Transverse Myelitis

What is transverse myelitis?

Transverse myelitis is a neurological disorder caused by inflammation of the spinal cord. When the spinal cord gets inflamed, this inflammation can damage the insulating material, called myelin, that covers nerve cell fibers. Myelitis refers to inflammation of the spinal cord.

The part of the spinal cord where the damage happens determines which parts of the body are affected. Usually, the body is affected from the site of the damage and below. In people with transverse myelitis, myelin damage most often occurs in nerves in the upper back. The term “transverse” refers to the pattern of symptoms. A person with transverse myelitis will often feel a band-like sensation across the trunk of the body and may experience sensory symptoms and weakness below that area.

Most people with transverse myelitis have at least partial recovery, with most recovery taking place within the first three months after symptoms begin. Although some people recover from transverse myelitis with minor or no lasting problems, the healing process can take many months. Some people may have permanent effects that affect their ability to perform ordinary tasks of daily living. Some people will have only one episode of transverse myelitis, but others may have a recurrence, especially if an underlying illness, such as multiple sclerosis, caused the inflammation.

Transverse myelitis may be either acute (developing over minutes to several days) or subacute (usually developing over one to four weeks).

Symptoms of transverse myelitis

Classic features and symptoms of transverse myelitis include:

• Weakness of the legs and arms—People with transverse myelitis often have weakness in the legs that worsens rapidly. If the myelitis affects the upper spinal cord, it affects the arms as well. People may develop partial paralysis in their legs (called paraparesis) that may progress to complete paralysis and require the person to use a wheelchair to get around.
   
• Pain—Initial symptoms usually include lower back pain or sharp, shooting pain that radiates down the legs or arms or around the person’s torso.
   
• Sensory alterations—Transverse myelitis can cause abnormal sensations such as burning, tickling, pricking, numbness, coldness, or tingling in the legs. These are called paresthesias. People with transverse myelitis can also lose sensation in parts of their bodies. Abnormal sensations in the torso and genital region are also common.
   
• Bowel and bladder dysfunction—People with transverse myelitis often have an increased frequency or urge to use the toilet, incontinence or urinary retention, and constipation.

Other symptoms may include muscle spasms, a general feeling of discomfort, and loss of appetite. Some people experience respiratory problems, sexual dysfunction, and chronic pain.

Who is more likely to get transverse myelitis?

Transverse myelitis can affect people of any age, gender, or race. It does not appear to be genetic or to run in families. The disorder occurs most frequently in people who are either adolescents and teens (ages 10 to 19) or in their thirties.

Transverse myelitis is usually caused by other conditions. The following conditions appear to cause the disorder:

• Immune system disorders can cause damage to the spinal cord. In some people, transverse myelitis is the first symptom of an autoimmune or immune-mediated disease such as multiple sclerosis or neuromyelitis optica spectrum disorder. Immune system disorders that can cause transverse myelitis include:
   
  • Multiple sclerosis (MS), a disorder in which immune system cells mistakenly attack the protective coating of myelin in the brain, optic nerves, and spinal cord
  • Neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein-associated disorder (MOGAD), disorders that affect the nerves of the eye and spinal cord 
  • Post-infectious or post-vaccine autoimmune phenomenon, in which the body's immune system mistakenly attacks its own tissue while responding to an infection or, rarely, a vaccine
  • An abnormal immune response to an underlying cancer that damages the nervous system
     
• Viral infections including herpes viruses such as varicella zoster (the virus that causes chickenpox and shingles), herpes simplex, enterovirus, poliovirus, cytomegalovirus, and Epstein-Barr; flaviviruses such as West Nile and Zika; influenza, echovirus, hepatitis B, mumps, measles, and rubella. It is unclear whether direct viral infection or a post-infectious response causes transverse myelitis.
   
• Bacterial infections such as syphilis, tuberculosis, actinomyces, pertussis, tetanus, diphtheria, and Lyme disease. Bacterial skin infections, middle-ear infections, campylobacter jejuni gastroenteritis, and mycoplasma bacterial pneumonia have also been associated with transverse myelitis.
   
