Transverse Myelitis

Disease/Disorder

Definition

Transverse Myelitis (TM) is an inflammatory disorder of the spinal cord that may be idiopathic or related to other diseases.^1,2 It is characterized by acute or subacute dysfunction of the spinal cord affecting the motor, sensory, and autonomic (bowel, bladder, sexual) systems below the lesion level.²

Consensus diagnostic criteria for idiopathic TM^2,3

• Bilateral (not necessarily symmetric) sensorimotor and autonomic spinal cord dysfunction.
• Clearly defined sensory level.
• Demonstration of spinal cord inflammation: cerebrospinal fluid pleocytosis or elevated immunoglobulin G index, or magnetic resonance imaging (MRI) revealing a gadolinium-enhancing cord lesion.
• Progression to nadir of clinical deficits between 4 hours and 21 days after symptom onset.
• Exclusion of compressive, post-radiation, neoplastic, and vascular causes.

Etiology

Acute TM (ATM) occurs as an immune-mediated phenomenon or direct infection/invasion from viruses (20-40%), of which Coxsackie virus A7, A9 and A23 and B strains are most common. It can also occur from mycoplasma pneumonia and schistosomiasis infection. There have been several case reports of TM as a neurological manifestation of SARS-CoV-2 infection and COVID-19 vaccination.^4,5,21 It has been noted as a presenting symptom of systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS) in up to 39-50% of cases, but it can also be associated with other autoimmune or disease-associated causes such as multiple sclerosis (MS) and neuromyelitis optica (NMO). Despite thorough evaluation, 15-30% of the cases remain idiopathic²

Epidemiology including risk factors and primary prevention

Annual incidence of TM in the United States is between 1 and 8 new cases per one million people per year.²¹ Incidence in children is lower than in adults with up to 28% of the reported cases. There are three peaks of distribution occurring between 0 and 2 years of age and 5 to 17 years of age in the pediatric population and between 30-39 years old in adults.² Idiopathic ATM has no racial, sex, familial, or geographical predilection, and there are no particular risk factors or method of primary prevention.

Patho-anatomy/physiology

Histopathology of TM is characterized by lymphocytes and monocytes infiltrating focal areas of the cord with varying degrees of inflammation, demyelination, axonal injury, and astroglial and microglial activation. Necrosis and cavitation can result in more severe cases. The cord involvement in most cases of TM occurs in a central, uniform, and symmetric pattern in comparison with MS, which has patches of peripheral lesions. This may occur because of direct tissue damage or immune mediated infection-triggered tissue damage. The latter may involve mechanisms such as molecular mimicry, autoantibody development, or superantigen effect.² Lesions may occur at any level of the spinal cord but more commonly at the thoracic level.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

• Onset of back pain,¹ motor weakness, sensory deficits, and bladder or bowel dysfunction typically evolves over hours to days. Symptoms are usually bilateral but are occasionally unilateral or asymmetric.²
• Common symptoms include back pain (80-95%), allodynia (80%), paraparesis (50%), bladder symptoms (almost 100%) and sensory level (80%).¹
• Progression to the nadir of clinical deficits is between 4 hours and 21 days after onset of symptoms (part of diagnostic criteria).²
• Clinically, it can present as a complete or partial spinal cord injury syndrome. Complete ATM characteristically results in paresis of lower and/or upper extremities and a sensory level, whereas a partial ATM would present with asymmetric neurological impairments.⁷ The course is typically monophasic but relapsing idiopathic TM may occur.²
• Most recovery occurs in the first 3 months after injury, but improvement may occur up to a year or longer.²

Specific secondary or associated conditions and complications

TM is a form of nontraumatic spinal cord injury (NTSCI), and thus has medical complications of NTSCI depending on the severity of injury to the cord. As with spinal cord injury (SCI), medical complications involving every organ system are common after TM. Medical management and complications are similar to SCI and should be managed in the same manner.⁸ It is crucial to determine the etiology, whether disease-associated or idiopathic, as this helps identify recurrence risk, appropriate treatment and surveillance that may be required to improve outcomes.⁹

Specifically, secondary complications such as impaired mobility and sensation, pressure ulcers, bowel and bladder dysfunction, sexual dysfunction, spasticity, autonomic dysregulation, and pain, should also be addressed.

