transverse myelitis

What condition is this?

● is an acute or subacute myelopathy with spinal cord inflammation

● “Transverse” refers to the sensory level detected in many cases but does not always imply complete spinal cord involvement

● Partial TM affects only a portion of the spinal cord, while some cases extend longitudinally

Transverse Myelitis

This condition is an acute or subacute myelopathy with spinal cord inflammation

Transverse Myelitis

refers to the sensory level detected in many cases but does not always imply complete spinal cord involvement

● “Transverse”

affects only a portion of the spinal cord, while some cases extend longitudinally

● Partial TM

In transverse myelitis, what are under its etiology?

Disease-Associated TM

Idiopathic TM

In the etiology of Transverse Myelitis, what are under Disease-Associated TM?

• Linked to central nervous system (CNS) inflammatory demyelinating diseases (IDDs) (e.g., multiple sclerosis [MS]).

• May result from infections (e.g., varicella zoster virus myelitis).

• Some cases were previously classified as idiopathic but are now linked to biomarkers like AQP4-IgG in neuromyelitis optica spectrum disorder (NMOSD)

In a Disease-Associated TM, give an example of a CNS demyelinating disease

Multiple Sclerosis

In a Disease-Associated TM, give an example of an infection

varicella zoster virus myelitis

TRUE OR FALSE:

In the epidemiology of Transverse Myelitis. it affects all ages and genders, though the ratio varies by etiology

TRUE

In Transverse Myelitis, children are more prone to what?

• MOG antibody disease

• Acute flaccid myelitis (linked to enterovirus infections).

This is linked to enterovirus infections

Acute flaccid paralysis

In Transverse Myelitis, what are the gender differences in specific TM causes?

Enumerate the clinical manifestations of Transverse Myelitis

[PoToToy Co nasa Spine Spine Severe Specific]

• Possible triggers

• Typical Symptoms

• Time Course and Clues to Etiology

• CNS demyelinating disease as the cause

• Spinal cord localization indicators

• Spinal Shock

• Severe bowel/bladder dysfunction

• Specific Syndromes and Association

In Transverse Myelitis, what are the possible triggers?

• Infections or vaccinations (especially MOG-IgG related).

• Nausea, vomiting, or hiccups may indicate area postrema involvement in AQP4-IgG positive NMOSD.

In Transverse Myelitis, what are the typical symptoms?

• Subacute sensory loss (often with a sensory level on the torso).

• Motor symptoms: Weakness (upper and lower motor neuron signs).

• Autonomic dysfunction: Neurogenic bowel, bladder, or sexual dysfunction.

What is the TM onset to peak symptoms?

4 hours to 21 days

In Transverse Myelitis, what does it indicate if there is a rapid onset of severe symptoms?

Suggests spinal cord infarction rather than myelitis.

In Transverse Myelitis, what does it mean if the symptoms persist beyond 21 days?

Consider sarcoidosis or other non-inflammatory myelopathies (e.g., spondylosis, dural AV fistula, tumor).

In Transverse Myelitis, what does it mean if the symptoms worsen with exertion or corticosteroids?

Dural arteriovenous fistula

In Transverse Myelitis, enumerate the CNS demyelinating disease as the cause

• Lhermitte’s Sign

• Paroxysmal painful tonic spasms

• McArdle sign

Electric shock sensation down the spina with neck flexion — Suggests CNS demyelination

Lhermitte’s Sign

Lhermitte’s Sign

• Electric shock sensation down the spina with neck flexion — Suggests what?

• CNS demyelination

Involuntary contractions after TM episode — Responsive to carbamazepine

Paroxysmal painful tonic spasms

Paroxysmal painful tonic spasms

• Involuntary contractions after TM episode — Responsive to what medication?

• carbamazepine

This is the worsening pyramidal weakness with neck flexion — Suggests CNS demyelinating disease.

McArdle sign

McArdle sign

• Worsening pyramidal weakness with neck flexion — Suggests what?

• CNS demyelinating disease.

In Transverse Myelitis, what are the spinal cord localization indicators?

• Sensory level on the torso

• Upper motor neuron signs (hyperreflexia, spasticity, Babinski sign).

Acute TM may cause _________, mimicking peripheral nervous system disorders

Acute TM may cause flaccid paraplegia with areflexia, mimicking peripheral nervous system disorders

In Transverse Myelitis,

bowel/bladder dysfunction — Suggests ________ rather than peripheral nervous system

In Transverse Myelitis,

bowel/bladder dysfunction — Suggests spinal cord involvement rather than peripheral nervous system

In Transverse Myelitis, enumerate the specific syndromes & associations

• Elsberg syndrome

• CMV-associated cauda equina syndrome

• Connective tissue disorders (e.g., lupus, Sjogren’s, antiphospholipid syndrome)

• Oral & genital ulcers

• Genital herpes infection

■ Cauda equina syndrome with lumbar myeloradiculitis — Often linked to HSV-2 genital infection

Elsberg syndrome

■ Seen in immunocompromised patients (g.g., HIV)

CMV-associated cauda equina syndrome:

In Transverse Myelitis, this should raise suspicion for AQP4-IgG positive NMOSD.

