Clinical Features of Transverse Myelitis
Transverse myelitis (TM) is characterized by acute or subacute inflammation of the spinal cord resulting in bilateral neurological deficits including motor weakness, sensory disturbances, and autonomic dysfunction that typically evolve over hours to days, with most cases progressing to maximal severity within 10 days of onset. 1, 2
Core Clinical Manifestations
Motor symptoms: Bilateral weakness (paraparesis) occurs in approximately 50% of patients at maximal clinical severity. The weakness typically begins in the lower extremities and may ascend to involve upper extremities depending on the level of spinal cord involvement 1
Sensory disturbances: Almost all patients experience sensory abnormalities with a clearly defined sensory level corresponding to the affected spinal cord segment. Symptoms include numbness, tingling, burning sensations, and dysesthesias below the level of the lesion 1, 2
Autonomic dysfunction: Bladder and bowel dysfunction are present in most patients, manifesting as urinary retention, incontinence, constipation, or fecal incontinence 1, 3
Pain: Back or radicular pain is common and often precedes or accompanies the development of other neurological symptoms 3
Clinical Progression and Presentation
Symptoms typically develop rapidly over hours to days, with most patients reaching maximal clinical severity within 10 days 1
The clinical presentation depends on the level of spinal cord involvement:
- Cervical lesions: Quadriparesis, respiratory compromise if high cervical involvement
- Thoracic lesions: Paraparesis with preserved arm function 2
Residual disability outcomes are divided approximately equally between severe, moderate, and minimal/none 1
Associated Clinical Features
Fever and meningism: May be present, particularly in children or in cases with infectious etiology 4
Respiratory compromise: Can occur with high cervical lesions affecting diaphragmatic innervation 3
Spasticity: May develop during the course of the illness or as a long-term complication 3
Neuropathic pain: Can persist as a chronic complication 3
Distinguishing Features from Similar Conditions
Unlike Guillain-Barré syndrome (GBS), which typically presents with ascending weakness starting in the distal limbs, TM often presents with a more clearly defined sensory level and more prominent autonomic dysfunction 4
Unlike multiple sclerosis (MS), isolated TM affects a restricted area of the spinal cord in a single episode, though TM can be the first presentation of MS in some cases 4
Unlike cerebral venous thrombosis, which can present with headache and focal neurological deficits, TM specifically involves spinal cord dysfunction with a clear sensory level 4
Diagnostic Considerations
MRI typically shows T2-weighted hyperintense lesions in the spinal cord, often spanning multiple segments 1
CSF analysis frequently shows mild-to-moderate abnormalities (50-70% of cases) including pleocytosis and elevated protein 4
The clinical presentation can vary based on etiology (idiopathic, parainfectious, associated with systemic autoimmune disorders, or part of demyelinating conditions) 2, 5
Red Flags and Warning Signs
Rapidly progressive weakness with respiratory involvement requires urgent medical attention 3
Presence of fever, meningeal signs, or systemic symptoms may suggest an infectious or parainfectious etiology 4
History of autoimmune disorders (particularly SLE or Sjögren's syndrome) increases the risk of TM and may influence treatment approach 6
Longitudinally extensive transverse myelitis (spanning ≥3 vertebral segments) may suggest neuromyelitis optica spectrum disorder, especially when associated with optic neuritis 4
Early recognition of these clinical features is essential for prompt diagnosis and treatment, which can significantly impact long-term outcomes and reduce the risk of permanent disability 3, 5.