Transverse Myelitis - Neurology/IM

Question 1

Definition of Transverse myelitis

Answer 1

It’s an acute syndrome of inflammation of the spinal cord, usually involving multiple segments both gray and white matter, with resultant myelopathy or spinal cord dysfunction (functionally transects the cord).

Question 2

What is the etiology of Transverse myelitis ?

Answer 2

1) Infection: - Viral: Influenza, chicken pox, post-vaccination.
- Bacterial: T.B., Syphilis, diphtheria.
2) Toxic: Post-lumbar anesthesia.
3) Demyelinating: MS, neuromyelitis optica and ADEM.

Question 3

What is the clinical picture of Transverse myelitis ?

Answer 3

• Initial symptoms usually include lower back pain or sharp, shooting sensations that radiate down the legs.
• Shock stage (2-6 weeks): sudden flaccid paraplegia with complete loss of sensation below the level of the lesion and retention of urine.
• Recovery stage: Spastic weakness (UMN) of the lower limbs with hypothesia below the level of the lesion (sensory level) and precipitancy of micturition.

Question 4

Investigations used in Transverse myelitis

Answer 4

1) MRI spine: to confirm the presence of a lesion.
2) CSF examination: to confirm an inflammatory process & to look for possible infectious etiologies. There are increased cells and proteins. (IgG OCBs in MS).
3) Blood tests: to look for systemic inflammatory disease & infection especially in febrile patients. Also, for the presence of autoantibodies (anti- aquaporin 4 in NMO).

Question 5

ttt of transverse myelitis

Answer 5

1) In severe or rapidly progressive cases, initial empiric treatment includes IV methylprednisolone 1 g for 3-5 days & IV acyclovir while definitive diagnostic tests are pending.
2) If no response: plasmapheresis (5 exchanges with 1.5 volumes per exchange).
3) Symptomatic treatment: Pain, incontinence…etc.
4) Physical therapy.

Question 6

Definition of Syringomyelia

Answer 6

It is a chronic disease characterized development of a fluid-filled gliosis-lined cavity (syrinx) around the central canal in the gray matter of the spinal cord specially in the lower cervical & upper thoracic segments and to a lesser extent in the lumbar segments.

Question 7

Etiology of SYRINGOMYELIA

Answer 7

1) Obstruction of CSF flow is the most common cause (e.g., Chiarin malformations, basal arachnoiditis and meningeal carcinomatosis).
2) Spinal cord injury (i.e., spinal trauma, radiation necrosis, hemorrhage from aneurysm rupture or AVM & infection).
3) Intramedullary tumors.
4) Idiopathic.

Question 8

clinical picture of cervical SYRINGOMYELIA

Answer 8

1) Motor manifestations:
- Early: In the UL: Localized LMN weakness with fasciculations due to encroachment on AHCs (wasting of hand muscles).
- Late: In the LL: Spastic paraplegia due to encroachment on the pyramidal tracts.
2) Sensory manifestations: Jacket sensory loss of dissociated nature (loss of pain & temperature with intact proprioception) in the area of skin supplied by the affected segments with sacral spare.
3) Autonomic manifestations: Trophic ulcers of the fingers, painless nail infection and vasomotor changes (Morvan’s syndrome).
4) Associated skeletal anomalies: as pes cavus, and spina bifida are common.

Question 9

Clinical presentation of syringobulbia

Answer 9

• Pain in the face followed by loss of sensation of dissociated nature in the distribution of the trigeminal nerve.
• Vertigo and nystagmus.
• Bulbar symptoms with lost palatal and pharyngeal reflexes.
• Wasting of the tongue with fasciculations.

Question 10

What is the clinical presentation of cauda equina syndrome ?

Answer 10

• Incapacitating back and lower extremity pain
• Numbness, dermatomal hypothesia and saddle area hypothesia.
• Profound weakness of the lower extremities (LMN) with marked hyporeflexia
• Inability to urinate (early) and urinary incontinence (later)
• Distention, constipation and bowel incontinence (late) and diminished anal tone.
• Sexual dysfunction (impotence)