Connective tissue disorders (e.g., lupus, Sjögren’s, antiphospholipid syndrome)

In Transverse Myelitis, oral & genital ulcers suggests what disease?

Behçet’s disease.

In Transverse Myelitis, this suggests

Behçet’s disease.

oral & genital ulcers suggests

In Transverse Myelitis, this suggests Elsberg Syndrome

Genital herpes infection

In Transverse Myelitis, genital herpes infection suggests what condition?

Elsberg Syndrome

What are the classifications of Transverse Myelitis?

Partial TM

Complete TN

○ Affects only a portion of the spinal cord

○ May present with unilateral symptoms or only sensory or motor involvement

○ Often associated with MS

Partial TM:

A classification of TM that affects only a portion of the spinal cord

Partial TM:

A classification of TM that may present with unilateral symptoms or only sensory or motor involvement

Partial TM:

A classification of TM that is often associated with MS

Partial TM:

○ Involves the entire cross-section of the spinal cord

○ Bilateral symptoms with severe disability

○ Can be part of longitudinally extensive TM (LETM), seen in AQP4-IgG positive NMOSD

Complete TM

A classification of TM that involves the entire cross-section of the spinal cord

Complete TM

A classification of TM that presents with bilateral symptoms with severe disability

Complete TM

A classification of TM that can be part of longitudinally extensive TM (LETM), seen in AQP4-IgG positive NMOSD

Complete TM

What is the onset of Transverse Myelitis?

Onset

• Acute to subacute in nature

• Neurological symptoms are prominent and typically evolve rapidly

What are the types of symptoms in Transverse Myelitis?

Motor

Sensory

Autonomic

This is the most common feature in Transverse Myelitis

Sensory

What type of symptom is this in TM?

■ Rapidly progressing paraparesis

■ Initially flaccidity, followed by spasticity due to white matter damage

■ Severity and pattern depend on spinal cord level involved.

Motor

What type of symptom is this in TM?

■ Rapidly progressing paraparesis

Motor

What type of symptom is this in TM?

■ Initially flaccidity, followed by spasticity due to white matter damage

Motor

What type of symptom is this in TM?

■ Severity and pattern depend on spinal cord level involved.

Motor

What type of symptom is this in TM?

■ Most common feature

■ Includes pain, dysesthesia, paresthesia, usually at or near the level of the lesion

○ Sensory

What type of symptom is this in TM?

■ Most common feature

○ Sensory

What type of symptom is this in TM?

■ Includes pain, dysesthesia, paresthesia, usually at or near the level of the lesion

○ Sensory

What type of symptom is this in TM?

■ Urinary urgency, retention, incontinence

■ Constipation or other bowel dysfunction

■ Sexual dysfunction

■ Urinary retention may be an early warning sign

Autonomic

What type of symptom is this in TM?

■ Urinary urgency, retention, incontinence

What type of symptom is this in TM?

■ Constipation or other bowel dysfunction

Autonomic

What type of symptom is this in TM?

■ Sexual dysfunction

Autonomic

What type of symptom is this in TM?

■ Urinary retention may be an early warning sign

Autonomic

In Transverse Myelitis, enumerate the Symptoms Based on Spinal Cord Level

• Cervical (C1-C5)

• Lower Cervical (C5-T1)

• Thoracic (T1-T12)

• Lumbosacral (L1-S5)

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ May affect all four extremities

○ If lesion affects C3-C5 (phrenic nerve — Potential diaphragmatic dysfunction or respiratory failure.

○ Accounts for ~20% of TM cases

Cervical (C1-C5):

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ May affect all four extremities

Cervical (C1-C5):

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ If lesion affects C3-C5 (phrenic nerve — Potential diaphragmatic dysfunction or respiratory failure.

Cervical (C1-C5):

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ Accounts for ~20% of TM cases

Cervical (C1-C5):

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ May show mixed upper and lower motor neuron signs in upper extremities

○ Upper motor neuron signs in lower extremities

● Lower Cervical (C5-T1):

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ May show mixed upper and lower motor neuron signs in upper extremities

● Lower Cervical (C5-T1):

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ Upper motor neuron signs in lower extremities

● Lower Cervical (C5-T1):

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ Most commonly affected region (~70% of cases).

○ Upper and lower motor neuron signs in the lower extremities

Thoracic (T1-T12)

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ Most commonly affected region (~70% of cases).

Thoracic (T1-T12)

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ Upper and lower motor neuron signs in the lower extremities

Thoracic (T1-T12)

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ May also show upper and lower motor neuron signs in the lower extremities

○ Accounts for 10% of cases.

Lumbosacral (L1-S5) ○

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ May also show upper and lower motor neuron signs in the lower extremities

Lumbosacral (L1-S5) ○

In Transverse Myelitis, these symptoms are based on what spinal cord level?

○ Accounts for 10% of cases.

Lumbosacral (L1-S5)