• Fungal infections in the spinal cord, including aspergillus, blastomyces, coccidioides, and cryptococcus.
   
• Parasites including toxoplasmosis, cysticercosis, shistosomiasis, and angtiostrongyloides.
   
• Other inflammatory disorders that can affect the spinal cord, such as sarcoidosis, systemic lupus erythematosus, Sjogren's syndrome, mixed connective tissue disease, scleroderma, and Bechet's syndrome.
   
• Vascular disorders such as arteriovenous malformation, dural arterial-venous fistula, intra-spinal cavernous malformations, spinal cord infarct, or disk embolism.

In many cases, the exact cause of transverse myelitis and the accompanying nerve damage in the spinal cord is unknown. When doctors cannot identify a cause for the disorder, they refer to it as idiopathic, which means the cause is unknown.

How is transverse myelitis diagnosed and treated?

Diagnosing transverse myelitis

Physicians diagnose transverse myelitis by taking a medical history and performing a thorough neurological examination. These tests can help diagnose the disorder and rule out or evaluate underlying causes:

• MRI (magnetic resonance imaging) will almost always confirm the presence of a damaged area (lesion) within the spinal cord. An MRI of the brain can provide clues to other underlying causes, especially MS.
• Blood tests can identify or rule out various disorders, including HIV infection and vitamin B12 deficiency.
• Lumbar puncture and spinal fluid analysis (also called a spinal tap) can identify infections, more protein than usual in some people with transverse myelitis and an increased number of white blood cells (leukocytes) that help the body fight infections.

In some cases, PET (positron emission tomography), which uses a safe, radioactive tracer, can help identify diseased cells and diagnose some possible underlying causes, such as sarcoidosis or cancer.

Treating transverse myelitis

Treatments are designed to address infections that may cause the disorder, reduce spinal cord inflammation, and manage and reduce symptoms.

Some of the most common initial treatments for transverse myelitis are:

• Intravenous (IV) corticosteroid drugs may decrease swelling and inflammation in the spinal cord and reduce immune system activity. Such drugs may include methylprednisolone or dexamethasone. These medications may also help reduce the chance of a recurrence of transverse myelitis in people with underlying disorders.
   
• Plasma exchange therapy (plasmapheresis) may be used for people who don't respond well to IV steroids. Plasmapheresis is a procedure that reduces immune system activity by removing plasma (the fluid in which blood cells and antibodies are suspended) and replacing it with special fluids, thus removing the antibodies and other proteins thought to be causing the inflammatory reaction.
   
• IV immunoglobulin (IVIG) is a treatment that can help to reset the immune system. IVIG is a highly concentrated injection of antibodies pooled from many healthy donors. It can bind to the antibodies that may cause transverse myelitis and remove them from circulation.
   
• Pain medicines to reduce muscle pain include acetaminophen, ibuprofen, and naproxen. Nerve pain may be treated with certain antidepressant drugs (such as duloxetine), muscle relaxants (such as baclofen, tizanidine, or cyclobenzaprine), and anticonvulsant drugs (such as gabapentin or pregabalin).
   
• Antiviral medications may help people who have a viral infection of the spinal cord.

Medications for other symptoms also may be used to treat symptoms of incontinence, painful muscle contractions called tonic spasms, stiffness, sexual dysfunction, and depression.

Following initial therapy, it is critical to keep the person's body functioning during the recovery period. In rare cases when breathing is significantly affected, the person may need a respirator to help them breathe, but this is usually temporary.

Rehabilitation and long-term therapy for transverse myelitis

Many forms of long-term rehabilitation are available for people who have disabilities resulting from transverse myelitis. Strength and functioning can improve even years after the initial episode. Although rehabilitation cannot reverse the physical damage resulting from transverse myelitis, it can help people, even those with severe paralysis, become as functionally independent as possible and attain the best possible quality of life.

