Transverse myelitis is a neurological disorder caused by inflammation
across both sides of one level, or segment, of the spinal cord. The term myelitis refers
to inflammation of the spinal cord; transverse simply describes the position of the
inflammation, that is, across the width of the spinal cord. Attacks of inflammation can
damage or destroy myelin, the fatty insulating substance that covers nerve cell fibers.
This damage causes nervous system scars that interrupt communications between the nerves
in the spinal cord and the rest of the body.
Symptoms of transverse myelitis
Symptoms of transverse myelitis include a loss of spinal cord function
over several hours to several weeks. What usually begins as a sudden onset of lower back
pain, muscle weakness, or abnormal sensations in the toes and feet can rapidly progress to
more severe symptoms, including paralysis, urinary retention, and loss of bowel control.
Although some patients recover from transverse myelitis with minor or no residual
problems, others suffer permanent impairments that affect their ability to perform
ordinary tasks of daily living. Most patients will have only one episode of transverse
myelitis; a small percentage may have a recurrence.
The segment of the spinal cord at which the damage occurs determines which parts of the
body are affected. Nerves in the cervical (neck) region control signals to the neck, arms,
hands, and muscles of breathing (the diaphragm). Nerves in the thoracic (upper back)
region relay signals to the torso and some parts of the arms. Nerves at the lumbar
(mid-back) level control signals to the hips and legs. Finally, sacral nerves, located
within the lowest segment of the spinal cord, relay signals to the groin, toes, and some
parts of the legs. Damage at one segment will affect function at that segment and segments
below it. In patients with transverse myelitis, demyelination usually occurs at the
thoracic level, causing problems with leg movement and bowel and bladder control, which
require signals from the lower segments of the spinal cord.
Who gets transverse myelitis?
Transverse myelitis occurs in adults and children, in both genders, and in
all races. No familial predisposition is apparent. A peak in incidence rates (the number
of new cases per year) appears to occur between 10 and 19 years and 30 and 39 years.
Although only a few studies have examined incidence rates, it is estimated that about
1,400 new cases of transverse myelitis are diagnosed each year in the United States, and
approximately 33,000 Americans have some type of disability resulting from the disorder.
What causes transverse myelitis?
Researchers are uncertain of the exact causes of transverse myelitis. The
inflammation that causes such extensive damage to nerve fibers of the spinal cord may
result from viral infections, abnormal immune reactions, or insufficient blood flow
through the blood vessels located in the spinal cord. Transverse myelitis also may occur
as a complication of syphilis, measles, Lyme disease, and some vaccinations, including
those for chickenpox and rabies. Cases in which a cause cannot be identified are called
Transverse myelitis often develops following viral infections. Infectious agents suspected
of causing transverse myelitis include varicella zoster (the virus that causes chickenpox
and shingles), herpes simplex, cytomegalovirus, Epstein-Barr, influenza, echovirus, human
immunodeficiency virus (HIV), hepatitis A, and rubella. Bacterial skin infections,
middle-ear infections (otitis media), and Mycoplasma pneumoniae (bacterial pneumonia) have
also been associated with the condition.
In post-infectious cases of transverse myelitis, immune system mechanisms, rather than
active viral or bacterial infections, appear to play an important role in causing damage
to spinal nerves. Although researchers have not yet identified the precise mechanisms of
spinal cord injury in these cases, stimulation of the immune system in response to
infection indicates that an autoimmune reaction may be responsible. In autoimmune
diseases, the immune system, which normally protects the body from foreign organisms,
mistakenly attacks the bodys own tissue, causing inflammation and, in some cases,
damage to myelin within the spinal cord.
Because some affected individuals also have autoimmune diseases such as systemic lupus
erythematosus, Sjogrens syndrome, and sarcoidosis, some scientists suggest that
transverse myelitis may also be an autoimmune disorder. In addition, some cancers may
trigger an abnormal immune response that may lead to transverse myelitis.
