What is the treatment for transverse myelitis?

Treatment of Transverse Myelitis

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

Acute Treatment Options

Transverse myelitis (TM) is an inflammatory condition affecting the spinal cord that requires prompt intervention to minimize neurological damage. The treatment approach follows a stepwise algorithm:

1. First-line treatment:

   • IV methylprednisolone 1g/day for 3-5 days 1, 2
   • Begin immediately after ruling out infectious causes 1
   • Monitor for potential side effects including hypertension, hyperglycemia, mood changes, and increased risk of infection 2

2. Second-line options (if inadequate response to steroids):

   • Plasma exchange: 5-10 sessions every other day 1
   • IVIG: 2g/kg divided over 5 days 1

3. Third-line/refractory cases:

   • Cyclophosphamide 3, 1, 4
   • Rituximab (especially for cases associated with autoimmune disorders) 1

Treatment Based on Etiology

Treatment may be modified based on the underlying cause:

• Idiopathic TM: Follow standard protocol above
• SLE-associated TM: Combination of pulse methylprednisolone followed by cyclophosphamide for approximately 6 months has shown significant improvement in mobility and sphincter control 4
• AQP4-IgG positive patients: Consider rituximab or cyclophosphamide 1
• Parainfectious TM: Rule out active infection before immunosuppression 1

Maintenance Therapy

Maintenance immunosuppressive therapy is crucial to prevent relapses, which occur in 50-60% of patients during corticosteroid dose reduction 1:

• Gradual tapering of corticosteroids to minimize risk of adrenal insufficiency 2
• Consider steroid-sparing agents for long-term management
• Regular monitoring for treatment response and side effects

Management of Complications

1. Spasticity:

   • Baclofen or tizanidine
   • Physical therapy 1

2. Neuropathic pain:

   • Pregabalin, gabapentin, or duloxetine 1

3. Autonomic dysfunction:

   • Monitor for cardiac arrhythmias, blood pressure fluctuations, and urinary retention 1

4. Respiratory failure:

   • Early intubation if vital capacity falls below 15 ml/kg or negative inspiratory force is less than -20 cm H₂O 1

Special Considerations

• Pregnancy: IVIG may be preferred over steroids 1
• Patients with cirrhosis: Reduced dosage may be needed due to decreased metabolism of corticosteroids 2
• Patients with cardiac issues: Use corticosteroids with caution in patients with congestive heart failure or hypertension due to sodium retention 2
• Osteoporosis risk: Consider calcium/vitamin D supplementation with long-term steroid use 2

Prognostic Factors

Early treatment initiation is associated with better outcomes 1. Poor prognostic factors include:

• Extensive lesions on spinal MRI
• Reduced muscle strength or sphincter dysfunction at onset
• Positive antiphospholipid antibodies
• Delayed initiation of treatment 1

Important Cautions

• Patients should not discontinue corticosteroids abruptly due to risk of adrenal crisis 2
• Monitor for tumor lysis syndrome in patients with malignancies receiving systemic corticosteroids 2
• Regular monitoring of intraocular pressure is recommended if steroid therapy continues beyond 6 weeks 2
• Adjust dosage of antidiabetic medications as corticosteroids may increase blood glucose 2

Early recognition and aggressive treatment of transverse myelitis are essential to improve outcomes and reduce long-term disability.