Transverse Myelitis
Inflammatory spinal cord injury causing bilateral motor and sensory deficits
ICD-10: G37.3 · systemic condition
Transverse myelitis (TM) is an inflammatory disorder of the spinal cord that disrupts myelin and axonal function across one or more spinal cord levels, producing bilateral motor weakness, sensory deficits, and autonomic dysfunction below the level of inflammation. The term "transverse" refers to the involvement spanning the width of the cord rather than the direction of spread. It can occur as an isolated monophasic illness or as a manifestation of multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), or systemic autoimmune conditions. The clinical presentation typically evolves over hours to a few days. A sensory level — a clear band below which all sensation is diminished — is a hallmark finding. Bladder dysfunction, often urinary retention, is nearly universal. Back pain at the level of inflammation frequently precedes motor symptoms. MRI of the spine with gadolinium is the key diagnostic test, revealing T2 signal abnormality within the cord parenchyma. Acute treatment is high-dose intravenous corticosteroids; plasma exchange (PLEX) is used for steroid-refractory cases. Prognosis is variable. Approximately one-third of patients recover fully, one-third have moderate residual deficits, and one-third have severe permanent disability. Recovery, when it occurs, typically happens over three to six months.
Anatomy & Pathology
The spinal cord is organized into ascending sensory tracts and descending motor tracts. Inflammation at a given vertebral level disrupts all pathways below that point, producing a "sensory level" — a line on the body below which sensation is diminished or absent — as well as weakness or paralysis of muscles controlled by segments below the lesion. The thoracic cord is affected most often in TM.
Symptoms
- Sudden or subacute onset of bilateral leg weakness or paralysis
- Sensory level — band of altered or absent sensation at the affected spinal cord level
- Urinary retention or incontinence as autonomic hallmark
- Back or neck pain at the level of inflammation preceding neurological symptoms
- Bowel dysfunction: constipation or loss of sphincter control
- Electric shock or tight band sensation around the trunk (Lhermitte-like)
- Spasticity, hyperreflexia, and upgoing Babinski signs as the acute phase resolves
Causes & Risk Factors
- Idiopathic autoimmune inflammation (most common, ~50% of cases)
- Multiple sclerosis — TM is a common initial or relapsing manifestation
- Neuromyelitis optica spectrum disorder (NMOSD) with AQP4-IgG or MOG-IgG antibodies
- Post-infectious TM following viral illness (Epstein-Barr, COVID-19, enteroviruses)
- Systemic autoimmune disease: lupus, Sjögren syndrome, sarcoidosis, antiphospholipid syndrome
Treatment Options
Conservative
- High-dose IV methylprednisolone (1 g/day × 3–5 days) as first-line acute treatment
- Plasma exchange (PLEX) for steroid-refractory cases within 4–6 weeks of onset
- Inpatient rehabilitation: physical therapy, occupational therapy, and bladder management
Surgical
- Surgical decompression if structural cord compression coexists (rare in pure TM)
- Intrathecal baclofen pump placement for severe refractory spasticity in chronic TM
- Sacral neuromodulation or suprapubic catheter placement for neurogenic bladder management
When to see a spine specialist
Seek emergency evaluation for any sudden onset of limb weakness, inability to urinate, or a sensory level on the trunk. Transverse myelitis is a neurological emergency requiring MRI within hours to rule out compressive lesions treatable by surgery. Early steroid therapy improves outcomes — delays of even 24 hours can worsen prognosis.
Specialists Who Treat Transverse Myelitis
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Search spine specialists →Frequently Asked Questions
Is transverse myelitis the same as multiple sclerosis?
Transverse myelitis can be an initial presentation or relapse of MS, but most episodes of TM are not MS. Key distinguishing features include: MS typically causes partial cord involvement (asymmetric, short-segment T2 lesion less than 3 vertebral levels), while idiopathic and NMOSD-related TM often cause complete cord involvement spanning 3 or more levels (longitudinally extensive TM). Brain MRI, CSF analysis, and antibody testing (AQP4-IgG, MOG-IgG) help classify the underlying cause.
What is the chance of developing MS after a single episode of transverse myelitis?
The risk depends on brain MRI findings. Patients with a normal brain MRI at TM onset have a 10–15% lifetime risk of developing MS. Patients with brain white matter lesions consistent with demyelination have a 50–90% risk of eventually meeting MS diagnostic criteria. This is why brain MRI at the time of TM diagnosis is essential for counseling patients and determining whether disease-modifying therapy should be started prophylactically.
How long does recovery from transverse myelitis take?
Most recovery occurs within the first three to six months. Some patients continue improving for 12–24 months, though gains plateau over time. Prognostic factors for better recovery include rapid treatment, partial (rather than complete) deficit at nadir, short-segment MRI lesion, and younger age. Idiopathic TM tends to have better outcomes than NMOSD-related TM, which has a high relapse rate and cumulative disability without maintenance immunotherapy.