Transverse myelitis: Difference between revisions
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*May progress over days-weeks | *May progress over days-weeks | ||
*Neck or [[back pain]] + neuro complaints: | *Neck or [[back pain]] + neuro complaints: | ||
**Bilateral motor, sensory, and autonomic disturbances | **Bilateral [[weakness|motor]], [[numbness|sensory]], and autonomic disturbances | ||
**Fecal/[[urinary retention]] and incontinence | **Fecal/[[urinary retention]] and [[urinary incontinence|incontinence]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
*Neurologic findings that are consistent with epidural compression but normal MRI | *Neurologic findings that are consistent with epidural compression but normal [[mri|MRI]] | ||
*Must rule-out compressive lesion of the cord | *Must rule-out compressive lesion of the cord | ||
*[[MRI]] | *[[MRI]] | ||
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*[[LP]] | *[[LP]] | ||
**Contains monocytes, protein content is slightly increased, and IgG index is elevated<ref>http://www.merckmanuals.com/professional/neurologic_disorders/spinal_cord_disorders/acute_transverse_myelitis.html</ref> | **Contains monocytes, protein content is slightly increased, and IgG index is elevated<ref>http://www.merckmanuals.com/professional/neurologic_disorders/spinal_cord_disorders/acute_transverse_myelitis.html</ref> | ||
==Management== | |||
*Foley for bladder decompression | *Foley for bladder decompression | ||
*Consider work up for clotting disorder for spinal artery thrombosis, drug user, risk for [[aortic dissection]] | *Consider work up for clotting disorder for spinal artery thrombosis, drug user, risk for [[aortic dissection]] | ||
Revision as of 16:44, 3 October 2019
Background
- Inflammatory disorder that involves a complete transverse section of the spinal cord
- May present exactly like a compressive lesion of the spinal cord
- Usually thoracic origin, rarely cervical spine
Clinical Features
- May progress over days-weeks
- Neck or back pain + neuro complaints:
- Bilateral motor, sensory, and autonomic disturbances
- Fecal/urinary retention and incontinence
Differential Diagnosis
Weakness
- Neuromuscular weakness
- Upper motor neuron:
- CVA
- Hemorrhagic stroke
- Multiple sclerosis
- Amyotrophic Lateral Sclerosis (ALS) (upper and lower motor neuron)
- Lower motor neuron:
- Spinal and bulbar muscular atrophy (Kennedy's syndrome)
- Spinal cord disease:
- Infection (Epidural abscess)
- Infarction/ischemia
- Trauma (Spinal Cord Syndromes)
- Inflammation (Transverse Myelitis)
- Degenerative (Spinal muscular atrophy)
- Tumor
- Peripheral nerve disease:
- Neuromuscular junction disease:
- Muscle disease:
- Rhabdomyolysis
- Dermatomyositis
- Polymyositis
- Alcoholic myopathy
- Upper motor neuron:
- Non-neuromuscular weakness
- Can't miss diagnoses:
- ACS
- Arrhythmia/Syncope
- Severe infection/Sepsis
- Hypoglycemia
- Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
- Respiratory failure
- Emergent Diagnoses:
- Symptomatic Anemia
- Severe dehydration
- Hypothyroidism
- Polypharmacy
- Malignancy
- Aortic disease - occlusion, stenosis, dissection
- Other causes of weakness and paralysis
- Acute intermittent porphyria (ascending weakness)
- Can't miss diagnoses:
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
- Renal disease
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- Other
Evaluation
- Neurologic findings that are consistent with epidural compression but normal MRI
- Must rule-out compressive lesion of the cord
- MRI
- May show cord swelling
- Hyperintense lesion on T2 weighted images
- LP
- Contains monocytes, protein content is slightly increased, and IgG index is elevated[1]
Management
- Foley for bladder decompression
- Consider work up for clotting disorder for spinal artery thrombosis, drug user, risk for aortic dissection
- Neurological consultation
- Admit for corticosteroids and plasma exchange
- High dose steroid regimen, such as methylprednisolone 1 gram daily or dexamethasone 200 mg daily
- The more rapid the progression is, the worse the prognosis
References
- Perron AD, Huff JS. “Spinal Cord Disorders,” in Rosen’s Emergency Medicine Concepts and Clinical Practice, edited by Marx JA, Hockberger RS, Walls RM, et al., 1389-1395. Philadelphia: Mosby, 2010.