What is the prognosis for transverse myelitis?

Prognosis of Transverse Myelitis

The prognosis for transverse myelitis is variable, with approximately one-third of patients recovering with minimal to no sequelae, one-third developing moderate permanent disability, and one-third experiencing severe disability 1.

Clinical Outcomes and Recovery Patterns

Transverse myelitis (TM) is a focal inflammatory disorder of the spinal cord characterized by perivascular monocytic and lymphocytic infiltration, demyelination, and axonal injury 1. The clinical manifestations result from dysfunction of motor, sensory, and autonomic pathways in the spinal cord.

Recovery patterns typically follow these trajectories:

• Good recovery (approximately 33%): Minimal to no long-term sequelae
• Moderate disability (approximately 33%): Persistent moderate neurological deficits
• Poor outcome (approximately 33%): Severe permanent disability 1

Prognostic Factors

Several factors influence the prognosis of transverse myelitis:

Negative Prognostic Indicators

• Rapid onset of symptoms (less than 24 hours)
• Complete paraplegia at presentation
• Abnormal MRI findings (especially extensive lesions)
• Delayed initiation of treatment (>2 weeks after symptom onset) 2
• Young age combined with abnormal CT/MRI findings 2

Positive Prognostic Indicators

• Normal MRI findings (if imaging is performed early) 2
• Prompt initiation of appropriate therapy
• Incomplete motor deficits at presentation

Imaging Findings and Prognosis

MRI findings have significant prognostic value in transverse myelitis:

• Normal MRI is generally indicative of a good prognosis with full recovery anticipated 2
• Longitudinally extensive transverse myelitis (lesions extending over ≥3 vertebral segments) is associated with poorer outcomes 3
• The presence of gadolinium enhancement may indicate active inflammation and potential responsiveness to immunotherapy

Associated Conditions and Their Impact on Prognosis

The underlying etiology of transverse myelitis significantly affects prognosis:

• Idiopathic transverse myelitis: Generally better prognosis than secondary forms
• Autoimmune-associated TM (such as in SLE or Sjögren's syndrome): Historically poor prognosis, but early aggressive treatment with IV methylprednisolone and cyclophosphamide may improve outcomes 4, 5
• Neuromyelitis optica spectrum disorder (NMOSD): Higher risk of recurrence and poorer prognosis 3
• Multiple sclerosis-associated TM: Variable prognosis depending on disease course and treatment response

Treatment Response and Long-term Outcomes

Early and aggressive treatment significantly impacts prognosis:

• Patients treated with early IV pulse methylprednisolone followed by cyclophosphamide for autoimmune-associated TM show better functional recovery, with most regaining ability to walk and achieving partial or total sphincter control 5
• Interleukin-6 levels in cerebrospinal fluid during acute TM strongly correlate with and predict disability outcomes 1

Recovery Timeline

Recovery from transverse myelitis typically follows this pattern:

• Initial improvement may begin within 1-3 months of onset
• Most recovery occurs within the first 6 months
• Some continued improvement may occur up to 2 years after onset
• Deficits that persist beyond 2 years are generally permanent

Recurrence Risk

The risk of recurrence depends on the underlying etiology:

• Idiopathic isolated TM: Low recurrence risk
• NMOSD-associated TM: High recurrence risk without appropriate immunosuppressive therapy
• MS-associated TM: Variable recurrence risk based on overall disease activity and treatment

Functional Outcomes

At peak deficit in transverse myelitis:

• 50% of patients are completely paraplegic
• Nearly all have some degree of bladder dysfunction
• 80-94% experience sensory symptoms including numbness, paresthesias, or band-like dysesthesias 1

Long-term rehabilitation and multidisciplinary care are essential components of management to optimize functional outcomes regardless of the initial severity of presentation.