Demyelinating disorders: Update on transverse myelitis

  • Chitra Krishnan
  • Adam I. Kaplin
  • Carlos A. Pardo
  • Douglas A. Kerr
  • Sanjay C. Keswani


Transverse myelitis (TM) is a focal inflammatory disorder of the spinal cord. Perivascular monocytic and lymphocytic infiltration, demyelination, and axonal injury are prominent histopathogic features of TM. The clinical manifestations of TM are consequent to dysfunction of motor, sensory, and autonomic pathways. At peak deficit, 50% of patients with TM are completely paraplegic (with no volitional movements of legs), virtually all have some degree of bladder dysfunction, and 80% to 94% have numbness, paresthesias, or band-like dysesthesias. Longitudinal case series of TM reveal that approximately one third of patients recover with little to no sequelae, one third are left with a moderate degree of permanent disability, and one third have severe disability. Recent studies have shown that the cytokine interleukin-6 may be a useful biomarker, as the levels of interleukin-6 in the cerebrospinal fluid of acute TM patients strongly correlate with and are highly predictive of disability. Clinical trials testing the efficacy of promising axonoprotective agents in combination with intravenous steroids in the treatment of TM are currently underway.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Berman M, Feldman S, Alter M, et al.: Acute transverse myelitis: incidence and etiologic considerations. Neurology 1981, 31:966–971.PubMedGoogle Scholar
  2. 2.
    Transverse Myelitis Consortium Working Group: Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology 2002, 59:499–505. This manuscript established a new set of criteria for TM that distinguished it from noninfkammatory myelopathies and distinguished idiopathic TM from TM associated with either systemic inflammatory disease or from multifocal CNS disease.Google Scholar
  3. 3.
    Achiron A, Barak Y: Multiple sclerosis-from probable to definite diagnosis: a 7-year prospective study. Arch Neurol 2000, 57:974–979.PubMedCrossRefGoogle Scholar
  4. 4.
    Jeffery DR, Mandler RN, Davis LE: Transverse myelitis. Retrospective analysis of 33 cases, with differentiation of cases associated with multiple sclerosis and parainfectious events. Arch Neurol 1993, 50:532–535.PubMedGoogle Scholar
  5. 5.
    Christensen PB, Wermuth L, Hinge HH, Bomers K: Clinical course and long-term prognosis of acute transverse myelopathy. Acta Neurol Scand 1990, 81:431–435.PubMedCrossRefGoogle Scholar
  6. 6.
    Altrocchi PH: Acute transverse myelopathy. Arch Neurol 1963, 9:21–29.Google Scholar
  7. 7.
    Paine RS, Byers RK: Transverse myelopathy in childhood. AMA Am J Dis Child 1968, 85:151–163.Google Scholar
  8. 8.
    Knebusch M, Strassburg HM, Reiners K: Acute transverse myelitis in childhood: nine cases and review of the literature. Dev Med Child Neurol 1998, 40:631–639.PubMedCrossRefGoogle Scholar
  9. 9.
    Dunne K, Hopkins IJ, Shield LK: Acute transverse myelopathy in childhood. Dev Med Child Neurol 1986, 28:198–204.PubMedCrossRefGoogle Scholar
  10. 10.
    Sakakibara R, Hattori T, Yasuda K, Yamanishi T: Micturition disturbance in acute transverse myelitis. Spinal Cord 1996, 34:481–485.PubMedGoogle Scholar
  11. 11.
    Burns AS, Rivas DA, Ditunno JF: The management of neurogenic bladder and sexual dysfunction after spinal cord injury. Spine 2001, 26:S129-S136.PubMedCrossRefGoogle Scholar
  12. 12.
    DasGupta R, Fowler CJ: Sexual and urological dysfunction in multiple sclerosis: better understanding and improved therapies. Curr Opin Neurol 2002, 15:271–278.PubMedCrossRefGoogle Scholar
  13. 13.
    Patten SB, Metz LM: Depression in multiple sclerosis. Psychother Psychosom 1997, 66:286–292.PubMedCrossRefGoogle Scholar
  14. 14.
    Hummers LK, Krishnan C, Casciola-Rosen L, et al.: Recurrent transverse myelitis associates with anti-Ro (SSA) autoantibodies. Neurology 2004, 62:147–149.PubMedGoogle Scholar
  15. 15.
    Ropper AH, Poskanzer DC: The prognosis of acute and subacute transverse myelopathy based on early signs and symptoms. Ann Neurol 1978, 4:51–59.PubMedCrossRefGoogle Scholar
  16. 16.
    Irani DN, Kerr DA: 14-3-3 protein in the cerebrospinal fluid of patients with acute transverse myelitis. Lancet 2000, 355:901.PubMedCrossRefGoogle Scholar
  17. 17.
    Nagaswami S, Kepes J, Foster DB, Twemlow SW: Necrotizing myelitis: a clinico-pathologic report of two cases associated with diplococcus pneumoniae and mycoplasma pneumoniae infections. Trans Am Neurol Assoc 1973, 98:290–292.PubMedGoogle Scholar
