TRANSVERSE MYELITIS (TM) BMR 3201 CLINICAL NEUROSCIENCES

DEFINITION A neurological disorder caused by inflammation across both sides of one level, or segment, of the spinal cord. Myelitis refers to inflammation of the spinal cord; transverse simply describes the position of the inflammation (across the width of the spinal cord). Attacks of inflammation can damage or destroy myelin. This damage causes nervous system scars that interrupt communications between the nerves in the spinal cord and the rest of the body.

AETIOLOGY Viral and other infections of the respiratory or gastrointestinal tract have been implicated in TM. In most cases, this inflammatory disorder appears after recovery from the viral infection. Multiple sclerosis is a disorder in which the immune system destroys myelin surrounding nerves in your spinal cord and brain. TM can be the first sign of multiple sclerosis or represent a relapse. TM as a sign of multiple sclerosis usually manifests on only one side of your body. The exact reason for transverse myelitis is not known. In some cases, no cause can be found for transverse myelitis.

AETIOLOGY Neuromyelitis optica (Devic's disease) is a condition that causes inflammation and loss of myelin around the spinal cord and the nerve in the eye that transmits information to your brain. TM associated with neuromyelitis optica usually affects both sides of your body. Autoimmune disorders affecting other body systems likely contribute to transverse myelitis in some people. These disorders include lupus, which can affect multiple body systems, and Sjogren's syndrome.

AETIOLOGY Vaccinations for infectious diseases — including hepatitis B, measles-mumps-rubella, and diphtheria-tetanus vaccines — have occasionally been implicated as a possible trigger.

PATHOPHYSIOLOGY The cause is not known but one major theory states that immune-mediated inflammation is present as the result of exposure to a viral antigen. The diarrhea-causing bacteria Campylobacter jejuni is also a reported cause of transverse myelitis.

CLINICAL FEATURES Initial symptoms usually include localized lower back pain, sudden paresthesias (abnormal sensations such as burning, tickling, pricking, or tingling)in the legs, sensory loss, and paraparesis (partial paralysis of the legs). Paraparesis may progress to paraplegia (paralysis of the legs and lower part of the trunk). Urinary bladder and bowel dysfunction is common.

CLINICAL FEATURES Many patients also report experiencing muscle spasms, a general feeling of discomfort, headache, fever, and loss of appetite. Depending on which segment of the spinal cord is involved, some patients may experience respiratory problems as well. From this wide array of symptoms, 4 classic features of TM emerge: (1) weakness of the legs and arms, (2) pain, (3) sensory alteration, and (4) bowel and bladder dysfunction.

MEDICAL MANAGEMENT

DIAGNOSIS Physicians diagnose TM by taking a medical history and performing a thorough neurological examination. Since it is often difficult to distinguish between a patient with an idiopathic form of TM and one who has an underlying condition, physicians must first eliminate potentially treatable causes of the condition.

DIAGNOSIS When a spinal cord problem is suspected, physicians seek first to rule out structural lesions (damaged or abnormally functioning areas) that could cause spinal cord compression or otherwise affects its function. Such potential lesions include tumors, herniated or slipped discs, stenosis (narrowing of the canal that holds the spinal cord), abscesses, and abnormal collections of blood vessels.

TREATMENT As with many disorders of the spinal cord, no effective cure currently exists for people with transverse myelitis. Treatments are designed to reduce spinal cord inflammation and manage and alleviate symptoms. Physicians often prescribe anti-inflammatory corticosteroid therapy soon after the diagnosis is made in order to decrease inflammation and hopefully improve the chances and speed of neurological recovery.

TREATMENT Several therapies target the acute signs and symptoms of transverse myelitis: Intravenous steroids. These help to reduce the inflammation in the spinal column. Plasma exchange therapy. People who don't respond to intravenous steroids may undergo plasma exchange therapy. This therapy involves removing plasma and replacing the plasma with special fluids.

TREATMENT Antiviral medication. Some people who have a viral infection of the spinal cord may be treated with antiviral medication. Pain medication. Chronic pain is a common complication of transverse myelitis. Medications that may lessen muscle pain include common pain relievers, including acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve).

TREATMENT Medications to treat other complications. Doctors may prescribe other medications as needed to treat problems such as muscle spasticity, urinary or bowel dysfunction, depression, or other complications associated with transverse myelitis. Medications to prevent recurrent attacks of TM. People who have positive results for antibodies associated with neuromyelitis optica require ongoing immunosuppressive medications such as corticosteroids to reduce their chances of having recurrent attacks of TM or from developing optic neuritis.

TREATMENT Physical Therapy: Therapists treat disabilities that result from motor and sensory impairments. Their aim is to help patients increase their strength and endurance, improve coordination, reduce spasticity and muscle wasting in paralyzed limbs, and regain greater control over bladder and bowel function through various exercises. They also teach paralyzed patients techniques for using assistive devices such as wheelchairs, canes, or braces as effectively as possible.

TREATMENT Paralyzed patients also learn ways to avoid developing painful pressure sores on immobilized parts of the body, which may lead to increased pain or systemic infection. In addition, therapists are involved in pain management.

TREATMENT Occupational Therapy: Therapists help individuals learn new ways to maintain or rebuild their independence by participating in meaningful, self-directed, goal-oriented, everyday tasks such as bathing and dressing. They teach people how to function at the lightest level possible, by developing compensatory strategies, suggesting changes in their homes to improve safety, changing obstacles in their environment that interfere with normal activity, and instructing on how to use assistive devices.

TREATMENT Psychotherapy. A psychotherapist can use talk therapy to treat anxiety, depression, sexual dysfunction, and other emotional or behavioral issues that may be related to someone coping with transverse myelitis.

PROGNOSIS Recovery from transverse myelitis usually begins within 2 to 12 weeks of the onset of symptoms and may continue for up to 2 years (and in some cases longer). However, if there is no improvement within the first 3 to 6 months, complete recovery is unlikely (although incomplete recovery can still occur, which underlines the significant need for aggressive physical therapy and rehabilitation).

REFERENCE www.mayoclinic.org © 1998-2015 Mayo Foundation for Medical Education and Research. “Transverse Myelitis Fact Sheet,” NINDS. NIH Publication No. 12-4841 Transverse Myelitis Association, http://www.myelitis.org