Acute transverse myelitis is a heterogeneous syndrome characterized by inflammation of the white matter of the spinal cord. The condition occurs as a result of infectious, inflammatory, autoimmune processes, and occasionally develops as an idiopathic variant. The acute process is manifested by bilateral sensory disturbances below the lesion, flaccid paralysis, and pelvic disorders. Diagnosis requires spinal and cerebral MRI scanning, cerebrospinal fluid examination, and extensive blood tests. Treatment involves pathogenetic therapy in the acute period, and, if possible, conservative or surgical elimination of the root cause.
General information
The average incidence of acute transverse myelitis ranges from 1.34 to 4.6 cases per 1 million population (in New Zealand the figure reaches 10.8), 28% of cases affect children. Men and women suffer equally often; the pathology has two age peaks of manifestation - at 10-19 and 30-39 years. The name of the disease “transverse myelitis” does not reflect anatomical lesions across the spine, but characteristic sensory disorders that occur when the spinal cord pathways are involved in the process.
Acute transverse myelitis
Causes
The main etiological factor of acute transverse myelitis is multiple sclerosis. In such patients, diffuse neurodegenerative processes with an inflammatory component are observed, pathological changes spread to the spinal cord with the appearance of specific symptoms. Less common causes of acute inflammation include the following:
- Autoimmune processes. Transverse myelitis occurs as one of the symptoms of systemic lupus erythematosus, Behcet's disease, and rheumatoid arthritis. Less commonly, the cause is antiphospholipid syndrome, sarcoidosis, and Sjögren's disease. Cases of acute inflammation in autoimmune damage to the central nervous system - neuromyelitis optica - have been described.
- Infectious diseases. The condition can develop from any viral, bacterial or fungal infection. Typical diseases complicated by APM include syphilis, tuberculosis, Lyme disease and mycoplasma infection. Inflammation of the spinal cord appears within 4 weeks from the onset of infection.
- Spinal injuries. Inflammation is associated with complicated forms of acute spinal cord injury, in which the integrity of the spinal canal, neurons and nerve fibers is disrupted. The situation is often aggravated by the addition of spinal cord edema.
- Iatrogenic factors. Cancer patients receiving radiation therapy often develop myelitis due to toxic spinal lesions. An acute toxic process is also possible with inadequate drug treatment. Post-vaccination myelitis, an atypical hyperergic reaction to vaccination, is extremely rare.
Our specialists
Tarasova Svetlana Vitalievna
Expert No. 1 in the treatment of headaches and migraines. Head of the Center for the Treatment of Pain and Multiple Sclerosis.
Somnologist.
Epileptologist. Botulinum therapist. The doctor is a neurologist of the highest category. Physiotherapist. Doctor of Medical Sciences.
Experience: 23 years.Derevianko Leonid Sergeevich
Head of the Center for Diagnostics and Treatment of Sleep Disorders.
The doctor is a neurologist of the highest category. Vertebrologist. Somnologist. Epileptologist. Botulinum therapist. Physiotherapist. Experience: 23 years.
Bezgina Elena Vladimirovna
The doctor is a neurologist of the highest category. Botulinum therapist. Physiotherapist. Experience: 24 years.
Volkova Svetlana Anatolevna
Head of the Center for Parkinsonism and Extrapyramidal Diseases.
The doctor is a neurologist of the highest category. Epileptologist. Ozone therapist. Physiotherapist. Experience: 26 years.
Dolgikh Tatyana Anatolevna
The doctor is a neurologist of the highest qualification category. Experience: 24 years.
Zhuravleva Nadezhda Vladimirovna
Head of the center for diagnosis and treatment of myasthenia gravis.
The doctor is a neurologist of the highest category. Physiotherapist. Experience: 16 years.
Pathogenesis
The mechanism of development of the disease depends on its underlying cause. The main role in most cases of APM is played by autoimmune inflammation, which affects the myelin sheaths covering the spinal roots and the white matter of the spinal cord. Pathogenesis in systemic pathologies of connective tissue is associated with vasculitis, thrombus formation, and the formation of small focal infarctions in the spinal substance.
With an infectious lesion, spinal edema is observed, accompanied by circulatory disorders, limited necrotic processes and softening of the nervous tissue. Traumatic transverse myelitis develops with the addition of a secondary infection. In the pathogenesis of post-infectious forms, an important role is played by allergization of the body and intoxication by waste products of microorganisms.
Work ability
The patient’s ability to work after recovery depends on the location of the lesion, the course and degree of impairment of the disease. During the acute and subacute periods, the patient is temporarily incapacitated. High-quality rehabilitation of functions makes it possible to return to work. In case of residual deviations after treatment, patients are given the third disability group.