An acute, rapidly progressing form of transverse myelitis sometimes signals the first
attack of multiple sclerosis (MS), however, studies indicate that most people who develop
transverse myelitis do not go on to develop MS. Patients with transverse myelitis should
nonetheless be screened for MS because patients with this diagnosis will require different
Some cases of transverse myelitis result from spinal arteriovenous malformations
(abnormalities that alter normal patterns of blood flow) or vascular diseases such as
atherosclerosis that cause ischemia, a reduction in normal levels of oxygen in spinal cord
tissues. Ischemia can result from bleeding (hemorrhage) within the spinal cord, blood
vessel blockage or narrowing, or other less common factors. Blood vessels bring oxygen and
nutrients to spinal cord tissues and remove metabolic waste products. When these vessels
become narrowed or blocked, they cannot deliver sufficient amounts of oxygen-laden blood
to spinal cord tissues. When a specific region of the spinal cord becomes starved of
oxygen, or ischemic, nerve cells and fibers may begin to deteriorate relatively quickly.
This damage may cause widespread inflammation, sometimes leading to transverse myelitis.
Most people who develop the condition as a result of vascular disease are past the age of
50, have cardiac disease, or have recently undergone a chest or abdominal operation.
What are the symptoms of transverse myelitis?
Transverse myelitis may be either acute (developing over hours to several
days) or subacute (developing over 1 to 2 weeks). Initial symptoms usually include
localized lower back pain, sudden paresthesias (abnormal sensations such as burning,
tickling, pricking, or tingling) in the legs, sensory loss, and paraparesis (partial
paralysis of the legs). Paraparesis often progresses to paraplegia (paralysis of the legs
and lower part of the trunk). Urinary bladder and bowel dysfunction is common. Many
patients also report experiencing muscle spasms, a general feeling of discomfort,
headache, fever, and loss of appetite. Depending on which segment of the spinal cord is
involved, some patients may experience respiratory problems as well.
From this wide array of symptoms, four classic features of transverse myelitis emerge: (1)
weakness of the legs and arms, (2) pain, (3) sensory alteration, and (4) bowel and bladder
dysfunction. Most patients will experience weakness of varying degrees in their legs; some
also experience it in their arms. Initially, people with transverse myelitis may notice
that they are stumbling or dragging one foot or that their legs seem heavier than normal.
Coordination of hand and arm movements, as well as arm and hand strength may also be
compromised. Progression of the disease over several weeks often leads to full paralysis
of the legs, requiring the patient to use a wheelchair.
Pain is the primary presenting symptom of transverse myelitis in approximately one-third
to one-half of all patients. The pain may be localized in the lower back or may consist of
sharp, shooting sensations that radiate down the legs or arms or around the torso.
Patients who experience sensory disturbances often use terms such as numbness, tingling,
coldness, or burning to describe their symptoms. Up to 80 percent of those with transverse
myelitis report areas of heightened sensitivity to touch, such that clothing or a light
touch with a finger causes significant discomfort or pain (a condition called allodynia).
Many also experience heightened sensitivity to changes in temperature or to extreme heat
Bladder and bowel problems may involve increased frequency of the urge to urinate or have
bowel movements, incontinence, difficulty voiding, the sensation of incomplete evacuation,
and constipation. Over the course of the disease, the majority of people with transverse
myelitis will experience one or several of these symptoms.
How is transverse myelitis diagnosed?
Physicians diagnose transverse myelitis by taking a medical history and
performing a thorough neurological examination. Because it is often difficult to
distinguish between a patient with an idiopathic form of transverse myelitis and one who
has an underlying condition, physicians must first eliminate potentially treatable causes
of the condition. If a spinal cord injury is suspected, physicians seek first to rule out
lesions (damaged or abnormally functioning areas) that could cause spinal cord
compression. Such potential lesions include tumors, herniated or slipped discs, stenosis
(narrowing of the canal that holds the spinal cord), and abscesses. To rule out such
lesions and check for inflammation of the spinal cord, patients often undergo magnetic
resonance imaging (MRI), a procedure that provides a picture of the brain and spinal cord.
