Treatment for Transverse Myelitis

Diagnostic Approach

Neurologic consultation should be obtained promptly to guide diagnosis and management 1
MRI of the spine with thin axial cuts through the region of suspected abnormality is essential to detect T2-weighted hyperintense lesions 1, 2
Lumbar puncture should be performed to check cell count, protein, glucose, oligoclonal bands, viral PCRs, and onconeural antibodies 1
Blood tests should include B12, HIV, RPR, ANA, Ro/La, TSH, and aquaporin-4 IgG to rule out other causes 1, 2
Evaluation for urinary retention and constipation is important as these are common autonomic manifestations 1

Immediately discontinue any potential causative agents (such as immune checkpoint inhibitors if applicable) 1
Administer high-dose intravenous methylprednisolone 1g daily for 3-5 days 1, 2, 3
For moderate to severe cases (with significant weakness or sensory changes), combine corticosteroids with IVIG 2g/kg over 5 days 1, 2

Plasma exchange therapy should be considered for patients who do not respond adequately to corticosteroids and IVIG 3
Rituximab may be beneficial in cases with positive autoimmune encephalopathy antibodies or inadequate response to other therapies 3

After acute treatment, maintenance immunosuppressive therapy (such as azathioprine) is often necessary to prevent relapses, which occur in 50-60% of cases during corticosteroid dose reduction 3

For transverse myelitis associated with antiphospholipid antibodies, anticoagulation therapy should be considered in addition to immunosuppressive treatment 3
In cases of infectious etiology (such as schistosomiasis), appropriate antiparasitic treatment should be administered along with corticosteroids 4, 5
For neuromyelitis optica spectrum disorder (NMOSD)-associated transverse myelitis (positive aquaporin-4 IgG), more aggressive immunosuppression may be required 1, 2

Factors associated with poor prognosis include extensive spinal cord MRI lesions (especially longitudinally extensive transverse myelitis affecting ≥3 vertebral segments) 2, 3
Reduced muscle strength or sphincter dysfunction at presentation 3
Delay (>2 weeks) in the initiation of therapy 3

For autoimmune-associated transverse myelitis, continued immunosuppression may be necessary to prevent recurrence 3