Transverse Myelitis: Symptoms, Types, Causes and Treatment

Transverse myelitis is a rare but serious condition involving inflammation of the spinal cord, often leading to sudden and dramatic changes in movement, sensation, and autonomic function. Understanding its symptoms, forms, underlying causes, and treatment options is essential for patients, families, and medical professionals alike. In this comprehensive guide, we explore the latest evidence and expert insights on transverse myelitis, helping demystify this complex neurological syndrome.

Symptoms of Transverse Myelitis

Transverse myelitis can present suddenly and progress rapidly, making early recognition crucial. Symptoms often reflect the disruption of both motor and sensory pathways in the spinal cord, as well as the autonomic nerves that control vital body functions.

Symptom	Description	Onset	Source(s)
Weakness	Loss of strength in arms/legs, paraparesis	Rapid (hrs–days)	2 5 7
Sensory Changes	Numbness, tingling, sensory level on trunk	Rapid	2 5 7
Autonomic Issues	Bladder/bowel dysfunction, sexual problems	Rapid	2 3 5
Pain	Back pain, radicular or band-like sensations	Early/variable	5 7

Table 1: Key Symptoms

Motor Symptoms

The most dramatic symptom is often weakness, which can affect both legs (paraparesis) or all four limbs (quadriparesis), depending on the level and extent of spinal inflammation. This weakness can progress over hours to days, sometimes leading to complete paralysis at the affected level 5 7.

Sensory Alterations

Patients commonly report numbness, tingling, or a distinct "sensory level"—an area below which sensation is altered or lost. This sensory change can be accompanied by a tight, band-like feeling around the torso or limbs 2 5.

Autonomic Dysfunction

Transverse myelitis often disrupts autonomic nerve fibers, leading to urinary urgency, retention, incontinence, and constipation. Bowel dysfunction and sexual problems are also frequently reported. Some patients experience sudden episodes of high blood pressure or problems with temperature regulation 2 3 5.

Pain and Other Features

Pain is a common but variable feature. It may present as localized back pain or radiate along the nerves ("radicular" pain). The rapid onset of these symptoms, often reaching maximum severity within 10 days, distinguishes transverse myelitis from many other neurological disorders 5 7.

Types of Transverse Myelitis

Transverse myelitis is not a single disease, but a syndrome with several distinct forms based on underlying cause, clinical presentation, and MRI findings.

Type	Defining Feature	Associated Diseases	Source(s)
Idiopathic	No identifiable cause	None	4 7 8 9
Disease-associated	Linked to systemic or CNS disease	MS, NMO, SLE, infections	4 7 9 12
Longitudinally Extensive (LETM)	Lesion ≥3 spinal segments	NMO, SLE, infections	1 6 13
Partial	Incomplete or segmental involvement	MS, less severe forms	9 13

Table 2: Types of Transverse Myelitis

Idiopathic Transverse Myelitis

Idiopathic cases are defined by the absence of a known cause, even after thorough investigation. These cases often present acutely and may remain isolated or later evolve into other demyelinating diseases 4 7 9.

Disease-Associated Myelitis

Many cases are linked to underlying conditions:

• Multiple Sclerosis (MS): TM can be the first sign of MS, especially in younger adults.
• Neuromyelitis Optica (NMO): Characterized by severe, recurrent myelitis often with optic neuritis.
• Systemic Lupus Erythematosus (SLE): TM is a rare but severe complication 12.
• Infections: Viruses, bacteria, and post-vaccination responses can trigger TM 1 10.

Longitudinally Extensive Transverse Myelitis (LETM)

LETM involves spinal cord lesions extending three or more vertebral segments. This form is most often associated with NMO, but can also be seen in SLE and some infections. LETM has a higher risk of recurrence and severe disability 1 6 13.

Partial Transverse Myelitis

Some patients have incomplete or focal cord involvement, resulting in milder or more asymmetrical symptoms. Acute partial transverse myelitis carries a higher risk of evolving into MS 9 13.

Causes of Transverse Myelitis

The causes of transverse myelitis are diverse and may be challenging to pinpoint. Understanding the potential triggers is key to guiding treatment and prognosis.