Physicians also may perform myelography, which involves injecting a dye into the sac that
surrounds the spinal cord. The patient is then tilted up and down to let the dye flow
around and outline the spinal cord while X-rays are taken.
Blood tests may be performed to rule out various disorders such as systemic lupus
erythematosus, HIV infection, and vitamin B12 deficiency. In some patients with transverse
myelitis, the cerebrospinal fluid that bathes the spinal cord and brain contains more
protein than usual and an increased number of leukocytes (white blood cells), indicating
possible infection. A spinal tap may be performed to obtain fluid to study these factors.
If none of these tests suggests a specific cause, the patient is presumed to have
idiopathic transverse myelitis.
How is transverse myelitis treated?
As with many disorders of the spinal cord, no effective cure currently
exists for people with transverse myelitis. Treatments are designed to manage and
alleviate symptoms and largely depend upon the severity of neurological involvement.
Therapy generally begins when the patient first experiences symptoms. Physicians often
prescribe corticosteroid therapy during the first few weeks of illness to decrease
inflammation. Although no clinical trials have investigated whether corticosteroids alter
the course of transverse myelitis, these drugs often are prescribed to reduce immune
system activity because of the suspected autoimmune mechanisms involved in the disorder.
Corticosteroid medications that might be prescribed may include methylprednisone or
dexamethasone. General analgesia will likely be prescribed for any pain the patient may
have. And bedrest is often recommended during the initial days and weeks after onset of
Following initial therapy, the most critical part of the treatment for this disorder
consists of keeping the patients body functioning while hoping for either complete
or partial spontaneous recovery of the nervous system. This may sometimes require placing
the patient on a respirator. Patients with acute symptoms, such as paralysis, are most
often treated in a hospital or in a rehabilitation facility where a specialized medical
team can prevent or treat problems that afflict paralyzed patients. Often, even before
recovery begins, caregivers may be instructed to move patients limbs manually to
help keep the muscles flexible and strong, and to reduce the likelihood of pressure sores
developing in immobilized areas. Later, if patients begin to recover limb control,
physical therapy begins to help improve muscle strength, coordination, and range of
What therapies are available to help patients left with permanent
Many forms of long-term rehabilitative therapy are available for people
who have permanent disabilities resulting from transverse myelitis. Medical social
workers, often affiliated with local hospitals or outpatient clinics, are the best sources
for information about treatment programs and other resources that exist in a community.
Rehabilitative therapy teaches people strategies for carrying out activities in new ways
in order to overcome, circumvent, or compensate for permanent disabilities. Rehabilitation
as yet cannot reverse the physical damage resulting from transverse myelitis or other
forms of spinal cord injury. But it can help people, even those with severe paralysis,
become as functionally independent as possible and thereby attain the best possible
quality of life.
Commonly experienced permanent neurological deficits resulting from transverse myelitis
include severe weakness, spasticity (painful muscle stiffness or contractions), or
paralysis; incontinence; and chronic pain. Such deficits can substantially interfere with
a persons ability to carry out everyday activities such as bathing, dressing, and
performing household tasks.
People living with permanent disability may feel a range of emotions, from fear and
sadness to frustration and anger. Such feelings are natural responses, but they can
sometimes jeopardize health and potential for functional recovery. Those with permanent
disabilities frequently experience clinical depression. Fortunately, depression is
treatable, due to the development of a wide range of medications that can be used with
Today, most rehabilitation programs attempt to address the emotional dimensions along with
the physical problems resulting from permanent disability. Patients typically consult with
a range of rehabilitation specialists, who may include physiatrists (physicians
specializing in physical medicine and rehabilitation), physical therapists, occupational
therapists, vocational therapists, and mental health care professionals.
Physical Therapy: Physiatrists and physical therapists treat disabilities that result from
motor and sensory impairments. Their aim is to help patients increase their strength and
endurance, improve coordination, reduce spasticity and muscle wasting in paralyzed limbs,
and regain greater control over bladder and bowel function through various exercises.