People with lasting or permanent neurological defects from transverse myelitis typically see a range of rehabilitation specialists, who may include physiatrists, physical therapists, occupational therapists, vocational therapists, and mental health care professionals.

• Physical therapy can help retain muscle strength and flexibility, improve coordination, reduce stiffness, regain bladder and bowel control, and increase joint movement. Physical therapists can also provide support and education around using assistive devices such as wheelchairs, canes, or braces.
   
• Occupational therapy teaches people new ways to maintain or rebuild their independence by participating in meaningful, self-directed, everyday tasks such as bathing, dressing, preparing meals, and house cleaning.
   
• Vocational therapy helps people develop and improve work skills, identify potential employers, and assist in job searches. Vocational therapists act as mediators between employees and employers to secure reasonable workplace accommodations.
   
• Psychotherapy, counseling, or talk therapy for people living with permanent damage includes strategies and tools to deal with stress and a wide range of emotions and behaviors.

What are the latest updates on transverse myelitis?

NINDS, a part of the National Institutes of Health (NIH), is the nation's leading federal funder of research on neurological disorders. NINDS, the National Institute of Allergy and Infectious Diseases (NIAID), and several other components of NIH conduct research on transverse myelitis and fund research at major institutions and universities.

NINDS funding supports researchers who work to understand how the immune system destroys or attacks myelin in autoimmune disorders. Other research focuses on strategies to repair myelin in the spinal cord, including approaches that use cell transplantation. This research may lead to a greater understanding of how myelin gets damaged and may ultimately provide a means to prevent and improve treatments for transverse myelitis.

• Glial cell studies—Glia, or neuroglia, are non-neuronal cells (cells that do not generate electrical impulses) in the nervous system that form myelin and provide support and protection for neurons. Oligodendrocyte progenitor cells (OPCs) are stem cells that generate oligodendrocytes, a type of glial cell that produces myelin. NINDS-funded scientists are studying mechanisms in cells that control how OPCs form and mature and possible ways to increase oligodendrocyte proliferation and remyelination after spinal cord injury. Astrocytes, another type of glial cell, may activate parts of the immune system in neuromyelitis optica spectrum disorder (NMOSD), a disorder that causes transverse myelitis. Many researchers are trying to understand how astrocytes affect autoimmune diseases.
   
• Genetic studies—NINDS-funded scientists are studying a very rare genetic change that has been linked to the disorder to understand whether there may be a genetic component of idiopathic transverse myelitis.
   
• Regenerating nerve cells—Some researchers use animal models of spinal cord injury to learn ways to replace or regenerate spinal cord nerve cells. The goals of these studies are to find ways to restore function in people who have paralysis.
   
• Neuroimaging with MRI—Research funded by NINDS aims to develop and use new MRI techniques to study the relationship between problems in the spinal cord and neurological dysfunction in MS. This approach may assess changes in lesions and myelin in MS and possibly transverse myelitis. Other researchers are developing MRI approaches that can identify the extent of injury to the spinal cord and monitor recovery after injury. These techniques may allow earlier detection of transverse myelitis and other neurological disorders, such as MS.
   
• Brain-machine interfaces and prosthetic devices—Scientists are developing brain-machine interfaces and neural prostheses to help people with spinal cord damage regain functions by bypassing the injured area. While this research is at early stages, these sophisticated electrical and mechanical devices can connect with the nervous system to supplement or replace lost motor and sensory function.

More information on transverse myelitis and spinal cord injury research is available through the NIH RePORTER, a searchable database of current and previously funded research, as well as research results and publications.

How can I or my loved one help improve care for people with transverse myelitis?

Consider participating in a clinical trial so clinicians and scientists can learn more about transverse myelitis. Clinical research with human participants helps researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease.

All types of participants are needed—those who are healthy or may have an illness or disease—of all different ages, sexes, races, and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them.

For information about participating in clinical research visit NIH Clinical Research Trials and You. Learn about clinical trials currently looking for people with transverse myelitis at Clinicaltrials.gov.