Cause Category	Examples	Mechanism	Source(s)
Autoimmune	MS, NMO, SLE, Sjogren’s, APS	Immune-mediated	4 7 10 11 12
Infectious	Viruses (e.g. COVID-19, HSV), bacteria	Direct or para-infectious	1 3 10
Post-vaccination	e.g., ChAdOx1 nCoV-19 (COVID-19 vaccine)	Immune response	1 10
Idiopathic	Unknown	Presumed immune	4 8 9

Table 3: Causes of Transverse Myelitis

Autoimmune Causes

A substantial proportion of TM cases are due to autoimmune diseases. In MS and NMO, the immune system targets myelin or aquaporin-4 channels, leading to spinal cord inflammation. SLE and other connective tissue diseases can also cause TM via vasculitic or granulomatous processes 4 7 10 11 12.

Infectious and Para-infectious Causes

Viruses (such as herpesviruses, enteroviruses, and more recently, SARS-CoV-2) can directly infect the spinal cord or trigger an abnormal immune response after infection. Bacterial or other microbial infections are less common but important to consider 1 3 10.

Post-vaccination and Parainfectious TM

Rarely, TM can occur after vaccination, such as reported cases following COVID-19 vaccines. The immune system's response to vaccine antigens or adjuvants is believed to trigger inflammation in susceptible individuals 1 10.

Idiopathic Cases

Despite extensive testing, many cases remain idiopathic, presumed to be immune-mediated but with no clear trigger or systemic disease identified 4 8 9.

Treatment of Transverse Myelitis

Timely and targeted treatment of transverse myelitis is vital for maximizing recovery and minimizing disability. Management strategies vary depending on the underlying cause and severity of symptoms.

Therapy	Indication	Efficacy/Notes	Source(s)
High-dose steroids	First-line, most cases	Reduce inflammation	3 7 12 14
Plasma exchange	Steroid-refractory cases	Removes autoantibodies	8 13
Immunosuppressants	Autoimmune, severe/refractory	Cyclophosphamide, rituximab	12 13 14
Supportive care	All cases	Rehab, prevent complications	3 5 7

Table 4: Treatment Approaches

Acute Management

• High-Dose Corticosteroids: IV methylprednisolone is the mainstay of initial therapy, rapidly reducing inflammation and limiting neurological injury. Treatment is typically given for several days, followed by a tapering oral regimen 3 7 12 14.
• Plasma Exchange (PLEX): For patients who do not respond to steroids, plasma exchange can be effective by removing autoantibodies and immune complexes from the circulation 8 13.
• Immunosuppressive Agents: Cases associated with autoimmune diseases or severe presentations may require additional drugs such as cyclophosphamide or rituximab, particularly for SLE-associated TM or NMO 12 13 14.

Supportive and Long-Term Care

• Rehabilitation: Physical and occupational therapy are critical for maximizing function and independence.
• Prevention of Complications: Early attention to bladder, bowel, skin, and respiratory care reduces morbidity 3 5 7.
• Monitoring for Relapse: Some forms of TM, particularly those associated with NMO or MS, may require ongoing immunomodulatory therapy to prevent recurrence 13.

Special Considerations in Children

Children with TM often respond well to high-dose steroids, and most recover with minimal long-term disability. However, some may later develop other demyelinating conditions, such as NMO or MS, warranting close follow-up 3.

Conclusion

Transverse myelitis is a complex neurological syndrome with a wide range of symptoms, causes, and outcomes. Prompt recognition and a systematic approach to diagnosis and treatment can significantly improve prognosis.

Key Points:

• Symptoms include rapid-onset weakness, sensory changes, and autonomic dysfunction.
• TM can be idiopathic or linked to diseases like MS, NMO, SLE, or infections.
• Causes are diverse—autoimmune, infectious, post-vaccination, or idiopathic.
• Treatment relies on high-dose steroids, with plasma exchange and immunosuppressants for severe or refractory cases.
• Rehabilitation and long-term monitoring are essential for optimizing recovery.

Understanding the nuances of transverse myelitis empowers patients and clinicians to work together for the best possible outcomes.