Essentials of Assessment

History

Signs of myelopathy, such as motor weakness, sensory abnormalities, pain, bowel or bladder dysfunction, as well as recent infections, vaccinations, travel, medical history, review of systems, social history, family medical history, and surgical history, should be considered in order to direct the investigation for a specific etiology.

In the pediatric population, 50-100% of the cases are preceded by a mild febrile illness ~3 weeks prior to onset of symptoms.⁹

Physical examination

The physical exam will likely change as the neurologic deficits progress or improve depending on the patient’s individual course. Serial exams will help identify the nadir of clinical findings.

Initial physical exams should evaluate the following:

• Muscle strength, tone, and muscle stretch reflexes.
• Sensory reflexes, including abdominal and bulbocavernosus reflexes.
• Rectal exam
• Detailed sensory exam of dermatomes. Sensory loss is often described in a band-like or transverse level, with decreased sensation distally.⁹
• Autonomic instability or dysfunction.
• Consider using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI, previously known as the American Spinal injury Association, or ASIA) exam to classify completeness of the spinal cord injury. The ISNCSCI exam may be used for completeness and level of injury but does not provide the same positive predictive value as with traumatic spinal cord injury.
• Skin evaluation for pressure ulcers, especially over insensate areas and bony prominences such as the occiput, sacrum, ischia, and heels.

Functional assessment

• The Functional Independence Measure (FIM) and WeeFIM (for children) are commonly used tools to measure motor and cognitive functional status.¹⁰
• Spinal Cord Independence Measure (SCIM) is an alternative to the FIM to assess 16 categories of functional independence.
• Walking Index for Spinal Cord Injury (WISCI) assesses the amount of physical assistance and devices needed for ambulation.
• The SCIM and WISCI can be used for traumatic and nontraumatic and acute and chronic SCI for ages 13 to >65 years.

Laboratory studies

Lab studies focus on determining the etiology of the TM syndrome. This includes serology, cerebrospinal fluid, polymerase chain reaction, or specific markers to assess for

• Infections
• Central nervous system (CNS) manifestations of infections, for example syphilis, Lyme disease, human immunodeficiency virus, human T-lymphotropic virus type I, mycoplasma, herpes viruses, and enteroviruses.
• Connective tissue disease, for example sarcoidosis, Behcet disease, Sjogren disease, SLE, APS, and mixed connective tissue disease.
• Paraneoplastic causes
• Acquired CNS demyelinating disease: presence of CSF oligoclonal bands in multiple sclerosis; aquaporin-4 specific autoantibodies (NMO-immunoglobulin G) for neuromyelitis optica and Myelin Oligodendrocyte (MOG)-antibody immunoglobulin positivity in serum for MOG-antibody disease¹¹
• Postinfectious or postvaccination causes.²
• Endocrinopathies such as thyroid disease.⁷
• Other: serum vitamin D, vitamin B12 and E, serum copper and ceruloplasmin in those at risk.⁷

Imaging

MRI of the spine with gadolinium is required as the initial workup for acute myelopathy and to rule out conditions such as extrinsic spinal cord compression, ischemia, tumor, arteriovenous malformation and toxicities such as Vitamin B12 deficiency, or post-radiation myelopathy.

Partial and complete acute transverse myelitis (ATM) would commonly present on MRI as a single lesion spanning 1 or 2 vertebral levels. The differentiating feature is that in complete ATM there is full-thickness involvement of the spinal cord or its central portion is maximally affected, whereas in partial ATM the involvement is limited to a small portion of the spinal cord in axial sections. If the lesion extends over 3 or more vertebral segments, it is classified as a longitudinally extensive transverse myelitis (LETM),⁷ which is the most common finding in idiopathic monophasic ATM in children.^6,12

MRI of the brain may be done as part of the initial investigation to evaluate for MS, NMO or a concomitant encephalopathy (e.g., Acute Disseminated Encephalomyelitis or ADEM).

