Spinal Cord Disorders

SEMINAR

YEAR 5 | GROUP 5 | ROTATION 2 | INTERNAL MEDICINE | 02.02.2024

 Table of content
Anatomy of spinal cord Darrshini Kumar
BMS19096037

History and physical examination- Pang Sze Ern

BACK PAIN BMS19096033

Types and differential diagnosis of Lim Jie Ying

back pain BMS19096083

Spinal cord compression Sophia Emerald Ravikumar

Ankylosing Spondylitis BMS19096857

Cauda equina syndrome Zeinab Moawin

BMS19096399

Brown Sequard syndrome Chua Jia Yi

BMS 19096023

Transverse myelitis Stephanie Lee Shiau Wei

BMS19096382
Anatomy of
Spinal Cord
 -Spinal Cord-

➢ The spinal cord or the spinal medulla is the most important content of the vertebral canal. In
adults, it occupies only the upper 2⁄3 of the vertebral canal.
➢ It begins as a downward extension of medulla oblongata at the level of the upper border of the
first cervical vertebrae (C1) and extends down to the level of the lower border of the first
lumbar vertebrae (L1).
➢ The level varies with flexion or extension of the spine.
➢ The lowest part of the spinal cord is conical and called the conus medullaris.
➢ The conus is continuous below, with a fibrous cord called the filum terminale which is a
prolongation of pia mater and is attached to the posterior surface of the first piece of coccyx.
Dimensions of the Cord
The length of the cord is about 45cm. The spinal cord is not out of uniform thickness.
It resembles a flattened cylinder. The transverse diameter shows 2 enlargements at the
cervical level and lumbar level. The spinal segments that contribute to the nerves of
the upper limbs ( from 3rd cervical to 2nd thoracic segments) are enlarged to form the
cervical enlargement of the cord. Similarly, the segments innervating the lower limbs
(1st lumbar to 3rd sacral segments ) from lumbar enlargement.

Age-Wise Changes in the Cord

In early fetal life ( 3rd month ), the spinal cord is as long as the vertebral canal and
each spinal nerves arises from the cord at the level of the corresponding intervertebral
foramen. In subsequent development, the spinal cord does not grow as much as the
vertebral column, and its lower and, therefore, gradually ascends the reach the level of
the 3rd lumbar vertebrae at the time of birth and to the lower border of the 1st lumbar
vertebrae in the adult.
External Features of Spinal Cord
● The anterior surface of the spinal cord is marked by a deep anterior median fissure,
which contains anterior spinal artery.
● The posterior surface is marked by a shallow posterior median sulcus
● The anterior median fissure and posterior median sulcus divide the surface of the cord
into 2 symmetrical halves.
● Each of the cord is further subdivided into posterior, lateral and anterior regions by
anterolateral and posterolateral sulci.
● The rootlets of the dorsal or sensory roots of spinal nerves enter the cord at the
posterolateral sulcus on either side.
● The rootlets of the ventral or motor roots of spinal nerves emerge through the
anterolateral sulcus on either side.

Functions of Spinal Cord

I. It acts as a pathway for motor information, which travels down the spinal cord.
II. It serves as a passage for sensory information in the reverse direction.
III. It is a centre for coordinating simple reflexes.
 Spinal Nerves
The spinal cord gives attachment on either side to 31 pairs of spinal nerves:
➔ 8 cervical
➔ 12 thoracic
➔ 5 lumbar
➔ 5 sacral
➔ 1 coccygeal

Each spinal nerves arises by 2 roots:

I. Anterior motor
II. Posterior sensory root

● The dorsal root is marked by a swelling called the dorsal nerve root ganglion or spinal
ganglion.
● The obliquity and length of the roots are most marked in the lower nerves and many of
these roots occupy the vertebral canal below the level of the spinal cord.
● These roots constitute the cauda equina.
Spinal Meninges and Spaces
Dura Mater Arachnoid Mater Pia Mater

