What is the treatment for transverse myelitis?

Treatment for Transverse Myelitis

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

Treatment Algorithm

First-Line Treatment

• IV Methylprednisolone: 1g/day for 3-5 days 1
  • Should be started immediately after diagnosis
  • Aims to reduce inflammation and prevent further neural damage
  • Most effective when initiated early in the disease course

Second-Line Options (if inadequate response to steroids)

• Plasma Exchange (PLEX): 5-10 sessions on alternate days 1
• Intravenous Immunoglobulin (IVIG): 2g/kg divided over 5 days 1
  • Choice between PLEX and IVIG depends on:
    • Patient comorbidities
    • Contraindications
    • Availability

Third-Line/Refractory Cases

• Cyclophosphamide: For patients not responding to first and second-line treatments 1, 2
  • Particularly beneficial in transverse myelitis associated with systemic autoimmune diseases like SLE and Sjögren's syndrome 2
• Rituximab: Consider for AQP4-IgG positive patients or those who fail first-line therapy 1

Special Considerations

Etiology-Specific Approaches

• For AQP4-IgG positive patients (neuromyelitis optica spectrum disorder):
  • Consider rituximab or cyclophosphamide 1
• For autoimmune-associated TM (e.g., SLE, Sjögren's syndrome):
  • Early aggressive treatment with IV methylprednisolone and cyclophosphamide may improve prognosis 2
• For parasitic infections (e.g., Schistosomiasis):
  • Praziquantel 40mg/kg twice daily for 5 days plus dexamethasone 1

Symptomatic Management

• 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 function: Monitor vital capacity; consider early intubation if vital capacity falls below 15 ml/kg 1

Important Precautions

• Rule out infectious causes before starting immunosuppression 1
• For pregnant patients, IVIG may be preferred over steroids 1
• Regular assessment for treatment response, side effects, and remission is essential 1

Prognostic Factors

• Better prognosis: Early treatment initiation, prompt neurological response, absence of extensive MRI lesions 1
• Poorer prognosis: Extensive lesions on spinal MRI, reduced muscle strength or sphincter dysfunction at onset, positive antiphospholipid antibodies, delayed treatment initiation 1

Clinical Pitfalls to Avoid

• Delayed treatment: Early intervention is critical for better outcomes 1, 3
• Inadequate evaluation: Thorough workup to identify potential underlying causes is essential before labeling as idiopathic 4
• Insufficient monitoring: Regular assessment of respiratory function and autonomic symptoms is crucial to prevent life-threatening complications 1
• Overlooking maintenance therapy: Maintenance immunosuppressive therapy is important to prevent relapses, which occur in 50-60% of patients during corticosteroid dose reduction 1

The evidence strongly supports early aggressive treatment with high-dose corticosteroids as the cornerstone of transverse myelitis management, with escalation to plasma exchange, IVIG, or cyclophosphamide for refractory cases 1, 3, 5.