Other imaging during the initial evaluation should include

• Venous Doppler if there is concern for deep venous thrombosis.
• Renal ultrasound for possible renal parenchymal damage.
• Voiding Cystourethrogram for possible urinary reflux.
• Subsequent imaging needs are dependent on the patient’s clinical presentation and response to treatment.

Supplemental assessment tools

Urodynamic studies will allow optimization of a bladder management program.

Electrodiagnostic studies may play an important role in distinguishing peripheral from central lesions. For instance, nerve conduction studies can aid in distinguishing acute inflammatory demyelinating polyneuropathy (AIDP) from ATM. In the former, prolonged distal latencies & late responses, slowing of conduction velocities, and conduction block/temporal dispersion are characteristic findings. In ATM, such findings of peripheral demyelination would not be present.

Ophthalmological examination, ideally with patterned visual evoked potentials and ocular coherence tomography, to evaluate for optic neuritis even if the patient is asymptomatic, as this has important diagnostic implications for disease-associated transverse myelitis and recurrence risk.⁹

Differential diagnosis

The differential diagnosis for TM can be extensive, encompassing conditions that present as acute myelopathy such as those mentioned above. Acute inflammatory demyelinating polyneuropathy and ATM may be indistinguishable in the acute phase. Both may present similarly with depressed reflexes, weakness, bladder and bowel dysfunction and autonomic dysregulation. With AIDP, there is a lack of prominent sensory symptoms and involvement of cranial nerves, excluding the optic nerve. Spine MRI will demonstrate enhancement of spinal nerve roots and absence of intramedullary disease. Cerebrospinal fluid studies will show elevated protein in both conditions, but only ATM will demonstrate pleocytosis. In more obscure cases, a nerve conduction study may assist by demonstrating an acquired neuropathy in AIDP. Although rare, there have been reports of ATM and AIDP occurring together.⁹

Acute flaccid myelitis (AFM) has a similar presentation to ATM, though it has predominantly motor related symptoms, the hallmark of which is asymmetric flaccid limb weakness and hyporeflexia. Acute flaccid myelitis is characterized by injury to the anterior horn cells (AHC) of the spinal cord. In contrast to ATM, there can be pain and paresthesia in the affected limb, with little to no sensory deficits. Cranial nerve and bulbar weakness may also be seen in AFM and there is relatively fewer incidences of bowel or bladder dysfunction. Association with viral infections, particularly enteroviruses such as West Nile and Enterovirus D68 (EV-D68) among other non-polio enteroviruses, suggests the primary mechanism is direct infection of the motor neuron. Findings on MRI indicate a predilection for gray matter and AHC lesions for AFM, as opposed to both white and gray matter lesions for ATM.¹³ Treatment is similar to that of ATM. However, the probability for residual motor deficits is higher than in other types flaccid paralysis.¹⁴

Once a diagnosis of TM is made, further differentiation is needed whether it is idiopathic or disease related.

