From the Guidelines
Transverse myelitis should be treated with high-dose intravenous corticosteroids, such as methylprednisolone, as early as possible, and may require additional immunosuppressive therapy, such as cyclophosphamide, in severe cases or those associated with autoimmune disorders like SLE. The causes of transverse myelitis are varied and include autoimmune disorders, infections, and idiopathic cases 1. Treatment should prioritize reducing inflammation and preventing permanent nerve damage.
Key Considerations
- High-dose intravenous corticosteroids, such as methylprednisolone, are the first line of treatment for transverse myelitis, and should be initiated as soon as possible 1.
- The combination of intravenous methylprednisolone and intravenous cyclophosphamide can be effective in SLE myelitis if used promptly, within the first few hours, and neurological response paralleled by MRI improvement occurs within a few days to 3 weeks 1.
- Plasma exchange therapy has been used in severe cases, and anticoagulation therapy in antiphospholipid-positive myelopathy with good results 1.
- Factors associated with severe neurological deficit include extensive spinal cord MRI lesions, reduced muscle strength or sphincter dysfunction at presentation, antiphospholipid antibodies, and delay (>2 weeks) in the initiation of therapy 1.
Treatment Approach
- Early treatment with high-dose intravenous corticosteroids, such as methylprednisolone, is crucial to reduce inflammation and prevent permanent nerve damage.
- Additional immunosuppressive therapy, such as cyclophosphamide, may be necessary in severe cases or those associated with autoimmune disorders like SLE.
- Supportive care, including physical therapy, occupational therapy, pain management, and bladder/bowel management, is essential to improve outcomes and reduce complications.
From the Research
Causes of Transverse Myelitis
- Transverse myelitis is a focal disorder of the spinal cord in which an immune-mediated process results in neural injury 2, 3
- It may exist as part of a multi-focal CNS disease (e.g. MS), multi-systemic disease (e.g. systemic lupus erythematosus), or as an isolated, idiopathic entity 3
- The etiologic spectrum of transverse myelitis includes acquired demyelinating and inflammatory disorders, such as neuromyelitis optica spectrum disorders, multiple sclerosis, and infectious or parainfectious myelitis 4
Treatment of Transverse Myelitis
- Corticosteroids, such as methylprednisolone, are commonly used in the treatment of transverse myelitis 4, 5
- Plasma exchange may be considered in patients with transverse myelitis who fail to improve after corticosteroid treatment 2, 5
- Cyclophosphamide may be beneficial in certain cases of transverse myelitis 2
- Rituximab may be considered in patients with transverse myelitis due to neuromyelitis optica to decrease the number of relapses 5
- Early institution of treatment, such as methylprednisolone, is important to reduce disability in patients with transverse myelitis 4
Diagnostic Approach
- A diagnostic work-up for transverse myelitis should include autoimmune, inflammatory, and infectious etiologies 6
- Neuroimaging, such as brain and spinal cord MRI, and CSF studies are important in the diagnosis of transverse myelitis 4, 6
- The presence of NMO-IgG antibodies (aquaporin-4-specific antibodies) may be useful in determining increased risk of transverse myelitis recurrence 5