From the Guidelines
Diagnosing transverse myelitis requires a comprehensive approach involving clinical evaluation, imaging, and laboratory tests, with MRI of the spine being essential to show inflammation across a segment of the spinal cord, as noted in the most recent study 1. The diagnosis begins with a thorough neurological examination to identify characteristic symptoms such as bilateral weakness, sensory abnormalities, and autonomic dysfunction (like bladder or bowel problems).
- Key symptoms to look for include:
- Bilateral weakness
- Sensory abnormalities
- Autonomic dysfunction Magnetic Resonance Imaging (MRI) of the spine is crucial, typically showing inflammation across a segment of the spinal cord, often appearing as T2 hyperintensity, as seen in studies 1.
- Imaging findings may include:
- T2 hyperintensity
- Longitudinally extensive transverse myelitis Cerebrospinal fluid (CSF) analysis obtained through lumbar puncture is also vital, often revealing elevated protein levels, pleocytosis (increased white blood cells), and sometimes oligoclonal bands, as mentioned in 1.
- Laboratory tests should include:
- CSF analysis
- Blood tests to rule out other conditions and identify potential underlying causes
- Tests for autoimmune disorders, infections, and vitamin B12 deficiency It's essential to exclude conditions that mimic transverse myelitis, such as spinal cord compression, multiple sclerosis, neuromyelitis optica, and vascular malformations, as discussed in 1.
- Differential diagnoses to consider:
- Spinal cord compression
- Multiple sclerosis
- Neuromyelitis optica
- Vascular malformations The diagnostic process should be prompt, as early treatment improves outcomes, and a multidisciplinary approach involving neurologists, radiologists, and sometimes rheumatologists is often necessary for accurate diagnosis and appropriate management, as emphasized in 1.
From the Research
Diagnostic Approach
To diagnose transverse myelitis, a thorough evaluation is necessary, including:
- Clinical history and examination to identify symptoms such as sensory alteration, weakness, and autonomic dysfunction 2
- Neuroimaging, particularly magnetic resonance imaging (MRI), to visualize spinal cord lesions and rule out compressive etiologies 2, 3, 4
- Cerebrospinal fluid (CSF) studies to indicate inflammation within the central nervous system and guide further work-up for autoimmune, inflammatory, and infectious etiologies 2, 3
Diagnostic Clues and Pitfalls
The diagnostic workup of acute transverse myelitis may be associated with diagnostic uncertainty due to the lack of specific CSF or MRI features 3
- A high percentage of multiple sclerosis (MS)-typical brain lesions and CSF findings may suggest a substantial number of MS-related myelitis 3
- The presence of multiple lesions, lateral, centromedullary, and posterior locations on MRI may aid in diagnosis 3
- Clinical impairment can range from mild to severe, with sensory disturbances being the most common symptom 3
Algorithm for Diagnosis and Management
An ordered, efficient, and cost-effective approach to diagnosis is recommended, based on the patient's clinical history, examination, and MRI findings 4