Table 1. Differentiating factors in Idiopathic and Disease-associated TM⁹

Early predictions of outcomes

According to the National Institute of Health data on idiopathic TM, ultimately one-third of patients have full recovery with the ability to walk, one-third have a fair recovery with some deficits, and one-third have poor recovery with significant neurologic deficits. Prognosis in children is not clear cut, but data suggest 30-50% make a full recovery, and a significant portion remain to have residual debilitating motor sequelae.⁹ Although crucial in diagnosis, MRI findings do not predict functional neurological status and outcomes in ATM.¹⁵Most cases of TM are singular events; however, relapses or recurrences can happen, which has prognostic and treatment implications. There are varied reports of sex and racial/ethnic distribution among all forms of transverse myelitis. Additionally, several laboratory markers for recurrent disease has been established such as vitamin D insufficiency and serum antibodies such as anti-aquaporin 4 antibodies, anti-Ro/SS-A antibodies, high ≥ (1:160) antinuclear antibody titers, and evidence of inflammation in the CSF.¹⁶ Radiographically, findings in MRI of LETM, brain stem extension, cord expansion, bright spotty lesions, and contrast enhancement are proposed to increase risk of relapse in idiopathic cases.¹⁷ Good prognosis is seen in older children⁶ and young adults with subacute progression of symptoms, when recovery begins early, and when posterior column function and deep tendon reflexes are preserved.¹⁸

Poor recovery has been associated with rapid onset/progression of symptoms, severe neurological deficits, sensory disturbances at cervical level, sphincter dysfunction at onset, lack of improvement in the first 3-6 months, presence of protein 14-3-3 in CSF,¹⁸ LETM¹⁹ and ATM associated with NMO. Infants tend to have worse outcomes, postulated due to their immature nervous system and impaired ability to recover after a fulminant inflammatory attack.⁹

Although ATM can be the initial manifestation of MS, it is a rare presenting symptom in pediatric MS.⁹

Environmental

Information about the patient’s home and work/school environment is important in determining appropriate adaptive devices and equipment. Depending on the degree of impairment, environmental modifications may be needed for wheelchair use at home and work/school, use of ramps and door width adjustments to ensure safe mobility. Attendants/aids, bath and toilet equipment, assistive and adaptive devices, and technology can be adjunctive support for people with SCI to promote as much functional independence as possible.

Social role and social support system

Information about the patient’s family, friends, home, work/school situations, and other support systems will be helpful in guiding treatment and rehabilitation. Those with chronic neurologic disability are at higher risk for depression, anxiety and cognitive-behavioral impairment, thus will need to be monitored closely to provide appropriate counseling intervention and support.

Rehabilitation Management and Treatments

Available or current treatment guidelines

• Treatment begins with intensive surveillance for acute life-threatening respiratory and autonomic complications.
• High-dose intravenous methylprednisolone (1000 mg/d for 3-5 days)^2,21
• Plasma exchange or IV immunoglobulin may be offered as second-line treatment to steroid unresponsive patients ²¹TM is associated with NMO spectrum disorders, immunosuppressive therapy with cyclophosphamide, mycophenolate, azathioprine or rituximab have been considered for maintenance therapy of chronic disease or first and second-line treatment resistant disease ²¹
• An intensive multidisciplinary rehabilitation program at an inpatient rehabilitation unit has been associated with neurological and functional recovery in patients with TM.¹⁵