If even after treatment the patient still has any abnormalities, he may be given disability
In case of gait and static disturbances, patients are recognized as conditionally incompetent, who from then on cannot work under normal conditions, and they are assigned the second disability group. If patients cannot live without constant outside care, then they are assigned the first group of disability. If there are no improvements, then the disability group acquires the status “indefinitely”.
Classification
In practical neurology, there is an expanded systematization of transverse myelitis, which is used by doctors to determine the severity of the condition and select the correct treatment. The classification takes into account the following factors:
- Duration of course: acute, subacute, chronic.
- Degree of prevalence: diffuse, multifocal, limited.
- Mechanism of development: primary (idiopathic), secondary (in combination with another disease).
- Etiology: infectious, post-infectious, traumatic, toxic, inflammation in autoimmune diseases.
Symptoms
In 60% of cases, the first sign of developing transverse myelitis is pain. It is neuropathic in nature: patients describe their sensations as aching, deep, debilitating. The pain is localized in the back along the midline, which corresponds to the projection of the inflammatory focus, or develops in the corresponding dermatome, which is innervated by the affected spinal root. When the roots are affected, the pain is often sharp and shooting.
The pathognomonic manifestation of an acute lesion is sensory disturbances that involve the entire body below the level of the spinal lesion. Sensory symptoms can be positive - burning paresthesia, hyperesthesia, allodynia, or negative - absence of pain, temperature and tactile sensitivity. The clinical picture is complemented by dysfunction of the pelvic organs and motor disorders (paresis, paralysis).
Patients develop irritative symptoms: tonic muscle spasms, dysesthesia (perverted perception of stimuli), Lhermitte's symptom (sensation of an electrical impulse passing through the spine). When the pathological process spreads over less than half of the transverse part of the spinal cord, the symptoms are blurred: mild sensory and motor disorders and transient dysfunction of the pelvic organs are noted.
Symptoms
Myelitis can be cervical, thoracic, and also lumbar. As the disease progresses, the functioning of the nerve endings is disrupted, which subsequently causes serious problems in both the sensory and motor systems.
Note! An increase in body temperature to forty degrees, weakness, chills and vomiting are the main signs of the acute form of the disease.
With myelitis, the first thing the patient encounters is paresis of the legs, arms and pain symptoms of moderate intensity. This is followed by motor and sensory disorders that can be observed for several days. Problems in the pelvic area are also common (as a rule, we are talking about malfunctions of organs).
Complications
Acute transverse myelitis is rarely combined with disseminated encephalomyelitis, which is accompanied by encephalopathy. In this case, convulsive syndrome, focal symptoms, and disturbances of consciousness of varying degrees of severity are possible. Inflammation that develops against the background of a herpetic infection is often combined with Brown-Séquard syndrome and syringomyelia. If the lesion is located high in the spinal cord, respiratory and circulatory disorders may occur.
Even with adequate comprehensive treatment of transverse myelitis, up to 2/3 of patients face serious consequences of the disease. About a third of patients, after the acute process subsides, suffer from irreversible neurological disorders: dysesthesia, paresis, urinary and fecal incontinence. 33% of patients who have transverse myelitis develop complete paralysis, requiring ongoing medical care and periodic supportive care.
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Diagnostics
During the initial examination of the patient by a neurologist, typical acute disorders of sensory functions are determined, which indicates spinal injuries. With accompanying symptoms of irritation of the nerve roots, motor disorders, and the presence of a burdened medical history, it is possible to assume transverse myelitis. To confirm the diagnosis and select a treatment regimen, a set of studies is required, including:
- MRI of the spinal cord. "Gold standard" for the diagnosis of acute transverse myelitis. The disease is characterized by the presence of an area of increased signal in the T2 mode of the study. The lesion occupies more than 2/3 of the diameter of the organ and extends to 2 or more spinal segments. In its center, unchanged gray matter tissue is occasionally detected.
- MRI of the brain. If multiple sclerosis is suspected as the cause of transverse myelitis, treatment is prescribed only after neuroimaging. To identify plaques in the phase of active inflammation, gadolinium contrast is used. MRI machines with high magnetic field strength make it possible to distinguish perivenular plaques in MS from nonspecific lesions.
- Lumbar puncture. When examining the cerebrospinal fluid, low lymphocytic pleocytosis and increased protein levels are determined - signs indicating the presence of an inflammatory process. In some cases, the composition of the cerebrospinal fluid does not change, which complicates the diagnosis of APM.
- Blood tests. Standard clinical and biochemical blood tests can detect an acute inflammatory process in order to prescribe anti-inflammatory treatment in a timely manner. If there are symptoms of systemic autoimmune pathologies, tests for rheumatoid factor, antinuclear antibodies and other specific markers are recommended.
