishing; 2025."},{"issue":"2","key":"bib6","series-title":"Am J Med","first-page":"183.e1","article-title":"Prevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease","volume":"123","author":"Boelaert","year":"2010","unstructured":"Boelaert KNewby PRSimmonds MJPrevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease. Am J Med. 2010;123(2):183.e1-183.e9. doi:10.1016\/j.amjmed.2009.06.030"},{"issue":"4","key":"bib7","series-title":"J Inherit Metab Dis","first-page":"673","article-title":"Vitamin B12, folate, and the methionine remethylation cycle-biochemistry, pathways, and regulation","volume":"42","author":"Froese","year":"2019","unstructured":"Froese DSFowler BBaumgartner MR.Vitamin B12, folate, and the methionine remethylation cycle-biochemistry, pathways, and regulation. J Inherit Metab Dis. 2019;42(4):673-685. doi:10.1002\/jimd.12009"},{"issue":"7","key":"bib8","series-title":"Cureus","first-page":"e9088","article-title":"Nitrous oxide-induced vitamin B12 deficiency resulting in myelopathy","volume":"12","author":"Campdesuner","year":"2020","unstructured":"Campdesuner VTeklie YAlkayali TPierce DGeorge J.Nitrous oxide-induced vitamin B12 deficiency resulting in myelopathy. Cureus. 2020;12(7):e9088. doi:10.7759\/cureus.9088"},{"issue":"1","key":"bib9","series-title":"Best Pract Res Clin Endocrinol Metab","first-page":"101373","article-title":"Thyro-entero-gastric autoimmunity: pathophysiology and implications for patient management","volume":"34","author":"Lahner","year":"2020","unstructured":"Lahner EConti LCicone FThyro-entero-gastric autoimmunity: pathophysiology and implications for patient management. 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Clin Neurol Neurosurg. 2018;173:163-168. doi:10.1016\/j.clineuro.2018.08.016"},{"issue":"3","key":"bib15","series-title":"Oman Med J","first-page":"194","article-title":"The effect of vitamin B12 infusion on prevention of nitrous oxide-induced homocysteine increase: a double-blind randomized controlled trial","volume":"29","author":"Kiasari","year":"2014","unstructured":"Kiasari AZFirouzian ABaradari AGNia HSKiasari SHM.The effect of vitamin B12 infusion on prevention of nitrous oxide-induced homocysteine increase: a double-blind randomized controlled trial. 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