Transverse Myelitis

Overview

Transverse myelitis is a neurological disorder characterized by inflammation across both sides of one level, or segment, of the spinal cord. This inflammation can disrupt the normal functioning of the spinal cord, resulting in varying degrees of motor, sensory, and autonomic dysfunction. The condition may occur as a one-time episode or as part of a broader disease process, such as multiple sclerosis or neuromyelitis optica. Although transverse myelitis can affect individuals of any age or gender, it most commonly occurs in young adults and middle-aged individuals. The onset is typically acute or subacute, developing over hours to days, and can lead to significant disability if not treated promptly.

Causes

Transverse myelitis can be idiopathic (with no identifiable cause) or secondary to other underlying conditions. Common causes include:

• Autoimmune diseases: Conditions like multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and systemic lupus erythematosus can trigger immune-mediated attacks on the spinal cord.

• Infections: Viral (e.g., herpesviruses, Epstein-Barr virus, HIV, Zika), bacterial (e.g., Lyme disease, syphilis), fungal, or parasitic infections can lead to post-infectious or direct infectious inflammation.

• Post-vaccination responses: Rarely, vaccines may trigger an autoimmune response leading to transverse myelitis.

• Paraneoplastic syndromes: Autoimmune responses associated with cancers can target the spinal cord.

• Other inflammatory disorders: Sarcoidosis and Sjögren’s syndrome have also been associated with transverse myelitis.

Symptoms

Symptoms of transverse myelitis vary depending on the level and severity of spinal cord inflammation. Common clinical features include:

• Motor symptoms: Weakness in the arms or legs, often starting on one side and progressing to both sides (paraparesis or quadriparesis).

• Sensory disturbances: Numbness, tingling, or a band-like sensation (a tight feeling) around the torso or limbs.

• Autonomic dysfunction: Bladder and bowel issues such as urinary retention, urgency, constipation, or incontinence.

• Pain: Localized back pain or radicular pain radiating from the spine, sometimes severe.

• Rapid progression: Symptoms can worsen over hours to days, often reaching their peak within 2 to 4 days of onset.

In severe cases, paralysis and complete loss of sensation below the affected spinal level may occur.

Diagnosis

Diagnosing transverse myelitis involves a combination of clinical evaluation, imaging, and laboratory tests to confirm spinal cord inflammation and rule out other conditions. Key diagnostic tools include:

• MRI of the spine: Reveals areas of inflammation and helps exclude compressive causes such as tumors or herniated discs. Lesions typically appear over one or more vertebral segments.

• Lumbar puncture (spinal tap): Analyzes cerebrospinal fluid (CSF) for elevated white blood cells, protein, or oligoclonal bands suggestive of autoimmune or infectious causes.

• Blood tests: To check for infections, autoimmune markers, vitamin deficiencies, and antibodies associated with MS (e.g., aquaporin-4, MOG antibodies).

• Evoked potentials: May be used to assess the functional integrity of nerve pathways.

The diagnosis requires exclusion of structural abnormalities and confirmation of non-compressive spinal cord inflammation.

Treatment

The treatment of transverse myelitis is aimed at reducing spinal cord inflammation, managing symptoms, and preventing long-term complications. Common treatment options include:

• High-dose corticosteroids: Intravenous methylprednisolone is typically given for 3–5 days to reduce inflammation.

• Plasma exchange (plasmapheresis): Used in severe or steroid-refractory cases, especially in autoimmune-mediated transverse myelitis.

• Immunosuppressive therapy: In cases linked to autoimmune conditions like NMOSD or lupus, medications such as azathioprine, rituximab, or mycophenolate mofetil may be prescribed.

• Antibiotics or antivirals: If an infectious cause is identified, targeted antimicrobial therapy is initiated.

• Rehabilitation: Physical and occupational therapy to improve mobility, muscle strength, and daily function.

• Symptomatic management: Includes pain control, bladder and bowel management, and treatment of spasticity with muscle relaxants or physical therapy.

Prognosis

The prognosis for transverse myelitis varies depending on the cause, severity of the initial attack, and promptness of treatment. Key considerations include:

• Recovery timeline: Some individuals recover fully within a few months, while others may experience residual weakness, numbness, or bladder dysfunction.

• Degree of recovery: Approximately one-third of patients recover completely, one-third have moderate disability, and one-third have severe disability requiring assistive devices or long-term care.

• Recurrent episodes: While idiopathic cases are often monophasic, patients with underlying autoimmune disorders like MS or NMOSD may experience recurrent attacks.

• Early intervention: Prompt diagnosis and treatment greatly improve the chances of recovery and reduce long-term disability.

Long-term follow-up with neurology and rehabilitation specialists is often required to monitor disease progression and optimize quality of life.