Can transverse myelitis present with a sensory level?

Can Transverse Myelitis Present with a Sensory Level?

Yes, transverse myelitis characteristically presents with a sensory level, which is one of its defining clinical features along with motor weakness and autonomic dysfunction below the level of the spinal cord lesion. 1, 2, 3

Core Clinical Presentation

Transverse myelitis (TM) is an inflammatory disorder of the spinal cord that produces a classic triad of symptoms:

• Sensory level: Loss of sensation below a specific dermatomal level corresponding to the spinal cord lesion 1, 4, 3
• Motor weakness: Paresis or paralysis below the level of injury 2, 5, 3
• Autonomic dysfunction: Bladder, bowel, and sexual dysfunction 1, 2, 3

Sensory Manifestations in Detail

The sensory symptoms in TM typically manifest as:

• Acute or subacute onset of sensory loss that progresses over hours to days 4, 3
• Bilateral sensory changes that respect a horizontal dermatomal level 3
• Various sensory modalities affected: Including pain, temperature, vibration, and proprioception 2
• Paresthesias or dysesthesias may precede or accompany the sensory level 4

Diagnostic Approach When Sensory Level is Present

When you encounter a patient with a sensory level, immediately consider TM and proceed with:

• MRI of the spine with thin axial cuts through the suspected region to identify T2-weighted hyperintense lesions 1
• Lumbar puncture to evaluate CSF cell count, protein, glucose, oligoclonal bands, viral PCRs, and onconeural antibodies 1
• Serology: B12, HIV, RPR, ANA, Ro/La, TSH, and aquaporin-4 IgG 1
• Neurologic consultation should be obtained promptly 1

Clinical Pitfalls

The sensory level in TM can sometimes be "suspended" with preserved sensation both above and below the area of abnormality, though this is more characteristic of tethered cord syndrome 6. In TM, the sensory level is typically consistent and corresponds to the spinal cord lesion level 3.

Progressive nature: The sensory changes in TM may start distally and become more proximal over time, or present suddenly with pain that evolves into neurologic deficits 4. One case report describes a patient who initially presented with abdominal and flank pain before developing progressive sensory changes and weakness 4.

Prognosis Related to Sensory Findings

The extent of sensory involvement correlates with prognosis:

• Extensive spinal cord MRI lesions (≥3 vertebral segments) indicate worse prognosis 1
• Sphincter dysfunction at presentation suggests more severe disease 1
• Delay >2 weeks in initiating therapy worsens outcomes 1