Transverse myelitis * epidemiology * etiology * sign and symptoms * clinical features * pathophysiology * management etc.

1. Transverse Myelitis

2. Transverse myelitis is an inflammation of both sides of one section
of the spinal cord.
This neurological disorder often damages the insulating material covering
nerve cell fibers (myelin).
Transverse myelitis interrupts the messages that the spinal cord nerves send
throughout the body.
This can cause pain, muscle weakness, paralysis, sensory problems, or
bladder and bowel dysfunction.
TM leads to severe motor, sensory and autonomic dysfunction.

4. Epidemiology
The incidence of TM is 1 (severe) to 8 (mild) cases/million per year.
It occurs in adults and children, in both genders, and in all races.
Transverse myelitis can affect men and women equally. Women tend to predominate
those associated with multiple sclerosis.
A peak in incidence rates (the number of new cases per year) appears to occur
between 10 and 19 years and 30 and 39 years.
According to one case series, 64% of cases were idiopathic (primary TM) in nature,
and 36% were associated with a disease (secondary TM).

5. Etiology
There are multiple causes of transverse myelitis, but they can be broadly divided into
idiopathic, postinfectious, systemic inflammation, or central nervous system disease.
The most common cause of TM is idiopathic, and there is no causative factor found.
Infections leading to TM include, but are not limited to, enteroviruses, West Nile virus,
herpes viruses, HIV, human T-cell leukemia virus type 1 (HTLV-1), Zika virus,
Mycoplasma and Treponema pallidum.
Some of the acquired central nervous system autoimmune disorders include multiple
sclerosis, neuromyelitis optica spectrum disorder, and acute disseminated
encephalomyelitis.

6. Causes
There are many different causes of transverse myelitis, including
• infections and immune system disorders that attack the body's tissues.
• myelin disorders, such as multiple sclerosis.
• Infections :-
viruses (HIV, Herpes, Cytomegalovirus)
Bacterial (mycoplasma pneumoniae)

7. Signs and symptoms
Signs and symptoms of transverse myelitis usually develop over a few hours to few days
and may sometimes progress gradually over several weeks. It usually affects both sides of
the body below the affected area of the spinal cord, but sometimes there are symptoms
on just one side of the body.
Typical signs and symptoms include:
▪ Pain- Transverse myelitis pain may begin suddenly in the lower back. Sharp pain may
shoot down to legs or arms or around the chest or abdomen.
▪ Abnormal sensations- Some people with transverse myelitis report sensations of
numbness, tingling, coldness or burning. Some are especially sensitive to the light touch
of clothing or to extreme heat or cold. You may feel as if something is tightly wrapping
the skin of your chest, abdomen or legs.

8. ▪ Weakness in your arms or legs- Some people notice heaviness in the legs, or that
they're stumbling or dragging one foot. Others may develop severe weakness or
even total paralysis.
▪ Bladder and bowel problems- This may include needing to urinate more frequently,
urinary incontinence, difficulty urinating and constipation.
TM characterized by weakness and numbness of the limbs, deficits in sensations and
motor skills, dysfunction in urethral and anal sphincter activities, dysfunction in
autonomic nervous system that can lead to episodes of high BP

9. Pathophysiology
Pathophysiology of transverse myelitis is varied and is related to the underlying
etiology. Classically, the majority of cases were characterized by perivascular
infiltration, demyelination, and axonal injury by monocytes and lymphocytes at the
lesion site.
The mechanism of injury is inflammation of the spinal cord causing damage to the
myelin sheath of the nerves.

10. Clinical Features and presentation
The onset of transverse myelitis is acute to subacute.
Neurologic symptoms are prominent. Symptoms include motor, sensory, and/or
autonomic dysfunction.
Motor deficits include rapidly progressing paraparesis, which can involve, upper
extremities initially with flaccidity followed by spasticity.
This may be caused by damage to white matter structures in the spinal cord.
Most commonly, there is sensory involvement with symptoms, including pain and
paresthesia at the level involved.
Autonomic features of TM include urinary urgency, bladder/bowel incontinence,
difficulty/inability to void, bowel constipation, or sexual dysfunction. Urinary retention
may be the first sign of myelitis and should warrant further investigation into myelopathy.

