From the Guidelines
Transverse myelitis should be treated with high-dose glucocorticoids, such as intravenous methylprednisolone, as early as possible, and continued if infection has been ruled out, as this approach has been shown to be effective in reducing neurological deficits and improving outcomes 1. The management of transverse myelitis involves a combination of diagnostic tests and therapeutic interventions.
- Diagnostic tests include MRI to exclude cord compression and detect T2-weighted hyperintense lesions, as well as determination of serum NMO IgG (aquaporin) antibodies to diagnose co-existing neuromyelitis optica (NMO) 1.
- Therapeutic interventions may include high-dose glucocorticoids, such as intravenous methylprednisolone, which can be effective in reducing inflammation and improving neurological function 1.
- In severe cases, the combination of intravenous methylprednisolone and intravenous cyclophosphamide can be effective in reducing neurological deficits and improving outcomes 1.
- Additionally, plasma exchange therapy and anticoagulation therapy may be used in certain cases, such as severe cases or those with antiphospholipid-positive myelopathy 1.
- Factors associated with severe neurological deficit include extensive spinal cord MRI lesions, reduced muscle strength or sphincter dysfunction at presentation, antiphospholipid antibodies, and delay (>2 weeks) in the initiation of therapy 1.
- Rehabilitation is crucial and includes physical therapy to improve strength and mobility, occupational therapy for daily activities, and pain management with medications such as gabapentin or pregabalin.
- Bladder and bowel dysfunction may require specific management strategies including intermittent catheterization or medications. The goal of treatment is to reduce inflammation, prevent further damage to the spinal cord, and improve neurological function, with the ultimate goal of minimizing morbidity, mortality, and improving quality of life.
From the Research
Definition and Symptoms of Transverse Myelitis
- Transverse myelitis (TM) is a clinical syndrome in which an immune-mediated process causes neural injury to the spinal cord, resulting in varying degrees of weakness, sensory alterations, and autonomic dysfunction 2.
- Symptoms typically develop over hours or days and then worsen over a matter of days to weeks, and can include sensory alteration, weakness, and autonomic dysfunction such as bowel and bladder problems, temperature dysregulation, or even bouts of hypertension 3.
Diagnosis and Management
- Evaluation for compressive etiologies must be a priority as compressive myelopathy and transverse myelitis are often clinically indistinguishable and emergent surgical intervention is indicated in such cases 3.
- A work-up for myelitis must include autoimmune, inflammatory, and infectious etiologies, and acute management of these patients is dictated by which etiology is suspected 3.
- The role of neuroimaging, and the utility of both CSF and serological studies are important in the management of these patients 3.
Treatment Options
- Methylprednisolone may not be beneficial in the treatment of acute transverse myelitis, as a study found that the outcome was not significantly improved with its use 4.
- A retrospective study found that patients who received plasma exchange or cyclophosphamide as part of their treatment regimen showed clinical benefit 5.
- The combination of γ-globulin with methylprednisolone may be effective in the treatment of acute transverse myelitis, with fewer adverse reactions and improved immune function and quality of life compared to combination with dexamethasone 6.