Recreational use of nitrous oxide (NO) has increased rapidly in recent years and is now the second most commonly used recreational drug among young people in the UK. There has been a corresponding rise in cases of nitrous oxide-induced subacute combined degeneration of the cord (NO-SACD), a pattern of myeloneuropathy usually associated with severe vitamin B deficiency. This can cause serious and permanent disability in young people but, if recognised early, may be effectively treated. All neurologists should be aware of NO-SACD and its treatment; however, there are currently no agreed guidelines. Based on our experience in East London, an area of high NO use, we provide practical advice on its recognition, investigation and treatment.