At different disease stages

Acute and chronic disease management includes the following

• Motor deficits: patients will likely have impaired function in mobility, ambulation, and activities of daily living (ADLs). Working with physical and occupational therapists, along with the use of orthoses and assistive/adaptive devices can help increase independence with mobility, ADLs, and vocational skills.
• Sensory deficits: impaired sensation combined with impaired mobility may predispose patient to skin abrasions and pressure wounds, which can lead to infections and prolonged hospitalization. Patients and caregivers are educated on routinely doing pressure relief strategies and skin inspections for any pressure or irritation.  Early mobility (when possible), scheduled repositioning regimens and bed checks are important interventions.²
• Bladder dysfunction: urinary tract infections are common. This may predispose patients to urinary stones, renal parenchymal damage, and bladder cancer. Bladder dysfunction persists in about 90% of patients despite apparent motor recovery. Urodynamic findings include detrusor over activity, detrusor-sphincter dyssynergia, low bladder compliance, and increased detrusor leak point pressure. Prolonged indwelling catheter use may predispose the patient to infections and may cause a small increased risk of bladder cancer. Clean intermittent catheterization program and/or anticholinergic medications should be instituted as soon as deemed necessary.
• Respiratory dysfunction: higher cervical spinal cord inflammation may result in respiratory difficulty due to diaphragmatic dysfunction and accessory muscles may be weak with cervical and/or thoracic cord involvement. Additional considerations are superimposed respiratory infections or pulmonary disease. Patients with respiratory dysfunction may require ventilation or other respiratory support devices.²³
• Bowel dysfunction: constipation, fecal impaction, incontinence, and rectal prolapse are common consequences of neurogenic bowel. A bowel program is highly important, which may include diet modifications, the use of laxatives, stool softeners, suppositories, or enemas. The goal is to promote bowel continence and prevent complications.
• Sexual dysfunction: manifests as reduced genital sensation, pain, reduced ability to achieve arousal or anorgasmia. Review patient history, drug use, relationship issues. Men might benefit from pro-erectile agents, women from EROS device to enhance genital blood flow, lubricating agents, or high intensity genital vibrators²
• Autonomic Dysreflexia risk for lesions at/above T6: This potential life-threatening complication is due to the uninhibited sympathetic outflow manifested as hypertension, reflex bradycardia, sweating, headache, visual impairment due to cerebral vasodilatation. Common triggers include overdistended bladder, severe constipation, ingrown toenail and pressure ulcers. Acute treatment includes elevation of head and trunk, avoidance/removal of noxious stimuli such as prophylactic intermittent urinary catheterization, and bowel decompression.  Sublingual nifedipine or nitropaste application may be used as abortive agents for hypertension if unable to remove the noxious stimulus quickly.
• Spasticity: increased muscle tone may be beneficial to some patients with spasticity to aid with standing or bed mobility. However, it may also interfere with ADL’s and transfers. Treatment is focused on symptom relief and goals, ranging from physical modalities such as stretching or bracing, to pharmacologic management including oral baclofen, tizanidine, benzodiazepines, focal chemodenervation with botulinum toxin, alcohol or phenol; or intrathecal baclofen pump therapy.
• Pain: neuropathic pain is common and may arise at the level of injury or in areas that are partially innervated. Pain is reported in up to 50% of cases in children.^4,9 Gabapentin, pregabalin, and amitriptyline are commonly used and may require dose titration over time. Nociceptive pain may be caused by wounds, deep vein thrombosis, and musculoskeletal conditions such as heterotopic ossification and sprain/strain injuries.

Coordination of care

As with SCI, individuals with TM benefit from a coordinated rehabilitation team including physical therapy, occupational therapy, care management, social work, rehabilitation nursing, neurology, physiatry, the patient, and family. Appropriate and feasible goals are determined as a team. Medical care as well as outpatient and/or school therapies should be well-coordinated to maximize recovery, improve function, and prevent secondary complications.

Patient & family education

The patient and family must be well-versed in this new life-changing event. As previously described, TM is highly variable in its course. Emphasizing the importance of prevention of secondary complications is paramount and coordinated efforts that promote education will help with understanding and coping.

Cutting Edge/Emerging and Unique Concepts and Practice

Patients presenting with LETM and who are seropositive for NMO-IgG experience high relapse rates or eventually develop NMO.¹⁸ Paraneoplastic-associated ATM has been reported in association with some serological markers, such as the collapsing response mediator protein (CRMP)-5-IgG associated with small cell lung carcinoma and Amphiphysin-IgG associated with women with breast cancer.¹⁸

Advances in Myelin Oligodendrocyte (MOG) antibody detection using cell-based assays has allowed it to be recognized as a nosological entity within the spectrum of neuroinflammatory disorders, including MS and NMO spectrum disorders. Characterized by a relapsing course in 44-83% of patients, with involvement of the optic nerve, particularly swelling in the optic nerve head and poorly demarcated T2 hyperintensities on MRI. Neurological outcomes of patients with positive MOG antibody are more favorable compared to those with anti-aquaporin 4 antibodies in some studies. This was determined by lower patient scores on the Expanded Disability Status Scale (EDSS)in MOG antibody positive TM patients. Diagnostic difficulty remains with this method due to low specificity of MOG antibody in serum and fluctuating levels. ²² While randomized controlled trials of therapeutic options are scarce, further future studies could show further delineation in diagnosis and treatment from other neuroinflammatory diseases going forward.¹¹