Physiatrists and physical therapists teach paralyzed patients techniques for using
assistive devices such as wheelchairs, canes, or braces as effectively as possible.
Paralyzed patients also learn ways to avoid developing painful pressure sores on
immobilized parts of the body, which may lead to increased pain or systemic infection. In
addition, physiatrists and physical therapists are involved in pain management. A wide
variety of drugs now exist that can alleviate the pain that results from spinal cord
injuries such as those caused by transverse myelitis. These include nonsteroidal
anti-inflammatory drugs such as ibuprofen or naproxen; antidepressant drugs such as
amitryptyline (tricyclic) and sertraline (a selective serotonin reuptake inhibitor); and
anticonvulsant drugs such as phenytoin and gabapentine.
Occupational Therapy: Occupational therapists help patients learn new ways of performing
meaningful, self-directed, goal-oriented, everyday tasks (occupations) such as bathing,
dressing, preparing a meal, house cleaning, engaging in arts and crafts, or gardening.
They teach people how to develop compensatory strategies, how to make changes in their
homes to improve safety (such as installing grab bars in bathrooms), how to change
obstacles in their environment that interfere with normal activity, and how to use
Vocational Therapy: In addition to acquainting people with their rights as defined under
the Americans with Disabilities Act of 1990 and helping people develop and promote work
skills, vocational therapists identify potential employers, assist in job searches, and
act as mediators between employees and employers to secure reasonable workplace
What is the prognosis concerning transverse myelitis?
Recovery from transverse myelitis usually begins within 2 to 12 weeks of
the onset of symptoms and may continue for up to 2 years. However, if there is no
improvement within the first 3 to 6 months, significant recovery is unlikely. About
one-third of people affected with transverse myelitis experience good or full recovery
from their symptoms; they regain the ability to walk normally and experience minimal
urinary or bowel effects and paresthesias. Another one-third show only fair recovery and
are left with significant deficits such as spastic gait, sensory dysfunction, and
prominent urinary urgency or incontinence. The remaining one-third show no recovery at
all, remaining wheelchair-bound or bedridden with marked dependence on others for basic
functions of daily living. Unfortunately, making predictions about individual cases is
difficult. However, research has shown that a rapid onset of symptoms generally results in
poorer recovery outcomes.
The majority of people with this disorder experience only one episode although in rare
cases recurrent or relapsing transverse myelitis does occur. Some patients recover
completely, then experience a relapse. Others begin to recover, then suffer worsening of
symptoms before recovery continues. In all cases of relapse, physicians will likely
investigate possible underlying causes such as MS or systemic lupus erythematosus since
most people who experience relapse have an underlying disorder.
What research is being done concerning transverse myelitis?
Within the Federal Government, the National Institute of Neurological
Disorders and Stroke (NINDS), one of the National Institutes of Health (NIH), has primary
responsibility for conducting and supporting research on spinal cord disorders and
demyelinating diseases such as transverse myelitis. The NINDS conducts research in its
laboratories at the NIH and also supports studies through grants to major medical
institutions across the country.
NINDS researchers seek to clarify the role of the immune system in the pathogenesis of
demyelination in autoimmune diseases or disorders. Other work focuses on strategies to
repair demyelinated spinal cords including approaches using cell transplantation. The
knowledge gained from such research should lead to a greater knowledge of the mechanisms
responsible for demyelination in transverse myelitis and may ultimately provide a means to
prevent and treat this disorder.
The NINDS also funds researchers who are using animal models of spinal cord injury to
study strategies for replacement or regeneration of spinal cord nerve cells. The ultimate
goals of these studies are to encourage the same regeneration in humans and to restore
function to paralyzed patients. Scientists are also developing neural prostheses to help
patients with spinal cord damage compensate for lost function. These sophisticated
electrical and mechanical devices connect with the nervous system to supplement or replace
lost motor and sensory function. Neural prostheses for spinal cord injured patients are
being tested in humans.
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892