  18. 18.
    Mirich DR, Kucharczyk W, Keller MA, Deck J: Subacute necrotizing myelopathy: MR imaging in four pathologically proved cases. Am J Neuroradiol 1991, 12:1077–1083.PubMedGoogle Scholar
  19. 19.
    Katz JD, Ropper AH: Progressive necrotic myelopathy: clinical course in 9 patients. Arch Neurol 2000, 57:355–361.PubMedCrossRefGoogle Scholar
  20. 20.
    Brocke S, Hausmann S, Steinman L, Wucherpfennig KW: Microbial peptides and superantigens in the pathogenesis of autoimmune diseases of the central nervous system. Semin Immunol 1998, 10:57–67.PubMedCrossRefGoogle Scholar
  21. 21.
    Kaplin AI, Krishnan C, Deshpande DM, et al.: Diagnosis and management of acute myelopathies. Neurologist 2005, 11:2–18. This review article provides details on the paraclinical and clinical features of a large cohort of patients with TM and presents some of the pathologic features of TM.PubMedCrossRefGoogle Scholar
  22. 22.
    Elovaara I, Lalla M, Spare E, et al.: Methylprednisolone reduces adhesion molecules in blood and cerebrospinal fluid in patients with MS. Neurology 1998, 51:1703–1708.PubMedGoogle Scholar
  23. 23.
    Sellebjerg F, Christiansen M, Jensen J, Frederiksen JL: Immunological effects of oral high-dose methylprednisolone in acute optic neuritis and multiple sclerosis. Eur J Neurol 2000, 7:281–289.PubMedCrossRefGoogle Scholar
  24. 24.
    Bracken MB, Shepard MJ, Collins WF, et al.: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 1990, 322:1405–1411.PubMedCrossRefGoogle Scholar
  25. 25.
    Defresne P, Meyer L, Tardieu M, et al.: Efficacy of high dose steroid therapy in children with severe acute transverse myelitis. J Neurol Neurosurg Psychiatry 2001, 71:272–274.PubMedCrossRefGoogle Scholar
  26. 26.
    Lahat E, Pillar G, Ravid S, et al.: Rapid recovery from transverse myelopathy in children treated with methylprednisolone. Pediatr Neurol 1998, 19:279–282.PubMedCrossRefGoogle Scholar
  27. 27.
    Sebire G, Hollenberg H, Meyer L, et al.: High dose methylprednisolone in severe acute transverse myelopathy. Arch Dis Child 1997, 76:167–168.PubMedCrossRefGoogle Scholar
  28. 28.
    Kalita J, Misra UK: Is methyl prednisolone useful in acute transverse myelitis? Spinal Cord 2001, 39:471–476.PubMedCrossRefGoogle Scholar
  29. 29.
    Weinshenker BG: Plasma exchange for severe attacks of inflammatory demyelinating diseases of the central nervous system. J Clin Apheresis 2001, 16:39–42. This manuscript is one of several from the same group showing that plasma exchange is effective in severe CNS inflammatory disorders.PubMedCrossRefGoogle Scholar
  30. 30.
    Weinshenker BG: Therapeutic plasma exchange for acute inflammatory demyelinating syndromes of the central nervous system. J Clin Apheresis 1999, 14:144–148.PubMedCrossRefGoogle Scholar
  31. 31.
    Weinshenker BG, O’Brien PC, Petterson TM, et al.: A randomized trial of plasma exchange in acute central nervous system inflammatory demyelinating disease. Ann Neurol 1999, 46:878–886.PubMedCrossRefGoogle Scholar
  32. 32.
    Keegan M, Pineda AA, McClelland RL, et al.: Plasma exchange for severe attacks of CNS demyelination: predictors of response. Neurology 2002, 58:143–146. After the initial study, which showed that plasma exchange is effective in monosymptomatic CNS inflammatory disorders, this study defined clinical characteristics that predicted who responded to it.PubMedCrossRefGoogle Scholar
  33. 33.
    Wollinsky KH, Hulser PJ, Brinkmeier H, et al.: CSF filtration is an effective treatment of Guillain-Barre syndrome: a randomized clinical trial. Neurology 2001, 57:774–780. This is a novel study examining cerebrospinal fluid filtration in patients with Guillain-Barré syndrome compared with the accepted therapy, plasma exchange. The exciting finding was that cerebrospinal fluid filtration—accomplished by repeated exchange through a filter designed to remove cells, bacteria, endotoxins, immunoglobulins, and inflammatory mediators—is as effective as plasma exchange. If confirmed in larger studies, this would represent a major advance. Conceptually, this treatment would potentially be even more effective in patients with acute transverse myelitis.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  • Chitra Krishnan
  • Adam I. Kaplin
  • Carlos A. Pardo
  • Douglas A. Kerr
  • Sanjay C. Keswani
    • 1
  1. 1.Department of NeurologyJohns Hopkins University School of Medicine, Pathology 627BaltimoreUSA

Personalised recommendations