What is the approach to monitoring transverse myelitis?

Monitoring Approach for Transverse Myelitis

MRI of the spine is the cornerstone of monitoring transverse myelitis, with recommended follow-up scans every 3-6 months in the first year and annually thereafter for stable patients. 1, 2

Initial Diagnostic Evaluation

• MRI of the spine with thin axial cuts through the region of suspected abnormality is essential for diagnosis and serves as the baseline for future monitoring 1
• Lumbar puncture should be performed to assess cell count, protein, glucose, oligoclonal bands, viral PCRs, cytology, 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

Monitoring Protocol

• For severe cases (Grade 3-4), more frequent MRI monitoring is recommended (every 3-4 months) 1, 2
• For moderate cases (Grade 2), MRI monitoring should be conducted every 6 months 1, 2
• For mild cases (Grade 1), annual MRI monitoring is appropriate if symptoms are stable 1, 2

MRI Sequences for Monitoring

• T2-weighted and T2-FLAIR sequences are essential for detecting new or enlarging lesions 1
• Gadolinium-enhanced T1-weighted sequences should be included to detect active inflammation 1
• Diffusion-weighted imaging should be considered, especially when evaluating for complications 1

Additional Monitoring Considerations

• Clinical assessments measuring disability and recording relapses should always be performed in parallel with MRI 1
• Evaluation for urinary retention and constipation should be conducted at each follow-up visit 1
• Optical Coherence Tomography (OCT) should be considered as a complementary monitoring tool, especially if there are visual symptoms 3

Special Monitoring Situations

• For transverse myelitis associated with immune checkpoint inhibitor therapy, permanently discontinue the therapy and conduct more frequent monitoring (every 3 months) 1
• For patients at high risk of developing opportunistic infections who are on immunosuppressive therapy, brain MRI is recommended every 3-4 months 1
• For patients with radiation-induced transverse myelitis, monitoring should include assessment of the irradiated area and adjacent segments 4

Follow-up Protocol Timing

• First follow-up MRI should be performed 3-6 months after initial diagnosis 2
• Subsequent MRIs should be performed every 6-12 months depending on clinical stability 1, 2
• More frequent monitoring (every 3-4 months) is warranted for patients with:
  • Progressive symptoms 1
  • Immunosuppressive therapy 1
  • High risk of complications 1

Common Pitfalls in Monitoring

• Failing to distinguish between disease progression and treatment-related complications 1
• Inconsistent MRI protocols between follow-up scans, making comparison difficult 1
• Overlooking clinical assessment in favor of imaging findings alone 1
• Not considering spinal cord atrophy as a marker of disease progression 5