What is the treatment for transverse myelitis?

Treatment of Transverse Myelitis

High-dose intravenous methylprednisolone (1g/day for 3-5 days) is the first-line treatment for transverse myelitis and should be initiated as soon as possible after diagnosis, ideally within the first few hours of symptom onset. 1

First-Line Treatment Options

Acute Management

• Corticosteroids:
  • Methylprednisolone 1g/day IV for 3-5 days 1
  • Should be started immediately upon diagnosis
  • Higher doses may be considered in severe cases

Second-Line Therapies (if inadequate response to steroids)

• Plasma exchange:

  • 5-10 sessions administered every other day 1
  • Particularly useful for severe cases with minimal response to steroids

• Intravenous immunoglobulin (IVIG):

  • 2g/kg divided over 5 days 1
  • May be preferred in pregnant patients

Etiology-Specific Treatment

Autoimmune-Associated Transverse Myelitis

• For SLE-associated transverse myelitis:
  • IV methylprednisolone combined with IV cyclophosphamide 1, 2
  • This combination has shown improved outcomes in patients with SLE-related myelitis

Infectious Causes

• Parasitic infections:
  • Schistosomiasis: Praziquantel 40mg/kg twice daily for 5 days plus dexamethasone 1, 3
  • Toxocariasis: Albendazole plus corticosteroids for 3-4 weeks 3
  • Neurocysticercosis: Dexamethasone starting one day before praziquantel 3

Medication-Induced Myelitis

• For immune checkpoint inhibitor-related myelitis:
  • Permanently discontinue the immunotherapy agent 1
  • Initiate high-dose corticosteroids

Maintenance Therapy

• Essential to prevent relapses (which occur in 50-60% of patients during corticosteroid taper) 1
• Options include:
  • Cyclophosphamide (especially for SLE-associated myelitis)
  • Rituximab for antibody-mediated autoimmunity
  • Oral corticosteroid taper following IV pulse therapy

Management of Complications

• Neuropathic pain: Pregabalin, gabapentin, or duloxetine 1
• Spasticity: Baclofen, tizanidine, or physical therapy 1
• Autonomic dysfunction: Monitor for cardiac arrhythmias, blood pressure fluctuations, and urinary retention 1
• Respiratory failure: Consider early intubation if vital capacity falls below 15 ml/kg 1

Prognostic Factors

• Favorable prognosis:

  • Early treatment initiation
  • Prompt neurological response
  • Absence of extensive MRI lesions 1

• Poor prognosis:

  • Extensive lesions on spinal MRI
  • Reduced muscle strength or sphincter dysfunction at onset
  • Positive antiphospholipid antibodies
  • Delayed treatment initiation (>2 weeks) 1

Important Considerations

• Rule out infectious causes before starting immunosuppression 1
• For antiphospholipid antibody-positive patients, consider anticoagulation therapy 1, 4
• Early aggressive treatment significantly improves outcomes, as demonstrated in studies showing reduced time to independent walking (23 vs 97 days) and higher rates of full recovery (80% vs 10%) with early methylprednisolone treatment 5

Treatment Algorithm

1. Confirm diagnosis of transverse myelitis through clinical presentation, MRI, and CSF analysis
2. Rule out infectious causes that would contraindicate immunosuppression
3. Initiate IV methylprednisolone 1g/day for 3-5 days immediately
4. If inadequate response within 3-5 days, add plasma exchange or IVIG
5. For specific etiologies (SLE, infections), add appropriate targeted therapy
6. Implement maintenance therapy to prevent relapses
7. Manage complications (pain, spasticity, autonomic dysfunction)
8. Monitor for recovery and adjust treatment as needed