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Transverse myelitis

Last reviewed: 4 Apr 2025
Last updated: 22 Sep 2020

Summary

Definition

History and exam

Key diagnostic factors

  • age 10-19 or 30-39 years
  • motor weakness
  • paresthesias or sensory loss
  • bladder symptoms: urinary frequency, urgency, incontinence, or retention
  • bowel symptoms: incontinence or constipation
  • L'hermitte sign
  • McArdle sign
  • paroxysmal tonic spasms
  • upper motor neuron signs: hyperreflexia, positive Babinski sign, limb spasticity
  • sensory loss/sensory level
  • dyspnea/respiratory distress
Full details

Other diagnostic factors

  • back pain
  • trunk/limb pain
  • areflexia/hyporeflexia
  • hiccups
  • nausea/vomiting
Full details

Risk factors

  • preceding infectious illness
  • recent vaccination
  • female sex
  • history of recent physical trauma
  • spinal injection
Full details

Diagnostic tests

1st tests to order

  • MRI spinal cord
  • MRI brain
  • serum aquaporin-4 autoantibodies and myelin oligodendrocyte glycoprotein autoantibodies
  • cerebrospinal fluid cell count, cell differential, protein level, IgG index, oligoclonal bands
  • cerebrospinal fluid Gram stain, cultures (bacterial, tubercular, fungal), and India ink smear
  • cerebrospinal fluid, polymerase chain reaction for herpes simplex virus (HSV)-1, HSV-2, varicella zoster virus (VZV), Borrelia burgdorferi (Lyme disease), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and West Nile virus
  • cerebrospinal fluid Venereal Disease Research Laboratory test
  • serum anti-nuclear antibody, double-stranded DNA
  • extractable nuclear antigen (including SSA and SSB)
  • serum and cerebrospinal fluid paraneoplastic auto-antibodies
  • other neural autoantibodies
Full details

Tests to consider

  • serum and cerebrospinal fluid angiotensin-converting enzyme
  • chest x-ray
  • CT body (chest, abdomen, and pelvis)
  • whole-body PET scan
  • cerebrospinal fluid cytology and flow cytometry
  • serology for herpes simplex virus (HSV)-1, HSV-2, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, and West Nile virus
  • urinalysis
  • HIV antibodies
  • visual-evoked potential
  • optical coherence tomography
  • therapeutic trial with corticosteroid
  • spinal cord biopsy
Full details

Treatment algorithm

ACUTE

acute neurologic deficits

ONGOING

idiopathic TM

at risk for multiple sclerosis (typical demyelinating lesions on MRI)

aquaporin-4 autoantibody seropositive

myelin oligodendrocyte glycoprotein-IgG autoantibody seropositive

Contributors

Authors

Cristina Valencia-Sanchez, MD, PhD

Department of Neurology

Mayo Clinic

Scottsdale

AZ

Disclosures

CVS declares that she has no competing interests.

Acknowledgements

Dr Cristina Valencia-Sanchez would like to gratefully acknowledge Dr Dean Wingerchuk, the previous contributor to this topic. DMW has received compensation from MedImmune for service on a clinical trial adjudication committee, from Caladrius for consulting services, and research support paid to Mayo Clinic from Alexion and TerumoBCT. DMW is an author of a number of references cited in this topic.

Peer reviewers

Alireza Minagar, MD

Assistant Professor of Neurology

LSU Health Sciences Center

Shreveport

LA

Disclosures

AM declares that he has no competing interests.

Cory Toth, BSc, MD, FRCP(C)

Assistant Professor of Neurosciences

Hotchkiss Brain Institute

University of Calgary

Alberta

Canada

Disclosures

CT declares that he has no competing interests.

Abhijit Chaudhuri, DM, MD, PhD, FACP, FRCP

Consultant Neurologist

Clinical Director of Neurosciences

Department of Neurology

Queen's Hospital

Romford

UK

Disclosures

AC declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology. 2002 Aug 27;59(4):499-505. Abstract

Sechi E, Shosha E, Williams JP, et al. Aquaporin-4 and MOG autoantibody discovery in idiopathic transverse myelitis epidemiology. Neurology. 2019 Jul 23;93(4):e414-20. Abstract

de Seze J, Lanctin C, Lebrun C, et al. Idiopathic acute transverse myelitis: application of the recent diagnostic criteria. Neurology. 2005 Dec 27;65(12):1950-3. Abstract

Weinshenker BG, Wingerchuk DM. Neuromyelitis spectrum disorders. Mayo Clin Proc. 2017 Apr;92(4):663-79.Full text  Abstract

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 Dec;46(6):878-86. Abstract

Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018 Apr 24;90(17):777-88.Full text  Abstract

Cortese I, Chaudhry V, So YT, et al. Evidence-based guideline update: plasmapheresis in neurologic disorders: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2011 Jan 18;76(3):294-300.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Transverse myelitis images
  • Differentials

    • Compressive myelopathy
    • Infectious myelitis (e.g., TB)
    • Anterior spinal artery occlusion
    More Differentials
  • Guidelines

    • Practice guideline: disease modifying therapies in adults with multiple sclerosis
    • ACR appropriateness criteria: myelopathy
    More Guidelines
  • Patient information

    Multiple sclerosis

    More Patient information
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