● Extends from the ● Located between ● Innermost layer

foramen the dura of the
magnum to the mater and pia meninges.
filum terminale. mater. ● Covers the
● Separated from ● Separated by the spinal cord,
the walls of the subarachnoid nerve roots and
vertebral canal by space (CSF). blood vessels
epidural space. ● Lumbar cistern.
I. Linea splendens
II. Ligamenta
denticulata
III. Filum
terminale
Arterial Supply
Anterior Spinal Posterior Spinal Radicular Artery
Artery Artery

● Formed in the ● The right and left ● The main source of

posterior cranial fossa posterior spinal blood to the spinal
by the union of the arteries arteries from vertebral
right and left anterior are branches of 4th arteries.
spinal arteries. part of the vertebral ● The spinal arteries
● Branches of 4th part arteries. receive blood that
of the vertebral artery. ● Each artery reach
● Descends through descends the cord along the
the through foramen roots of spinal nerves.
foramen magnum and magnum as 2 ● Arise from spinal
runs down in the branches. branches of:
anterior median ● Pass in front and I. Vertebral
fissure of the spinal behind the dorsal roots II. Intercostal
cord. of the spinal nerves. III. Lumbar
IV. Sacral
 Venous Drainage
➔ The veins draining the spinal cord are arranged in the form of 6 longitudinal channels.
➔ These channels are interconnected by a plexus of veins that form a venous vasocorona.
➔ The blood from these veins is drained into radicular veins that open into a venous plexus lying
between the dura mater and the bony vertebral canal ( internal vertebral venous plexus ) and into
various segmental veins.

I. 2 median longitudinal channels

II. Paired anterolateral channels
III. Paired posterolateral channels
 Causes of low back pain

Mechanical ● Trauma (spine fracture)

Anatomical ● Scoliosis

Degenerative ● Disc herniation, spinal stenosis, spondylolisthesis

Inflammatory ● Ankylosing spondylitis, reactive arthritis

Infectious ● Paraspinal abscess, epidural abscess, osteomyelitis

Malignant ● Metastasis, tumours, multiple myeloma

 Back pain
Traumatic No Trauma

No neurological deficit Neurological deficit

Mechanical pain
Radiculopathy Myelopathy
(LMNL) (UMLN)
 Radiculopathy Myelopathy

Definition ● Nerve root lesion resulting in neurological ● Compression of spinal cord

deficits of affected dermatomes and
myotomes

Symptoms ● Shooting pain down to leg according to the ● Constant, progressive pain unrelieved by
compressed nerve root rest
● Paresthesia ● Paresthesia
● Sensory loss ● Severe cases → bladder and bowel
incontinence

Signs ● Weakness ● LMNL at the level of lesion and UMNL

● Loss of reflexes below the level of lesion
● Saddle anaesthesia → cauda equina
*motor, sensory or reflex signs limited to one syndrome
nerve root

Common ● Prolapsed intervertebral disc ● Spinal cord compression

causes ● Spondylosis ● Conus medullaris syndrome
● Spondylolisthesis ● Cauda equina syndrome
 Myelopathy

Radiculopathy
 Red flag features
Patient ● Age < 18 or > 50
characteristics ● Immunosuppression

Past medical ● History of malignancy

history ● History of abdominal aortic aneurysm
● Significant trauma

Medications ● Long-term steroids → osteoporosis, pathological fractures, spinal infection

● Anticoagulants → increased risk of spinal haematoma

Pain ● Pain that does not improve with rest

characteristics ● Persistent or progressive pain +/- neurological findings despite > 4 weeks of
conservative therapy

Signs of cord ● UMN features (spasticity, hyperreflexia) distal to site of compression

compression ● Saddle anaesthesia
syndrome ● Bladder or bowel dysfunction
History taking
Chief complaint: back pain
1) Site: localized, diffuse
2) Onset: duration, acute or gradual onset
3) Trigger: recent trauma, unusual physical activity
4) Characteristics: intermittent, continuous, shooting, more as back pain or leg
pain, only affect specific area (dermatome)
5) Radiation: legs, buttocks, neck
6) Timing: first time, recurrent, at rest, early morning, night, both
7) Aggravating & relieving movements: walking vs sitting, leaning forward vs
backward, coughing, laughing

