Transverse myelitis

Overview

Transverse myelitis is an inflammation of both sides of one section of the spinal cord. This neurological disorder often damages the insulating material covering nerve cell fibers (myelin).

Transverse myelitis interrupts the messages that the spinal cord nerves send throughout the body. This can cause pain, muscle weakness, paralysis, sensory problems, or bladder and bowel dysfunction.

There are many different causes of transverse myelitis, including infections and immune system disorders that attack the body's tissues. It could also be caused by other myelin disorders, such as multiple sclerosis. Other conditions, such as a stroke of the spinal cord, are often confused with transverse myelitis, and these conditions require different treatment approaches.

Treatment for transverse myelitis includes medications and rehabilitative therapy. Most people with transverse myelitis recover at least partially. Those with severe attacks sometimes are left with major disabilities.

Symptoms

Signs and symptoms of transverse myelitis usually develop over a few hours to a few days and may sometimes progress gradually over several weeks.

Transverse myelitis usually affects both sides of the body below the affected area of the spinal cord, but sometimes there are symptoms on just one side of the body.

Typical signs and symptoms include:

• Pain. Transverse myelitis pain may begin suddenly in your lower back. Sharp pain may shoot down your legs or arms or around your chest or abdomen. Pain symptoms vary based on the part of your spinal cord that's affected.
• Abnormal sensations. Some people with transverse myelitis report sensations of numbness, tingling, coldness or burning. Some are especially sensitive to the light touch of clothing or to extreme heat or cold. You may feel as if something is tightly wrapping the skin of your chest, abdomen or legs.
• Weakness in your arms or legs. Some people notice heaviness in the legs, or that they're stumbling or dragging one foot. Others may develop severe weakness or even total paralysis.
• Bladder and bowel problems. This may include needing to urinate more frequently, urinary incontinence, difficulty urinating and constipation.

When to see a doctor

Call your doctor or get emergency medical care if you're experiencing signs and symptoms of transverse myelitis. A number of neurological disorders can cause sensory problems, weakness, and bladder or bowel dysfunction including compression of the spinal cord, which is a surgical emergency.

Another less common cause is a stroke of the spinal cord due to impaired blood circulation. This can be caused by blockage of a blood vessel that supplies blood to the spinal cord, which may occur with surgery of the aorta or increased clotting of the blood. It's important to get a prompt diagnosis and appropriate treatment.

Causes

The exact reason for transverse myelitis is not known. Sometimes there is no known cause.

Viral, bacterial and fungal infections affecting the spinal cord may cause transverse myelitis. In most cases, the inflammatory disorder appears after recovery from the infection.

Viruses associated with transverse myelitis are:

• Herpes viruses, including the one that causes shingles and chickenpox (zoster)
• Cytomegalovirus
• Epstein-Barr
• HIV
• Enteroviruses such as poliovirus and coxsackievirus
• West Nile
• Echovirus
• Zika
• Influenza
• Hepatitis B
• Mumps, measles and rubella

Other viruses may trigger an autoimmune reaction without directly infecting the spinal cord.

Bacterial infections that are associated with transverse myelitis include:

• Lyme disease
• Syphilis
• Tuberculosis
• Actinomyces
• Pertussis
• Tetanus
• Diphtheria

Bacterial skin infections, gastroenteritis and certain types of bacterial pneumonia also may cause transverse myelitis.

Rarely, parasites and fungal infections may infect the spinal cord.

There are a number of inflammatory conditions that appear to cause the disorder:

• Multiple sclerosis is a disorder in which the immune system destroys myelin surrounding nerves in your spinal cord and brain. Transverse myelitis can be the first sign of multiple sclerosis or represent a relapse. Transverse myelitis as a sign of multiple sclerosis usually causes symptoms on only one side of your body.

• Neuromyelitis optica (Devic's disease) is a condition that causes inflammation and myelin loss around the spinal cord and the nerve in your eye that transmits information to your brain. Transverse myelitis associated with neuromyelitis optica usually affects both sides of your body.

  In addition to transverse myelitis, you may experience symptoms of damage to myelin of the optic nerve, including pain in the eye with movement and temporary vision loss. This can happen with or separately from transverse myelitis symptoms. However, some people with neuromyelitis optica don't experience eye-related problems and might have only recurrent episodes of transverse myelitis.

• Autoimmune disorders probably contribute to transverse myelitis in some people. These disorders include lupus, which can affect multiple body systems, and Sjogren's syndrome, which causes severe dryness of the mouth and eyes.

  Transverse myelitis associated with an autoimmune disorder may be a warning sign of neuromyelitis optica. Neuromyelitis optica occurs more frequently in people with other autoimmune diseases.

• Vaccinations for infectious diseases have occasionally been associated as a possible trigger. However, at this time the association is not strong enough to warrant limiting any vaccine.
• Sarcoidosis is a condition that leads to inflammation in many areas of the body, including the spinal cord and optic nerve. It may mimic neuromyelitis optica, but typically sarcoidosis symptoms develop more slowly. The cause of sarcoidosis isn't understood.

