Transverse Myelitis

Transverse Myelitis:

Transverse Myelitis Dr Rahul Chakor MD.,DM Dept of Neurology - T N Medical College & B Y L Nair Hospital, Mumbai, India

Transverse Myelitis:

Transverse Myelitis Definition Transverse section of the spinal cord Etiology Presentation Diagnosis Treatment

Definition:

Definition - Acute (over minutes or hours), subacute (over days or weeks) inflammatory spinal cord dysfunction without a compressive lesion. Motor, sensory, autonomic nerves and nerve tracts Clearly defined rostral border of sensory dysfunction MRI and CSF e/o inflammation - Not due to spinal AVM, arterial or venous infarction, neoplasms, nutrtional deficiencies

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Complete Transverse Myelitis Partial or incomplete Transverse Myelitis

Transverse section of the spinal cord:

Transverse section of the spinal cord

Etiology:

Etiology Post or parainfectious * Respiratory or gastrointestinal infections within 3 to 8 weeks * Serologic evidence for acute infection with rubella, measles, infectious mononucleosis, influenza, enteroviruses, mycoplasma, or hepatitis A, B, and C

Etiology:

Etiology Direct invasion of spinal cord * Herpes viruses Cytomegalovirus [CMV] Varicella-Zoster virus [VZV] Herpes Simplex Virus 1 and 2 [HSV-1 and HSV-2] Human Herpes Virus 6 [HHV-6] Ebstein-Barr virus [EBV]) * Human T-cell lymphotropic virus 1 (HTLV-1) * Human Immunodeficiency Virus 1 (HIV-1) * Borrelia burgdorferi (Lyme disease, Neuroborreliosis) * Treponema pallidum (syphilis)

Etiology:

Etiology Systemic autoimmune diseases * Systemic Lupus Erythematosus (SLE) * Antiphospholipid syndrome Microvascular thrombosis Multiple Sclerosis

Clinical presentation:

Clinical presentation Combination of sensory, motor, bladder symptoms Features of spinal cord lesion Band like sensation (pressure, pain, numbness) over the trunk Bladder symptoms (incontinence, difficulty urinating, retention) Horizontal level of sensory loss Unilateral posterior column loss, pyramidal weakness and contralateral spinothalamic loss (Brown S è quard syndrome)

Clinical presentation:

Clinical presentation Typical presentation Prior history of fever (nonspecific viral illness) Back pain, paresthesias, radicular pain in the legs Bilateral, asymmetric, unilateral, acute-sub acute progressive leg weakness with any of the features of spinal cord lesion

Brown-Sèquard syndrome:

Brown-S è quard syndrome At the level of the lesion Ipsilateral loss of all sensory modalities Ipsilateral paresthesias, dysesthesias, band like sensation Ipsilateral LMN weakness, flaccidity, atrophy, absent reflexes, fasciculation Below the lesion Ipsilateral loss of posterior column (JPS, touch, vibration) sense Ipsilateral pyramidal weakness and signs Contralateral loss of spinothalamic (pain, temp) sense few spinal levels below the lesion (dropped sensory loss)

Differentiate From:

Differentiate From GB Syndrome Progressive lower limb weakness (proximal>distal) Ascends to upper limbs & bifacial weakness Arreflexia Normal sensory examination No bladder symptoms No band like sensation No level for sensory loss

Transverse Myelitis and MS:

Transverse Myelitis and MS 10-20% of all TM go on to develop MS 30-50% progress to MS if * Partial spinal cord lesion * Posterior or posterolateral lesion * Additional Brain lesions * Lhermitte’s sign * MRI lesion < 1 to 2 vertebral segments * Female sex,, age between 10 to 50 yrs

Prognosis:

Prognosis Recovery not complete if * Complete cord syndrome * Significant back pain at the onset * Paralplegia within 24 hrs of onset * CSF shows WBC’s > 50 mm 3 , RBC’s * MRI – extensive lesion ( 2-3 segments, cervical lesion, hemorrhagic lesion

Approach to a patient of acute Myelopathy:

Approach to a patient of acute Myelopathy

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NO structural lesion NO Herniated disk, pathologic vertebral fracture, tumor metastasis NO TB spine, epidural abscess, spondylolisthesis Suspected Myelopathy MRI dorsal spine with contrast CSF study by lumbar puncture , evaluate for routine studies, & oligoclonal bands, immunoglobulin G (IgG) index, viral polymerase chain reactions (PCRs) (HSV, VZV, CMV, EBV, enterovirus), Lyme and mycoplasma antibodies, and Venereal Disease Research Laboratory test No microbial cause IV Methylprednisolone 1gm/d for 3 to 5 days Microbial cause Systemic autoimmune disease SLE ANA,,dsDNA, APL Ab Antibiotics, antivirals ? Monthly Pulse methylprednisolne Ischemia, AVM Spinal DSA Embolization,anticoagulation

Chronic Management of TM:

Chronic Management of TM

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