Treatment for Acute Transverse Myelitis
High-dose intravenous methylprednisolone (1g daily for 3-5 days) is the first-line treatment for acute transverse myelitis, with the addition of intravenous immunoglobulin (IVIG) strongly recommended for moderate to severe cases. 1, 2
Diagnostic Approach
- Prompt neurologic consultation is essential to guide diagnosis and management 1
- MRI of the spine with thin axial cuts through the region of suspected abnormality is crucial to detect T2-weighted hyperintense lesions 2, 1
- Lumbar puncture should be performed to check cell count, protein, glucose, oligoclonal bands, viral PCRs, and onconeural antibodies 2, 1
- Blood tests should include B12, HIV, RPR, ANA, Ro/La, TSH, and aquaporin-4 IgG to rule out other causes 2, 1
- Evaluation for urinary retention and constipation is important as these are common autonomic manifestations 1, 3
Treatment Algorithm
First-Line Treatment
- Permanently discontinue any potential causative agents (such as immune checkpoint inhibitors if applicable) 2
- Administer high-dose intravenous methylprednisolone 1g daily for 3-5 days 2, 1, 4
- For moderate to severe cases (with significant weakness or sensory changes), strongly consider adding IVIG 2g/kg over 5 days 2, 1
Second-Line Treatment (for refractory cases)
- Plasma exchange therapy should be considered for patients who do not respond adequately to corticosteroids and IVIG 1, 5
- Rituximab may be beneficial in cases with positive autoimmune encephalopathy antibodies or inadequate response to other therapies 2, 1
Special Considerations
- For transverse myelitis associated with antiphospholipid antibodies, consider anticoagulation therapy in addition to immunosuppressive treatment 1, 6
- In cases of neuromyelitis optica spectrum disorder (NMOSD)-associated transverse myelitis (positive aquaporin-4 IgG), more aggressive immunosuppression may be required 1, 2
- Longitudinally extensive transverse myelitis (affecting ≥3 vertebral segments) should raise suspicion for NMOSD and may require more aggressive treatment 3, 2
Prognostic Factors
- Factors associated with poor prognosis include extensive spinal cord MRI lesions (especially longitudinally extensive transverse myelitis) 1, 3
- Reduced muscle strength or sphincter dysfunction at presentation indicates poorer outcomes 1, 7
- Delay (>2 weeks) in the initiation of therapy significantly worsens prognosis 1, 8
Clinical Course and Outcomes
- Approximately one-third of patients experience complete recovery, one-third have significant improvement with residual deficits, and one-third develop permanent disability 7
- Relapses may occur and should prompt consideration of multiple sclerosis or other demyelinating disorders 7, 2
- Spastic paralysis with increased deep tendon reflexes is typical due to upper motor neuron damage, distinguishing transverse myelitis from conditions causing flaccid paralysis 3, 9