Complications

People with transverse myelitis usually experience only one episode. However, complications often linger, including the following:

• Pain, one of the most common debilitating long-term complications of the disorder.
• Stiffness, tightness or painful spasms in your muscles (muscle spasticity). This is most common in the buttocks and legs.
• Partial or total paralysis of your arms, legs or both. This may persist after the first symptoms.
• Sexual dysfunction, a common complication of transverse myelitis. Men may experience difficulty achieving an erection or reaching orgasm. Women may have difficulty reaching orgasm.
• Depression or anxiety, which is common in those with long-term complications because of the significant changes in lifestyle, the stress of chronic pain or disability, and the impact of sexual dysfunction on relationships.

Diagnosis

A doctor will diagnose transverse myelitis based on your answers to questions about your signs and symptoms, your medical history, a clinical assessment of nerve function, and test results.

These tests, which may indicate inflammation of the spinal cord and rule out other disorders, include the following:

• Magnetic resonance imaging (MRI) uses a magnetic field and radio waves to create 3D images of soft tissues. An MRI can show inflammation of the spinal cord and other potential causes of the symptoms, including abnormalities affecting the spinal cord or blood vessels.

• Lumbar puncture (spinal tap) uses a needle to draw a small amount of cerebrospinal fluid (CSF), the protective fluid that surrounds your spinal cord and brain.

  In some people with transverse myelitis, CSF may have abnormally high numbers of white blood cells or immune system proteins that indicate inflammation. Spinal fluid can also be tested for viral infections or certain cancers.

• Blood tests may include a test that checks for antibodies associated with neuromyelitis optica, a condition in which inflammation occurs both in your spinal cord and in the nerve in your eye. People with a positive antibody test are at increased risk of experiencing multiple attacks of transverse myelitis and require treatment to prevent future attacks.

  Other blood tests can identify infections that may contribute to transverse myelitis, or rule out other causes of symptoms.

Treatment

Several therapies target the acute signs and symptoms of transverse myelitis:

• Intravenous steroids. You'll probably receive steroids through a vein in your arm over the course of several days. Steroids help reduce the inflammation in your spinal column.

• Plasma exchange therapy. People who don't respond to intravenous steroids may need plasma exchange therapy. This involves removing the straw-colored fluid in which blood cells are suspended (plasma) and replacing the plasma with special fluids.

  It's not certain how this therapy helps people with transverse myelitis, but it may be that plasma exchange removes inflammatory antibodies.

• Antiviral medication. Some people who have a viral infection of the spinal cord may be treated with medications to treat the virus.

• Pain medication. Chronic pain is a common complication of transverse myelitis. Medications that may lessen muscle pain include common pain relievers, such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve.)

  Nerve pain may be treated with antidepressant drugs, such as sertraline (Zoloft), and anticonvulsant drugs, such as gabapentin (Neurontin, Gralise) or pregabalin (Lyrica).

• Medications to treat other complications. Your doctor 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 transverse myelitis. People who have antibodies associated with neuromyelitis optica need ongoing medications, such as corticosteroids and/or immunosuppressants, to reduce their chances of more transverse myelitis attacks or developing optic neuritis.

Other therapies

Additional therapies focus on long-term recovery and care:

• Physical therapy. This helps improve strength and coordination. Your physical therapist can teach you how to use any needed assistive devices, such as a wheelchair, canes or braces.
• Occupational therapy. This helps people with transverse myelitis learn new ways of performing day-to-day activities, such as bathing, preparing a meal and housecleaning.
• Psychotherapy. A psychotherapist can use talk therapy to treat anxiety, depression, sexual dysfunction, and other emotional or behavioral issues from coping with transverse myelitis.

Prognosis

Although most people with transverse myelitis have at least partial recovery, it may take a year or more. Most recovery occurs within the first three months after the episode and strongly depends on the cause of transverse myelitis.

About one-third of people with transverse myelitis fall into one of three categories after an attack:

• No or slight disability. These people experience only minimal lingering symptoms.
• Moderate disability. These people are mobile, but may have difficulty walking, numbness or tingling, and bladder and bowel problems.
• Severe disability. Some people may permanently need a wheelchair and require ongoing assistance with daily care and activities.

It's difficult to predict the course of transverse myelitis. The prognosis and responsiveness to treatment is strongly determined by the cause of the syndrome and to some extent by how early treatment is administered. Generally, people who experience a rapid onset of severe signs and symptoms and those who have a positive test for a particular antibody have a worse prognosis than do those with a relatively slower onset, milder symptoms and negative antibody test.

Preparing for your appointment

Signs and symptoms that might indicate transverse myelitis are usually severe and sudden. You'll likely need emergency or urgent care.

Questions that the attending doctor is likely to ask include the following:

• When did you begin experiencing symptoms?
• How quickly have your symptoms developed?
• Do you have pain, tingling or other unusual sensations?
• How would you rate the pain on a scale of 1 to 10, with 10 being most painful?
• Have you experienced weakness or lack of coordination?
• Have you had problems with bowel or bladder control?
• Are you having difficulty breathing?
• Have you been diagnosed with other medical conditions?
• Have you recently had any infections?
• Have you recently had any vaccinations?
• Have you traveled abroad lately? Where?
• Have you had any medical procedures recently?
• What prescription or over-the-counter medications do you take regularly? What is the dosage of each?