What is transverse myelitis (TM)?


Transverse Myelitis (TM) is a neurological condition where both sides of the same section of the spinal cord becomes inflamed. The inflammation damages the insulation myelin sheath protecting the nerves. TM disrupts the messages sent by the spinal cord to the body causing pain, muscle weakness, paralysis, sensory problems, urinary and bladder issues.

TM can occur in both genders and across all age groups. In some cases, TM may be the first sign of a larger underlying neurological disorder like multiple sclerosis or neuromyelitis optica.

Causes


In more than 60% of the cases, the cause of TM is idiopathic or unknown. In the rest of the 40% it is associated with other autoimmune conditions like multiple sclerosis, neuromyelitis optica, systemic lupus erythematosus, Sjogren’s syndrome or sarcoidosis. In some cases, a previous infection may be the cause of TM:

  • Lyme disease
  • Measles
  • Viral infections
  • Bacterial infections

TM can also be a result of spinal cord injuries or spinal malformations which reduces the amount of oxygen to the spinal cord leading to inflammation. In this case, the nerve cells begin to die due to lack of oxygen and the dying tissue causes inflammation.

Signs and Symptoms


Symptoms may take a few hours to develop or even develop over the days. It can gradually progress over a few weeks. TM can cause symptoms on both sides of the body below the area of the spinal cord. Sometimes symptoms can be seen only on one side of the body. Common symptoms are:

  • Pain - sudden, sharp pain in the lower back shooting down to the legs
  • Abnormal neurological sensations - pricking, poking, burning, tingling, numbness, coldness are some of the sensations
  • Weakness in the arms and legs - heaviness and extreme weakness in the arms and legs
  • Bladder and bowel issues - loss of sensation and control

Diagnosis


Physical exams, medical history and a range of tests are usually done to confirm the diagnosis of TM. A neurologist will require you to answer a range of questions after which you will do a number of tests:

  • Blood tests - to rule out infections like HIV, check for vitamin B12 deficiency, copper levels etc. Blood is tested for autoantibodies (anti- aquaporin-4, anti-myelin oligodendrocyte) and other antibodies indicated for TM. NMO-IgG should be tested and if negative MOG-IgG should also be done
  • Nerve conduction velocity test - to understand the signaling process in the nerves
  • Magnetic resonance imaging (MRI) - to view a cross-section or 3D image of the brain and spinal cord. Spinal MRI can indicate the presence of lesions. A contrast agent is usually given to see if the agent leaks out into the spinal cord. Such a leakage is a clear sign of inflammation
  • Lumbar puncture for cerebrospinal fluid (CSF) analysis is a must. Lumbar puncture can look for markers of inflammation in the spinal fluid. These include elevated CSF white cell counts, elevated CSF proteins and elevated IgG index or the presence of oligoclonal bands.

Types


It is important to distinguish between types of idiopathic TM. It could be:

  • Acute partial TM
  • Acute complete TM
  • Longitudinally extensive TM (LETM)

Acute partial TM refers to an MRI lesion of less than 3 vertebral segments. Acute complete TM has clinical deficits even below the lesions. LETM is longer than 3 vertebral segments.

Treatment


A number of different treatments are available for TM depending on the severity and rate of progression:

  • Intravenous steroids - is used as first-line treatment for acute TM. Corticosteroids have anti-inflammatory, immunosuppressive properties. Commonly used steroids for TM include methylprednisolone and dexamethasone
  • Plasma exchange (PLEX) - is again used in severe and moderate TM when the patient cannot walk or loses sensory abilities in the lower limbs. PLEX takes care of inflammatory activity causing the flare
  • Immunosuppressive treatment - last line therapy for those who do not respond to IV steroids and PLEX. Intravenous cyclophosphamide is used in these cases. Patients must be closely monitored by a clinical team

Long term management is critical for TM. Suitable physiotherapy with certified experts and rehabilitation care to get back functions is critical. In many cases, patients with TM present with loss of bladder and bowel sensation because of partial paralysis. In these cases, interventions like catheterization or usage of diapers may be necessary.

Severe to moderate neuropathic pain is a common feature of TM and patients may need pain medications acetaminophen, ibuprofen and naproxen sodium. Pain can be treated with neurological drugs like pregabalin or gabapentin.

Patients may need psychological counselling if they face issues like depression. It is important to provide hand holding and family-community support.

Prognosis


Prognosis is often unpredictable in TM though most people have at least a partial recovery. Recovery takes anywhere between 3 months to 1 year. People who present with a rapid onset of symptoms and test positive for certain antibodies have a more negative prognosis than those who present with symptoms that took time to develop.

It must be understood that people recovering from TM will have slight, moderate or severe disability. In most cases, patients should be given ongoing chronic care with physical assistance and support.

If you have TM, try to get social support from social media groups on Facebook. Connecting with patients will help you learn about the disorder and help with patient hacks. It is important to stay positive and connected to people who can help you.

References