What is the treatment for transverse myelitis?

Treatment for Transverse Myelitis

High-dose intravenous corticosteroids (methylprednisolone 1g/day for 3-5 days) followed by immunosuppressive therapy is the first-line treatment for transverse myelitis, particularly when it is considered to be of inflammatory origin. 1, 2

Diagnostic Approach

• Neurologic consultation should be obtained promptly to guide diagnosis and management 1
• MRI of the spine with thin axial cuts through the region of suspected abnormality is essential to detect T2-weighted hyperintense lesions 1, 2
• Lumbar puncture should be performed to check cell count, protein, glucose, oligoclonal bands, viral PCRs, and onconeural antibodies 1
• Blood tests should include B12, HIV, RPR, ANA, Ro/La, TSH, and aquaporin-4 IgG to rule out other causes 1, 2
• Evaluation for urinary retention and constipation is important as these are common autonomic manifestations 1

Treatment Algorithm

First-Line Treatment

• Immediately discontinue any potential causative agents (such as immune checkpoint inhibitors if applicable) 1
• Administer high-dose intravenous methylprednisolone 1g daily for 3-5 days 1, 2
• For moderate to severe cases (with significant weakness or sensory changes), combine corticosteroids with IVIG 2g/kg over 5 days 1, 2

Second-Line Treatment (for refractory cases)

• Plasma exchange therapy should be considered for patients who do not respond adequately to corticosteroids and IVIG 1, 3
• For transverse myelitis associated with systemic lupus erythematosus or other autoimmune conditions, cyclophosphamide (typically intravenous pulse therapy) should be added 1, 4
• Rituximab may be beneficial in cases with positive autoimmune encephalopathy antibodies or inadequate response to other therapies 1

Maintenance Therapy

• After acute treatment, maintenance immunosuppressive therapy (such as azathioprine) is often necessary to prevent relapses, which occur in 50-60% of cases during corticosteroid dose reduction 1

Special Considerations

• For transverse myelitis associated with antiphospholipid antibodies, anticoagulation therapy should be considered in addition to immunosuppressive treatment 1
• In cases of infectious etiology (such as schistosomiasis), appropriate antiparasitic treatment should be administered along with corticosteroids 1
• For neuromyelitis optica spectrum disorder (NMOSD)-associated transverse myelitis (positive aquaporin-4 IgG), more aggressive immunosuppression may be required 1, 2

Prognostic Factors

• Factors associated with poor prognosis include:
  • Extensive spinal cord MRI lesions (especially longitudinally extensive transverse myelitis affecting ≥3 vertebral segments) 1, 2
  • Reduced muscle strength or sphincter dysfunction at presentation 1
  • Presence of antiphospholipid antibodies 1, 5
  • Delay (>2 weeks) in the initiation of therapy 1

Follow-up Management

• Regular neurological assessments to monitor recovery and detect relapses 6
• Physical and occupational therapy to improve functional outcomes 6
• Management of residual symptoms including neuropathic pain, spasticity, and bladder/bowel dysfunction 6
• For autoimmune-associated transverse myelitis, continued immunosuppression may be necessary to prevent recurrence 1, 5

Early aggressive treatment with high-dose corticosteroids and appropriate immunosuppressive therapy is crucial for improving outcomes in transverse myelitis, with the therapeutic approach tailored based on the underlying etiology and severity of presentation.