This document discusses transverse myelitis, including its causes, differential diagnosis compared to multiple sclerosis and neuromyelitis optica, diagnostic testing, medical management, and role of physical therapy. Transverse myelitis is an inflammation of the spinal cord that presents with weakness, sensory changes, and bowel/bladder issues. It is usually caused by viral infections but can also be idiopathic. Differential diagnosis considers multiple sclerosis, neuromyelitis optica, and other potential causes. Medical management focuses on steroids, plasma exchange, and other immunotherapies. Physical therapy aims to improve function and manage symptoms like spasticity.

1. K E L S E Y T E R R E S O N , S P T
Q U E N T I N M E A S E C O M M U N I T Y H O S P I T A L
Transverse Myelitis: Differential
Diagnosis, Medical and Therapeutic
Management

2. Objectives
 Understand the clinical differences between
Transverse myelitis other syndromes that present
similarly
 Understand common medical management for
transverse myelitis
 Review briefly the role of physical therapy in treating
people with transverse myelitis

3. Description of Transverse Myelitis
 Inflammation (and demyelination) of
one level of the spinal cord (7,8)
 Present with rapidly progressing muscle
weakness, diminished sensation (pain,
temperature and pin prick) below level of injury
 May also have loss of proprioception and
vibration
 Bowel and bladder dysfunction
 Most commonly thoracic level of injury
(7,8)
 Symptoms greater in LEs
 UE involvement rarely occurs
 70-95% cases monophasic
 Generally no brain involvement

4. Transverse Myelitis
 Percentage of SCI (6)
 MVA 36.5%, Falls 28.5%, Acts of violence 14.3%, Sports and
recreation 9.2%, Disease/unknown 11.4%
 Epidemiology (7, 8)
 Approximately 1400 new cases of TM every year
 Affects people of all ages, but two peaks in frequency between
10-19 and 30-39
 Approximately 25% cases are children
 No gender, familial, ethnic association

5. Causes of Transverse Myelitis
 Autoimmune, inflammatory, and infectious etiologies
(7,8)
 Onset typically following an acute viral infection caused by: varicella
zoster, herpes simplex, cytomegalovirus, Epstein-Barr, influenza,
echovirus, HIV, hepatitis A, or rubella
 Can also follow (less commonly) bacterial skin infections, middle-ear
infections and bacterial pneumonia
 Poorly understood, while each of these infections can individually
attack the spinal cord it is also believed that in the post-acute phase
of the body mistakenly attacks the spinal cord
 Idiopathic – where the infection is not identified (7,8)

6. Differential Diagnosis
 Multiple Sclerosis
 Neuromyelitis Optica
 Other Diagnoses
 Diagnostic Testing

7. Differential Diagnosis – Multiple Sclerosis
 Multiple Sclerosis
 Autoimmune disorder that specifically targets the CNS
 Ruled out with the use of IgG test and MRI
 Lesions across space and time
 T cell mediated
 Epidemiology (9):
 Approximately 200 people diagnosed with MS each week
 Onset between 20-40 years of age
 Women are affected approximately twice as often as men,
except in individuals with the primary-progressive form of the
disease
 Increased prevalence farther from the equator

8. Differential Diagnosis – Neuromyelitis Optica
 Neuromyelitis Optica (4, 5)
 Rare autoimmune disorder that preferentially causes inflammation in
the optic nerve and spinal cord
 2006 Criteria: Optic neuritis + transverse myelitis, two of the following
(1) longitudinally extensive lesions (≥3 vertebral segments in length); (2)
magnetic resonance imaging (MRI) of the brain with normal findings or
with findings not consistent with MS; and (3) NMO-IgG seropositivity
 Aquaporin 4 antibody mediated
 Epidemiology (4)
 Average age of onset 41.1 years old
 NMO (67.4%) Seropositive (68.3%), Seronegative (31.7%)
 NMOSD (32.6%)
 Female 86.4%, Male 13.4%
 Race: Caucasian (47.6%), African descent (36.9%), Latin American (8%),
Asian (5.3%), Native American (2.1%)

9. Other Diagnoses/Blood Screens
 Sjorgren’s – systemic autoimmune disorder in which the
WBC attack moisture producing glands, people generally
present with dry mouth dry eyes, fatigue and joint pain
 Toxoplasmosis- parasitic disease, generally
asymptomatic or flue-like symptoms but in the immuno-
compromised can cause encephalitis or necrotizing
retinochoroiditis (decreased visual acuity in one eye)
 Anti-nuclear antibody (ANA) – found in people with
tendency toward autoimmune disorders
 Anti-dsDNA – test used to diagnose lupus (generally with
positive ANA)
 VDRL/RPR – screening tests for syphilis
 HSV – Herpes simplex can attack the eyes

