Transverse Myelitis

About 1400 new cases of transverse myelitis (TM) are diagnosed each year. TM is an inflammatory disorder that affects a restricted area of the spinal cord. It is characterized by symptoms and signs of neurologic dysfunction in motor and sensory tracts on both sides of the spinal cord. This is often associated with a clearly defined area of altered sensation on both sides of the body, weakness of both legs and sometimes the arms and urinary or bowel dysfunction. The “transverse” indicates dysfunction at a particular level across the spinal cord, reveals itself as altered function below this level and normal function above it. The cause of about 60 percent of TM cases is unknown, and is therefore referred to as idiopathic. Other cases can be linked to associated diseases.

TM is an unbiased condition, striking all age groups—from young children to the elderly—regardless of family history or gender. There are two age ranges, however, that are most common for the disorder to show up—10-19 years old and 30-39—years old. In younger patients, transverse myelitis may be a first indication of multiple sclerosis. In older adults, it may be a result of a spinal cord stroke.

Symptoms
There are four classic symptoms of transverse myelitis. Patients may have only one, or a combination of the following:

Weakness of the legs and/or arms: Some patients report stumbling, dragging one foot or notice that both legs seem heavier than normal. Depending on the level of involvement within the spinal cord, coordination or strength in the hands and arms may also be affected.

Sensory alteration: Patients who are experiencing altered sensitivity usually report numbness, tingling, coldness or burning. Up to 80 percent of patients experience heightened sensitivity to touch. Some even report that wearing clothes or a light touch with a finger causes significant pain.

Pain: Up to half of those with TM report pain as the first symptom of the disorder. It can be localized to the back, or appear as sharp, shooting pain that radiates down the legs, arms or around the torso. Loss of the ability to experience pain or temperature sensitivity is one of the most common sensory changes.

Bowel and bladder dysfunction: Some patients report bowel or bladder dysfunction as their first symptom of TM. This may mean an increased frequency or urge to urinate or defecate, incontinence, difficulty voiding, sensation of incomplete evacuation or constipation.

Diagnosis
There are two common evaluations following the onset of suspicious symptoms that are used as a first step:

MRI: An MRI may show a swelling of the spinal cord, a signal abnormality in the cord (which can indicate inflammation) or no abnormality at all.

Lumbar puncture (spinal tap): A spinal tap allows a sample of cerebrospinal fluid to be removed to determine the degree of inflammation present.

It is important to note that while both of the above procedures facilitate a diagnosis, the results do not predict a patient’s outcome from TM.

Treatment
Intravenous Steroids: This method is often used for patients with acute transverse myelitis. We routinely offer intravenous steroids for three to five days unless there are compelling reasons not to. The decision to offer continued steroids or add a new treatment is often based on the clinical course and MRI appearance at the end of five days of steroids.

Plasma Exchange (PLEX): This is often used for those with moderate to severe TM who don’t show much improvement after being treated with intravenous steroids. PLEX has been shown to be effective in adults with transverse myelitis or other inflammatory central nervous system disorders. Patients treated early (less than 20 days from the first symptom onset), men and those with a clinically incomplete lesion (i.e. with some motor function in the lower extremities, intact or brisk reflexes) tend to respond well to treatment with PLEX.

Other Treatments: Some patients respond very well to intravenous cyclophosphamide (a drug often used for lymphomas or leukemia). It is very important that an experienced oncology team be involved in the administration of this drug, and patients should be monitored carefully. Ongoing treatment with chemical agents that modify immune response (such as azathioprine, methotrexate, mycophenolate or oral cyclophosphamide) can be considered for the small subset of patients that experience recurrent TM.

Please see our transverse myelitis care - long term section for information about rehabilitative care and other ways to increase comfort.