Transverse myelitis: Difference between revisions

Revision as of 19:02, 3 October 2019

Background

Inflammatory disorder that involves a complete transverse section of the spinal cord
- Results from viral infection (30% of cases), postvaccination or as part of MS, SLE, or cancer
May present exactly like a compressive lesion of the spinal cord
Usually thoracic origin, rarely cervical spine

Clinical Features

Rapidly progressive paraplegia (as little as 4 hours), but may progress over days-weeks
Neck or back pain + neuro complaints:
- Bilateral motor, sensory (burning or tingling pain), and autonomic disturbances
- Fecal/urinary retention and incontinence

Differential Diagnosis

Weakness

Neuromuscular weakness
- Upper motor neuron:
  - CVA
  - Hemorrhagic stroke
  - Multiple sclerosis
  - Amyotrophic Lateral Sclerosis (ALS) (upper and lower motor neuron)
- Lower motor neuron:
  - Spinal and bulbar muscular atrophy (Kennedy's syndrome)
- Spinal cord disease:
  - Infection (Epidural abscess)
  - Infarction/ischemia
  - Trauma (Spinal Cord Syndromes)
  - Inflammation (Transverse Myelitis)
    - Acute flaccid myelitis
  - Degenerative (Spinal muscular atrophy)
  - Tumor
- Peripheral nerve disease:
  - Guillain-Barre syndrome
  - Toxins (Ciguatera)
  - Tick paralysis
  - Diabetic peripheral neuropathy
- Neuromuscular junction disease:
- Muscle disease:
  - Rhabdomyolysis
  - Dermatomyositis
  - Polymyositis
  - Alcoholic myopathy
Non-neuromuscular weakness
- Can't miss diagnoses:
  - ACS
  - Arrhythmia/Syncope
  - Severe infection/Sepsis
  - Hypoglycemia
  - Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
    - Hypokalemic periodic paralysis
    - Thyrotoxic periodic paralysis
  - Respiratory failure
- Emergent Diagnoses:
  - Symptomatic Anemia
  - Severe dehydration
  - Hypothyroidism
  - Polypharmacy
  - Malignancy
  - Aortic disease - occlusion, stenosis, dissection
- Other causes of weakness and paralysis
  - Acute intermittent porphyria (ascending weakness)

Lower Back Pain

Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
Renal disease
Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
Pelvic disease
- PID
Other
- Retroperitoneal hemorrhage/mass
- Meningitis

Evaluation

Neurologic findings that are consistent with epidural compression but normal MRI
Must rule-out compressive lesion of the cord
MRI
- May show cord swelling
- Hyperintense lesion on T2 weighted images
LP
- Contains monocytes, protein content is slightly increased, and IgG index is elevated^[1]

Management

Foley for bladder decompression
Consider work up for clotting disorder for spinal artery thrombosis, drug user, risk for aortic dissection
Neurological consultation
Admit for corticosteroids and plasma exchange
- High dose steroid regimen, such as methylprednisolone 1 gram daily or dexamethasone 200 mg daily
The more rapid the progression is, the worse the prognosis

References

↑ http://www.merckmanuals.com/professional/neurologic_disorders/spinal_cord_disorders/acute_transverse_myelitis.html

Perron AD, Huff JS. “Spinal Cord Disorders,” in Rosen’s Emergency Medicine Concepts and Clinical Practice, edited by Marx JA, Hockberger RS, Walls RM, et al., 1389-1395. Philadelphia: Mosby, 2010.

Authors:

[1] ttp://www.merckmanuals.com/professional/neurologic_disorders/spinal_cord_disorders/acute_transverse_myelitis.html

[1]

@@ Line 1: / Line 1: @@
 ==Background==
 *Inflammatory disorder that involves a complete transverse section of the spinal cord
-**Results from viral infection, postvaccination or as part of MS, SLE, or cancer
+**Results from viral infection (30% of cases), postvaccination or as part of [[MS]], [[SLE]], or cancer
 *May present exactly like a compressive lesion of the spinal cord
 *Usually thoracic origin, rarely cervical spine
 ==Clinical Features==
-*May progress over days-weeks
+*Rapidly progressive paraplegia (as little as 4 hours), but may progress over days-weeks
-*Neck or back pain + neuro complaints:
+*Neck or [[back pain]] + neuro complaints:
-**Bilateral motor, sensory, and autonomic disturbances
+**Bilateral [[weakness|motor]], [[numbness|sensory]] (burning or tingling pain), and autonomic disturbances
-**Fecal/urinary retention and incontinence
+**Fecal/[[urinary retention]] and [[urinary incontinence|incontinence]]
 ==Differential Diagnosis==
@@ Line 16: / Line 16: @@
 {{Lower back pain DDX}}
-==Diagnosis==
+==Evaluation==
-*Neurologic findings that are c/w epidural compression but normal MRI
+*Neurologic findings that are consistent with epidural compression but normal [[mri|MRI]]
-==Management==
 *Must rule-out compressive lesion of the cord
 *[[MRI]]
 **May show cord swelling
+**Hyperintense lesion on T2 weighted images
 *[[LP]]
 **Contains monocytes, protein content is slightly increased, and IgG index is elevated<ref>http://www.merckmanuals.com/professional/neurologic_disorders/spinal_cord_disorders/acute_transverse_myelitis.html</ref>
+==Management==
 *Foley for bladder decompression
 *Consider work up for clotting disorder for spinal artery thrombosis, drug user, risk for [[aortic dissection]]
-*Admit for [[corticosteroids]] and plasma exchange
+*Neurological consultation
+*Admit for [[corticosteroids]] and [[plasma exchange]]
+**High dose steroid regimen, such as [[methylprednisolone]] 1 gram daily or [[dexamethasone]] 200 mg daily
 *The more rapid the progression is, the worse the prognosis
-==Source==
+==References==
-*Tintinalli
+<references/>
 *Perron AD, Huff JS. “Spinal Cord Disorders,” in Rosen’s Emergency Medicine Concepts and Clinical Practice, edited by Marx JA, Hockberger RS, Walls RM, et al., 1389-1395. Philadelphia: Mosby, 2010.
 <references/>
-[[Category:Neuro]]
+[[Category:Neurology]]