Diagnostic procedures
Having understood the question of what myelitis is, you should understand how it is detected. The initial examination and patient complaints are usually not enough to make a diagnosis, so specialists almost always prescribe laboratory and hardware tests. Diagnostics consists of the following stages:
- Neurological examination. During the process, the doctor carefully examines the patient, conducts a series of simple tests to determine violations of the body’s natural reactions and reflexes, loss of sensitivity and muscle tone.
- Blood and urine tests. The results obtained show ESR and leukocyte levels, which indicate the extent of inflammation, the presence of antibodies and other data.
- Electroneuromyography. With its help, the conductivity of nerve impulses, the degree of disturbance and the location of the lesion are determined.
- MRI. One of the most informative research methods, which allows you to obtain images of the spinal cord in layers. The results help determine the boundaries of the infectious focus and choose the most effective treatment tactics.
MRI is often replaced by CT, which does not affect the quality of the study. Additionally, some patients are prescribed the use of contrast to increase the accuracy of the procedure. And it is also important to carry out tests to identify the pathogen if the cause of the lesion is infectious or viral. After its determination, the general antibiotic is changed to a highly specialized one that suppresses the growth and reproduction of specific pathogenic microflora.
MRI is the most informative way to determine the cause and extent of the lesion
In the process of making a diagnosis, it is extremely important not to confuse myelitis with epiduritis, which requires immediate surgical intervention. Their clinical pictures are very similar, but in addition to general tests, an additional explorative laminectomy will also be required. Affected tissues are examined for the presence of radicular disease or a purulent focus, which distinguishes the disease from myelitis. And also during the examination, a spinal cord tumor or acute kidney injury, hematomyelia, hematorahis are excluded, especially if the cause is trauma.
Treatment of acute transverse myelitis
Conservative therapy
There is no specific treatment for transverse myelitis. In the acute phase, it is necessary to stop the spreading pathological process, stop inflammation, and restore neurological functions. Etiotropic antimicrobial therapy is recommended for infectious variants of the pathology. Leading neurologists specializing in demyelinating diseases adhere to the following tactics for treating patients:
- Hormonal pulse therapy. Treatment begins with the prescription of high dosages of glucocorticoids for a period of 3-7 days to stop the inflammatory process. This therapy is especially effective if the cause of the disease is an autoimmune pathology.
- Plasmapheresis. Treatment with extracorporeal blood purification is indicated when corticosteroids are insufficiently effective. The procedure aims to remove autoantibodies from the body to quickly stop spinal cord damage.
- Other drugs. In acute idiopathic forms, it is advisable to use treatment with immunoglobulins and some cytostatic drugs. For the relief of transverse myelitis in multiple sclerosis or neuromyelitis optica, the effectiveness of antineoplastic cytostatics from the anthracenedione group has been proven.
Surgery
Neurosurgical operations are performed in cases of diagnosed spinal cord compression syndrome for emergency decompression and prevention of irreversible organic damage to the nervous tissue. Surgical treatment is also carried out for purulent epiduritis, purulent-septic foci located in close proximity to the spinal cord. The surgical tactics are selected individually for each patient.
Rehabilitation
From the very first days of the disease, it is advisable to use nootropics, energy-tropic drugs, and agents that improve microcirculation. This treatment helps restore neurological functions. During the period of residual manifestations, a rehabilitation program is prescribed, which includes methods of physiotherapeutic treatment (electrical stimulation, electrophoresis, phonophoresis), therapeutic massage, and kinesiotherapy.
Rehabilitation period
Restoration of damage and normal well-being occurs after relief of the acute stage, the most dangerous of all. To do this, the doctor prescribes the following courses:
- Massage. It perfectly helps to avoid the formation of bedsores on the body and gradually restore sensitivity to the lower extremities. It is carried out by medical specialists, since any incorrect actions or excessive pressure are dangerous for the patient.
- Physiotherapy. At first, it is carried out with medical personnel and for this the patient does not even need to leave the bed. The classes are very simple and are aimed at eliminating stagnant processes, gradually returning to physical activity, improving blood circulation in all tissues, and normalizing metabolism.
- Acupuncture. Impact on certain active points can affect the general condition, reduce pain and swelling, relieve inflammation, and get rid of dysfunction of the pelvic organs. As in other cases, only experienced specialists with a high level of qualifications are allowed to conduct sessions to obtain the desired result.
- Catheterization of the bladder or epicystostomy.
Myelitis is diagnosed in both men and women, but in the fair sex it appears more often due to more unstable hormonal levels and constant exposure to stress. The treatment complex is compiled for each patient individually based on the cause and extent of the lesion.
Prognosis and prevention
With transverse myelitis, the prognosis is questionable, since more than 66% of patients who have suffered the disease have neurological consequences of varying severity. Emergency treatment greatly increases the chances of successful recovery, so improving the quality of care is paramount. Prevention involves preventing diseases that can cause spinal inflammation.
You can share your medical history, what helped you during the treatment of acute transverse myelitis.