Acute Transverse Myelitis (TM)

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Acute onset, usually postinfectious, rapidly progressive neurologic syndrome caused by focal inflammation of the spinal cord. Thoracic spinal cord level is the most commonly involved. 

Clinical presentation 

  • Rapid progressive bilateral lower limb weakness
  • Backache and neuropathic pain

Investigations 

  • FBP, serum electrolytes
  • CSF analysis
  • Emergency MRI or CT/myelogram to rule out a compressive lesion.
  • Brain MRI—may be required to exclude multiple sclerosis

Perform baseline severity score such as American Spinal Injury Association (ASIA) impairment  score to assist in clinical management decisions and monitor improvement. 

Pharmacological management 

Give high-dose steroids 

D: methylprednisolone (IV) 500-1000mg/day for 3–5days 

Consider cyclophosphamide in refractory cases (under the direction of an oncologist) 

S: cyclophosphamide (IV) 800-1000mg/m2 pulse dose. 

Long term management 

Manage generalized pain with 

A: diclofenac (IM) 75mg 12hourly for 3-5days 

OR 

B: tramadol (PO) 50mg 8hourly for 7-14days. 

Manage neuropathic pain with 

D: pregabalin (PO) 75mg 12hourly (maximum dose 300mg) for 2-4weeks 

Manage spasticity with 

S: baclofen (PO) 10mg 8hourly, (maximum dose 120mg/day) for 2weeks 

OR 

S: tizanidine (PO) 2mg 8hourly, (maximum dose 36mg/day) for 2weeks 

Non-pharmacological management 

  • Monitor respiratory function, support ventilation where required
  • Catheterize bladder and offer stool softeners to aid bowel emptying
  • Provide manual position changes 2hourly to avoid pressure sores
  • Provide rehabilitation--exercises to assist ambulation
  • Offer assisted ambulation devices—e.g., high back wheelchairs