From the Guidelines
Transverse myelitis should be treated with high-dose intravenous methylprednisolone (1000 mg daily for 3-5 days) to reduce inflammation, as this approach has been shown to be effective in reducing morbidity and improving quality of life 1.
Key Considerations
- The condition can be idiopathic or associated with autoimmune disorders, infections, or demyelinating diseases like multiple sclerosis, and early diagnosis is crucial to guide treatment decisions 1.
- In addition to steroid treatment, plasma exchange therapy (5-7 exchanges over 10-14 days) may be used for patients who do not respond to steroids, and intravenous immunoglobulin (IVIG) at 2 g/kg divided over 2-5 days is another option for refractory cases 1.
- Pain management is also an important aspect of treatment, and may involve the use of gabapentin (300-1200 mg three times daily), pregabalin (75-300 mg twice daily), or amitriptyline (10-75 mg at bedtime) 1.
Treatment Approach
- Rehabilitation is crucial and should include physical therapy to improve strength and mobility, occupational therapy for daily activities, and bladder/bowel management 1.
- The goal of treatment is to eliminate inflammation, prevent disease complications, and restore quality of life, and treatment decisions should be guided by expert opinion and individual patient needs 1.
- Magnetic resonance imaging (MRI) is useful in diagnosing myositis and following treatment response, and myositis-specific autoantibodies may be useful in defining clinical subsets of the condition and suggesting a prognosis 1.
Important Factors
- 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.
- Early diagnosis and prompt treatment are essential to minimize long-term neurological damage and improve outcomes, and treatment should be tailored to the individual patient's needs and response to therapy 1.
From the Research
Definition and Characteristics of Transverse Myelitis
- Transverse myelitis (TM) is a pathobiologically heterogeneous syndrome characterized by acute or subacute spinal cord dysfunction resulting in paresis, a sensory level, and autonomic (bladder, bowel, and sexual) impairment below the level of the lesion 2.
- 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 3.
- Myelitis is a rare neurological disorder of the spinal cord that is caused by inflammation and can have devastating neurologic effects with up to two-thirds of patients having a moderate to severe degree of residual disability 4.
Etiologies and Classification of Transverse Myelitis
- Etiologies for TM can be broadly classified as parainfectious, paraneoplastic, drug/toxin-induced, systemic autoimmune disorders, and acquired demyelinating diseases 2.
- TM may exist as part of a multi-focal CNS disease (e.g. MS), multi-systemic disease (e.g. systemic lupus erythematosus), or as an isolated, idiopathic entity 3.
Diagnosis and Management of Transverse Myelitis
- 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 4.
- Acute management of patients with TM is dictated by which etiology is suspected and rapid initiation of that treatment portends a more favorable patient outcome 4.
- Treatment options for TM include corticosteroids, plasma exchange, or cyclophosphamide, with some patients receiving clinical benefit from plasma exchange or cyclophosphamide 5.
- However, the use of methyl prednisolone in acute transverse myelitis has not shown a beneficial role in the outcome of ATM 6.