10. Diagnostic Testing
 IgG test
 Blood testing, anti-aquaporin-4 antibody (NMO-IgG) highly
specific (>99%), sensitivity ranges from 49-72%
 Positive test more meaningful than a negative test
 MRI
 MS suspect to see other lesions in the CNS
 Looking with particular attention to the brain, as TM and NMO do
not attack the brain
 Looking for lesions displaced in time and space
 Involvement of the optic nerve
 CSF
 Oligoclonal bands ****

11. Differential Diagnosis Summary
Diagnosis Auto-immune or
Infection Based
General Progression
Neuromyelitis Optica Auto-immune 70% recurrent
Transverse Myelitis Infection based, immune
mediated
Typically monophasic
(70-90% of the time)
Multiple Sclerosis Auto-immune Recurrent and/or
progressive

12. Transverse Myelitis - Acute Phase
• Neurologic function declines during first 4-21 days
• 80% reach their maximum functional deficit
within 10 days of symptom onset (7,8)
• At this time 50% have lost all volitional movement in LEs
• 80-94% experience numbness, paresthesias,
banding/girdling
• Almost all have some bowel and/or bladder dysfunction
• Medical Management (7, 8, 10)
 Methylprednisolone
 Plasma exchange
 Cyclophosphamide – NMO, TM
 Rituximab - NMO

13. Rehabilitation – Transverse Myelitis
 Recovery usually begins 2 to 12 weeks after onset of
symptoms
 May continue for up to 2 years
 However, if there is no improvement within the first
3 to 6 months, significant recovery is unlikely
 Commonly cited statistic: 1/3 make significant
recovery, 1/3 have very little recovery and 1/3 make
some recovery, but are left with significant
impairments, however is very outdated (1981) (1)

14.  Rehabilitation will vary based on the person, but
some things to consider (in addition to functional
considerations):
 Spasticity
 Pain
 Bowel/bladder and sexual dysfunction
 Depression

15. Physical Therapy
 Calis et al. 2011 – Rehabilitation results of patients
with transverse myelitis. (2)
 Considered 13 pts, described management (including brief
information regarding frequency of use of spasticity,
intermittent catheterization (slightly more than half)
 MAS, Barthel and Functional Ambulation Category
(MDC/MCID not established)
 FIM – MCID = 17 pts, average change 14.9pts
 Significant difference made across all measures
 Conclusion that therapy is helpful for improving outcomes for
people with TM

16. Questions?

17. References
1. Berman M, Feldman S, Alter M, Zilber N, Kahana E. Acute transverse myelitis: incidence and etiologic
considerations. Neurology. 1981 Aug;31(8):966-71
2. Calis M, Kirnap M, Calis H, Mistik S, Demir H. Rehabilitation results of patients with transverse myelitis.
Bratisl Lek Listy. 2011; 112(3):154-156.
3. Flanagan EP, Weinshenker BG, Krecke KN, Lennon VA, Luccinetti CF, McKeon A, Wingerchuk DM,
Shuster EA, Jiao Y, Horta ES, Pittock SJ. Short myelitis in aquaporin-4-IgG-positive neuromyelitis optica
spectrum disorders. JAMA Neurology. Jan 2015. 72(1):81-7.
4. Mealy MA, Wingerchuk DM, Greenberg BM, Levy M. Epidemiology of Neuromyelitis Optica in the United
States: A Multicenter Analysis Arch Neurol. 2012;69(9):1176-1180. doi:10.1001/archneurol.2012.314.
5. Neuromyelitis Information Page. National Institute of Neurological Disorders and Stroke. January 2015.
http://www.ninds.nih.gov/disorders/neuromyelitis_optica/neuromyelitis_optica.htm
6. Spinal Cord Injury Facts and Figures. National Spinal Cord Injury Statistical Center. February 2013.
https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202013.pdf
7. Transverse Myelitis. Christopher and Dana Reeve Foundation.
http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.4453415/k.FE54/Transverse_Myelitis.htm#
8. Transverse Myelitis Fact Sheet. National Institute of Neurological Disorders and Stoke. February 2015.
http://www.ninds.nih.gov/disorders/transversemyelitis/detail_transversemyelitis.htm
9. Tullman MJ. Overview of the Epidemiology, Diagnosis, and Disease Progression Associated With Multiple
Sclerosis. Am J Manag Care. 2013;19:S15-S20
10. Wingerchuk DM. Diagnosis and Treatment of Neuromyelitis Optica. Neurologist. January 2007. 13(1): 2-
11.