Transverse myelitis

Background

• Inflammatory disorder that involves a complete transverse section of the spinal cord
  • Results from viral infection (30% of cases), postvaccination or as part of MS, SLE, or cancer
• May present exactly like a compressive lesion of the spinal cord
• Usually thoracic origin, rarely cervical spine

Clinical Features

• Rapidly progressive paraplegia (as little as 4 hours), but may progress over days-weeks
• Neck or back pain + neuro complaints:
  • Bilateral motor, sensory (burning or tingling pain), 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)
      • Acute flaccid myelitis
    • Degenerative (Spinal muscular atrophy)
    • Tumor
  • Peripheral nerve disease:
    • Guillain-Barre syndrome
    • Toxins (Ciguatera)
    • Tick paralysis
    • Diabetic peripheral neuropathy
  • Neuromuscular junction disease:
    • Myasthenia gravis crisis
    • Botulism
    • Organophosphate toxicity
    • Lambert-Eaton myasthenic syndrome
  • Muscle disease:
    • Rhabdomyolysis
    • Dermatomyositis
    • Polymyositis
    • Alcoholic myopathy
• Non-neuromuscular weakness
  • Can't miss diagnoses:
    • ACS
    • Arrhythmia/Syncope
    • Severe infection/Sepsis
    • Hypoglycemia
    • Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
      • Hypokalemic periodic paralysis
      • Thyrotoxic periodic paralysis
    • 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)

Lower Back Pain

• Spine related
  • Acute ligamentous injury
  • Acute muscle strain
  • Disk herniation (Sciatica)
  • Degenerative joint disease
  • Spondylolithesis
  • Epidural compression syndromes
    • Spinal cord compression (non-traumatic)
    • Cauda equina syndrome
    • Conus medullaris syndrome
    • Epidural abscess (spinal)
    • Epidural hematoma (spinal)
  • Thoracic and lumbar fractures and dislocations
  • Cancer metastasis
  • Spinal stenosis
  • Transverse myelitis
  • Vertebral osteomyelitis
  • Ankylosing spondylitis
  • Spondylolisthesis
  • Discitis
  • Spinal Infarct
• Renal disease
  • Kidney stone
  • Pyelonephritis
  • Nephrolithiasis
• Intra-abdominal
  • Abdominal aortic aneurysm
  • Ulcer perforation
  • Retrocecal appendicitis
  • Large bowel obstruction
  • Pancreatitis
• Pelvic disease
  • PID
• Other
  • Retroperitoneal hemorrhage/mass
  • Meningitis

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

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.