11. Motor symptoms may vary depending on the level of the spinal cord involved.
Upper cervical lesions (C1-C5) may affect all four extremities.
Additionally, if the lesion affects the phrenic nerve (C3, C4, C5), it could lead to
diaphragmatic dysfunction and respiratory failure.
Lesions in the lower cervical levels (C5-T1) many develop upper and lower motor
neuron signs in the upper extremities and exclusive upper motor neuron signs in the
lower extremities. Cervical lesions account for approximately 20% of cases.
Lesions in the thoracic region (T1-T12) may cause both upper and lower motor neuron
signs in the lower extremities. The thoracic region is the most commonly affected in TM
cases (70%).
Lesions in the lumbosacral regions (L1-S5) may cause both upper and lower motor
neuron signs in the lower extremities. Lumbar lesions account for approximately 10% of
cases.

12. Diagnosis
o MRI - To diagnose transverse myelitis, a compressive cord lesion must be
excluded first. Exclusion is usually performed by magnetic resonance imaging
(MRI).
o Lumbar puncture - for CSF analysis including cell count with differential,
protein, glucose, immunoglobulin G (IgG) index,
o Infectious serologic studies - Serum erythrocytes sedimentation rate (ESR), C-
reactive protein (CRP)
o Nasopharyngeal swab for enteroviral PCR

13. Differential Diagnosis
The most common aetiologies to be distinguished from idiopathic acute
transverse myelitis are:
• Multiple Sclerosis
• Guillain Barre Syndrome
• Disc herniation
• Compression of spinal cord caused by trauma

14. Medical Management
Treatments are intended to reduce spinal cord inflammation and alleviate
symptoms:
• Corticosteroids given intravenously
• Plasmapheresis - for moderate to severe cases, or those who do not respond to
steroids after 3-5 days
(a method of removing blood plasma from the body by withdrawing blood,
separating it into plasma and cells, and transfusing the cells back into the
bloodstream. It is performed especially to remove antibodies in treating
autoimmune conditions)
• Immunosuppresent medication

15. Physiotherapy Management
• Stretching programme – to prevent contractures
• Strengthening
• Transfers
• Gait training
• Wheelchair training
• Reduce risk of pressure ulcers
• Aid control of spasticity
• Pain reduction/management

18. Recent Studies
Jamison. L et al. (2020) conducted a study on “Effects of Training with Impairment
Based Therapeutic Intervention Program for Improvement in Function and
Independence in an Individual Diagnosed with Transverse Myelitis”
Treatment program was developed based on the patient’s impairment rather than the
diagnosis. Patient education, balance (core activation), gait activities, strength and
eccentric exercises were some of the interventions.
The patient was a 44-year-old male diagnosed with TM, displayed paresthesia from the
bilateral nipple line (T4) to the bilateral lower extremities, muscle weakness (RLE>LLE),
gait deviations (right knee buckling) and fatigue
Conclusion:- In this case study, the patient was unable to reach his personal goal of
walking independently, but he did fulfill most set physical therapy goals and exhibit
advancement in functional activities. Such as increased strength, gait mobility, motor
control, balance, and function.

19. Collin Schrader et al, (2018) conducted a case report on “Physical Therapy Management
of a Patient Diagnosed with Transverse Myelitis”
Patient was diagnosed with transverse myelitis, presented with severely decreased
functional status, requiring a wheelchair
Interventions: Physical therapy focused on improving functional movements such as
walking, transferring to and from bed, and ambulating stairs.
Patient was able to perform all bed mobility with standby assistance only. Sitting balance
had improved, transferring from bed to chair with the help of walker (minimum
assistance of one). sit to stand transfers had improved to minimum assistance of one to
light contact assistance.

20. Multiple sclerosis (MS) is an autoimmune disease, this chronic condition involves
the central nervous system (CNS). With MS, your immune system attacks myelin,
which is the protective layer around nerve fibers.
Neuromyelitis optica spectrum disorder or Devic's disease. It occurs when your
body's immune system reacts against its own cells in the central nervous system,
mainly in the optic nerves and spinal cord, but sometimes in the brain
Acute disseminated encephalomyelitis, affects children more often than adults. This
rare neurological disorder often occurs after a viral or bacterial infection.
characterized by a brief but widespread attack of inflammation in the brain and
spinal cord that damages myelin – the protective covering of nerve fibers.

21. THANK YOU
PRESENTED BY DINU DIXON
MPT(NEUROLOGY)