Transverse Myelitis

Transverse myelitis is an inflammatory condition in which the immune system attacks the spinal cord, causing damage across one or more segments of the cord. This disrupts nerve signal transmission both up and down the cord, resulting in motor, sensory, and autonomic dysfunction below the level of inflammation. It can occur as an isolated event or as a manifestation of an underlying systemic or neurological disease.

Transverse myelitis is one of several conditions that cause acute or subacute spinal cord dysfunction and must be carefully distinguished from others on MRI. Key differentials include Syringomyelia, which produces a fluid cavity within the cord rather than inflammation, and Cervical Myelopathy, which causes cord compression from degenerative disease rather than autoimmune attack. It is also closely related to spinal infection, which can produce similar cord signal changes on MRI and must be excluded promptly.

Causes

Inflammatory and autoimmune causes.

Transverse myelitis is most often immune-mediated. It can occur as a complication of viral or bacterial infections (including COVID-19, herpes viruses, and mycoplasma), following vaccinations, or in association with systemic autoimmune diseases such as lupus, Sjögren's syndrome, or sarcoidosis. It may also represent a first attack of multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD).

Idiopathic transverse myelitis

In a significant proportion of cases, no clear underlying cause is identified despite thorough evaluation. These cases are classified as idiopathic transverse myelitis.

Symptoms

Symptoms typically develop over hours to days and include a band-like tightness or pain at the level of inflammation, progressive weakness or paralysis of the legs (and sometimes arms, depending on the level), sensory loss below the affected spinal segment, and bladder and bowel dysfunction. A clearly defined sensory level — a horizontal line on the body above which sensation is normal and below which it is altered — is a characteristic finding. The severity and exact presentation depend on the spinal cord level affected and the extent of inflammation.

Diagnosis

MRI of the spine with contrast is the key imaging study, typically showing T2 signal abnormality spanning one or more cord segments, often with gadolinium enhancement in acute cases indicating active inflammation. A cervical spine MRI or lumbar spine MRI will be obtained depending on the level of symptoms, and brain MRI is also performed to evaluate for demyelinating lesions that might suggest MS. Cerebrospinal fluid (CSF) analysis via lumbar puncture typically shows elevated white cells and protein. Blood tests for autoimmune antibodies — including AQP4-IgG (NMO antibody) and MOG-IgG — are critical to identify specific treatable causes and predict risk of relapse.

Classification

Transverse myelitis is broadly categorized based on its association with underlying conditions.

• Idiopathic: No identifiable underlying cause — may represent a monophasic illness or a first demyelinating event.
• Disease-associated: Occurring in the context of MS, NMOSD, lupus, sarcoidosis, or other systemic conditions.
• Parainfectious/Post-infectious: Triggered by infection or vaccination through immune-mediated mechanisms.

Treatments

Acute treatment is aimed at reducing spinal cord inflammation as rapidly as possible to minimize permanent damage. Long-term management depends on identifying and treating any underlying condition to prevent recurrence.

Hospitalization is typically required during the acute phase for monitoring, supportive care, and initiation of treatment.

Acute treatment: High-dose intravenous corticosteroids (methylprednisolone) are the cornerstone of acute treatment, administered for 3–5 days to reduce inflammation. For severe or steroid-unresponsive cases, plasma exchange (plasmapheresis) may be used to remove inflammatory antibodies from the bloodstream. IVIG (intravenous immunoglobulin) is another option in selected patients.

Long-term and preventive treatment

Patients with NMOSD or MS-associated transverse myelitis require ongoing immunosuppressive or disease-modifying therapy to prevent future attacks. Rehabilitation — including physical therapy, occupational therapy, and bladder management — is essential to maximize functional recovery, which can continue over 1–2 years following the acute event.

Related Spine Conditions

• Syringomyelia
• Cervical Myelopathy
• Osteomyelitis and Spinal Abscess
• Arachnoiditis
• Spinal Tumors
• Back to all Spine Conditions