Transverse myelitis is a rare inflammatory disease affecting the spinal cord resulting in weakness, sensory alterations, and autonomic dysfunction. Inflammation within the spinal cord interrupts the motor and sensory pathways to and from from the body and brain, which is why transverse myelitis presents with rapidly progressing muscle weakness or paralysis, beginning with the legs and potentially moving to the arms. The arm and trunk involvement depends on the level of spinal cord involvement. Sensation to light touch, vibration, proprioception, and pain below the spinal level affected is the earliest and hence the most common feature of transverse myelitis. Patients also complain of a tight banding or girdle-like sensation around the trunk with paresthesia (being very sensitive to touch).
Transverse myelitis typically affects the mid-thoracic region in adults or the cervical region in children. This results in pain in the back, extremities, or abdomen, as well as tingling, numbness, burning sensations. In addition, sexual dysfunction can also be experienced due to sensory and autonomic involvement. There may be urinary urgency, bowel or bladder incontinence, difficulty or inability to void, and incomplete evacuation of bowel, or constipation. Other symptoms include spasticity and fatigue, which are also fairly common. Some patients also suffer from depression given the severity of symptoms. These symptoms can progress over a few hours or days, and last for a few weeks, although most symptoms decline within 2 weeks.
The recovery from transverse myelitis generally begins within 1 to 3 months after acute treatment, but it may not be complete. If there is no improvement by 3 months, there is a diminished chance of any significant recovery after that. Signs of poor prognosis include a rapid progression of clinical symptoms, the presence of back pain, the presence of spinal shock, and the presence of elevated 14-3-3 protein in the cerebrospinal fluid (CSF) during the acute phase.
In a small subset of patients, transverse myelitis can be recurrent, which can be predicted early on if there are multifocal lesions in the spinal cord, lesions in the brain, presence of an underlying mixed connective tissue disease, the presence of oligoclonal bands in the CSF, and/or NMO-IgG antibodies.
Transverse myelitis can be idiopathic or secondary. The idiopathic type is likely due to abnormal and excessive activation of an immune response (due to unknown causes) against the spinal cord resulting in inflammation and tissue damage. Alternatively, it can be secondary to a number of conditions, such as Multiple sclerosis and neuromyelitis (NMO-IgG autoantibody-mediated disorder). Transverse myelitis tends to be secondary to viral and bacterial infections, especially rubeola, varicella, variola, rubella, influenza, and mumps. It is thought that these infections cause derangement of the immune system, which leads to an autoimmune attack on the spinal cord, resulting in transverse myelitis.
The diagnosis of TM is based on clinical symptomology and radiologic-pathologic findings (contrast-enhanced MRI as gadolinium enhancement or on lumbar puncture as elevated CSF white blood cells or IgG index).
Treatment includes intravenous steroid administration, plasma exchange (PLEX), cyclophosphamide or other immunomodulatory agents. Ancillary care includes rehabilitative care, including occupational and physical therapies. Special attention needs to be paid to symptoms of autonomic/bowel/bladder/sexual dysfunction. The associated nerve pain can be hard to treat and certain antidepressants such as amitriptyline, or anticonvulsants, such as carbamazepine, phenytoin, pregabalin, or gabapentin are potentially helpful.