Human glial restricted progenitor cells (hGRPs) have been evaluated in an adult rat model of focal inflammatory demyelination, as occurs in transverse myelitis. Transplant safety and tolerability in ATM patients is currently under evaluation. It is postulated that these cells will integrate into spinal cord-demyelinated lesions to remyelinate these lesions and support damaged axons.²¹

A novel therapeutic option of microsurgical nerve transfer surgery has been proposed in the literature. The techniques may vary, but in general the procedure aims at “neurotizing” the affected (target) nerve by transferring axons from a functioning (donor) nerve. In one case report the procedure resulted in limited improvement of strength and motor function of the affected upper extremity of a child.²⁰The potassium channel blocker fampridine may potentiate neurotransmitter release in muscles and subsequently increase post-synaptic action potentials in the spinal cord. Most clinical trials have taken place in individuals with MS, however a 2017 study in ATM showed a trend in walking speed improvement in 85% with extended release fampridine compared to 69 % with placebo.²¹

Gaps in the Evidence-Based Knowledge

There is controversy regarding whether immunization is a causal agent for ATM. Some researchers have found a history of immunization 30 days prior the onset of symptoms.⁶ However, a causation between immunization and ATM has not been established.

There is some research data that suggest a possible higher risk of “conversion” to MS in 3-5 years for 10-30% of patients with ATM.²¹ Randomized trial data regarding the efficacy of high dose corticosteroids and immunosuppressive agents in the treatment of transverse myelitis is lacking.

References

1. Awad A, Stuve O. Idiopathic Transverse Myelitis and Neuromyelitis Optica: Clinical Profiles,Pathophysiology and Therapeutic Choices. Curr Neuropharmacol. 2011;9(3):417-428. doi:10.2174/157015911796557948
2. Frohman EM, Wingerchuk DM. Clinical practice. Transverse myelitis. N Engl J Med. 2010;363(6):564-572. doi:10.1056/NEJMcp1001112
3. Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology. 2002;59(4):499-505. doi:10.1212/wnl.59.4.499
4. Chakraborty U, Chandra A, Ray AK, Biswas P. COVID-19-associated acute transverse myelitis: a rare entity. BMJ Case Rep. 2020;13(8). doi:10.1136/bcr-2020-238668
5. Chow CCN, Magnussen J, Ip J, Su Y. Acute transverse myelitis in COVID-19 infection. BMJ Case Rep. 2020;13(8):e236720. doi:10.1136/bcr-2020-236720
6. Pidcock FS, Krishnan C, Crawford TO, Salorio CF, Trovato M, Kerr DA. Acute transverse myelitis in childhood: center-based analysis of 47 cases. Neurology. 2007;68(18):1474-1480. doi:10.1212/01.wnl.0000260609.11357.6f
7. Beh SC, Greenberg BM, Frohman T, Frohman EM. Transverse myelitis. Neurol Clin. 2013;31(1):79-138. doi:10.1016/j.ncl.2012.09.008
8. Gupta A, Taly AB, Srivastava A, Murali T. Non-traumatic spinal cord lesions: epidemiology, complications, neurological and functional outcome of rehabilitation. Spinal Cord. 2009;47(4):307-311. doi:10.1038/sc.2008.123
9. Wolf VL, Lupo PJ, Lotze TE. Pediatric acute transverse myelitis overview and differential diagnosis. J Child Neurol. 2012;27(11):1426-1436. doi:10.1177/0883073812452916
10. Calis M, Kirnap M, Calis H, Mistik S, Demir H. Rehabilitation results of patients with acute transverse myelitis. Bratisl Lek Listy. 2011;112(3):154-156. http://www.ncbi.nlm.nih.gov/pubmed/21452769.
11. Wynford-Thomas R, Jacob A, Tomassini V. Neurological update: MOG antibody disease. J Neurol. 2019;266(5):1280-1286. doi:10.1007/s00415-018-9122-2
12. Thomas T, Branson HM, Verhey LH, et al. The demographic, clinical, and magnetic resonance imaging (MRI) features of transverse myelitis in children. J Child Neurol. 2012;27(1):11-21. doi:10.1177/0883073811420495
13. Theroux LM, Brenton JN. Acute Transverse and Flaccid Myelitis in Children. Curr Treat Options Neurol. 2019;21(12):64. doi:10.1007/s11940-019-0603-0
14. Nelson GR, Bonkowsky JL, Doll E, et al. Recognition and Management of Acute Flaccid Myelitis in Children. Pediatr Neurol. 2016;55:17-21. doi:10.1016/j.pediatrneurol.2015.10.007
15. Gupta A, Kumar SN, Taly AB. Neurological and functional recovery in acute transverse myelitis patients with inpatient rehabilitation and magnetic resonance imaging correlates. Spinal Cord. 2016;54(10):804-808. doi:10.1038/sc.2016.23
16. Kimbrough DJ, Mealy MA, Simpson A, Levy M. Predictors of recurrence following an initial episode of transverse myelitis. Neurol Neuroimmunol neuroinflammation. 2014;1(1):e4. doi:10.1212/NXI.0000000000000004
17. Bulut E, Shoemaker T, Karakaya J, et al. MRI Predictors of Recurrence and Outcome after Acute Transverse Myelitis of Unidentified Etiology. AJNR Am J Neuroradiol. 2019;40(8):1427-1432. doi:10.3174/ajnr.A6121
18. Sá MJ. Acute transverse myelitis: a practical reappraisal. Autoimmun Rev. 2009;9(2):128-131. doi:10.1016/j.autrev.2009.04.005
19. Sepúlveda M, Blanco Y, Rovira A, et al. Analysis of prognostic factors associated with longitudinally extensive transverse myelitis. Mult Scler. 2013;19(6):742-748. doi:10.1177/1352458512461968
20. Dorsi MJ, Belzberg AJ. Nerve transfers for restoration of upper extremity motor function in a child with upper extremity motor deficits due to transverse myelitis: case report. Microsurgery. 2012;32(1):64-67. doi:10.1002/micr.20939
21. Fiani B, Covarrubias C, Jarrah R. Neuroimmunology and Novel Methods of Treatment for Acute Transverse Myelitis. Cureus. 2021 Aug 9;13(8):e17043. doi: 10.7759/cureus.17043. PMID: 34522521; PMCID: PMC8428159.
22. Perez-Giraldo G, Caldito NG, Grebenciucova E. Transverse myelitis in myelin oligodendrocyte glycoprotein antibody-associated disease. Front Neurol. 2023 Jul 6;14:1210972. doi: 10.3389/fneur.2023.1210972. PMID: 37483456; PMCID: PMC10359891.
23. Lim PAC. Transverse Myelitis. Essentials of Physical Medicine and Rehabilitation. 2020:952–9. doi: 10.1016/B978-0-323-54947-9.00162-0. Epub 2019 Apr 17. PMCID: PMC7151963.

Original Version of the Topic

Rochelle T. Dy, MD, Anand Allam, MD. Transverse Myelitis. 8/9/2012

Previous Revision(s) of the Topic

Rochelle T. Dy, MD, Mariella Hillebrand, MD. Transverse Myelitis. 8/23/2016

Mariella Hillebrand, MD, Irvin Quezon, MD, Rochelle T. Dy, MD. Transverse Myelitis. 5/7/2021

Author Disclosure

Kimberly C Hartman, MD, MHPE
Nothing to Disclose

Dominika Helm, BS
Nothing to Disclose