Neurological symptoms
● Paresthesia
● Tingling sensation
● Sensory loss (perianal sensory loss)
● Weakness
● Balance difficulty
● Disturbance gait
● Bowel or bladder dysfunction --> cauda equina syndrome
● Sexual dysfunction
TRO mechanical (lumbosacral sprains), neoplasms, inflammatory (ankylosis
spondylitis), infectious (TB, osteomyelitis), metabolic (osteoporosis), referred pain
(other medical conditions), surgical emergencies (AAA)
Associated symptoms
● Stiffness (timing, duration) --> spondylosis
● Weight loss --> malignancy
● Fever, dysuria --> pyelonephritis
● Abdominal pain, nausea & vomiting --> pancreatitis

PMX: malignancy, recent bacteremia, immunosuppression

Family hx: malignancy

Drug hx: glucocorticoid --> osteoporotic fracture

Social hx: smoking, alcohol, occupational or recreational activity (lifting weight)

Spine Examination
First of all, greet the patient, explain what going to examine, get consent.
General examination: pallor, jaundice, central/peripheral cyanosis, CRT, clubbing,
radial pulse

Cervical spine examination

Ask patient sitting upright shirt off, observe their back, side, front

Face the patient: Look for

1. Posture: erect, splinting, tilting & cervical lordosis & symmetry

2. Deformity: ‘wry neck’ (torticollis), loss of lordosis/flexion, increased lordosis,
lateral flexion
3. Scars, sinuses, swellings
Feel
1. Midline spinous processes from the occiput to T1
2. Paraspinous soft tissues
3. Supraclavicular fossae or cervical ribs or enlarged lymph nodes
4. Anterior neck structure, including thyroid
5. Tenderness in the spine, trapezius, intracapsular, paraspinal muscles
Move (active movement/passive movement)

Ask the patient to:-

● Cervical flexion (atlanto-occipital)

- Ask patient to look down to the ground, chin touch chest
- Normal: 0-80
● Cervical extension
- Ask patient to look up to the ceiling
- Normal: 0-50
● Lateral flexion
- Ask patient to put their ear on their left/right shoulder
- Normal: 0-45
● Lateral rotation (altanto-axialodontoid)
- Ask patient to look over their left/right shoulder
- Normal: 0-80

Look for any reduced of ROM (pain/stiffness), can apply gentle passive
movements, pain/paresthesia in the arm on passive movements suggests nerve
root involvement
Thoraco-lumbar spine examination

Ask patient standing, back and legs exposed, observe their

front, side, back

Look for:

a) Front: Scar
b) Side
- deformity: decreased/increased lordosis, scoliosis
c) Back:
- Tilting of the shoulder, pelvis, limb softening
- Skin changes/soft tissue abnormalities: birthmark, hairy
patches, lipoma,
Feel
a) Palpate the spinous process and paraspinal tissues (overall alignment/focal
tenderness)
b) After warning the patient, lightly percuss the spine with closed fist and note
any tenderness
Move
a) Flexion
- Ask the patient to touch their toes with their legs straight, observe the
smoothness
b) Extension
- Ask the patient to straighten up and lean back as far as possible (normal:
0-10/20)
c) Lateral flexion
- Ask the patient to reach down to each side, touching the outside of their
legs as far as possible while keeping their legs straight.
d) Rotation
- Ask patient to sit arms crossed. Ask patient to twist round both ways and
look behind.
Special test
a) Schober’s test for forward flexion
1) mark the skin in the midline at the
level of the posterior iliac spine (L5)
2) use a tape measure to draw 2 or
more marks: one 10 cm above (mark B)
and one 5 cm below this mark (mark C)
3) Place the end of the tape measure on
the upper mark B to C should increase
from 15 to >20cm
b) Root compression test

i) Sciatic nerve stretch test (L4-S1)

1) with the patient lying supine, lift

their foot to flex the hip passively,
keeping the knee straight

2) When a limit is reached, raise

leg to just less than this level, and
dorsiflex the foot to test for nerve
root torsion

Pain→ positive
ii) Femoral nerve stretch test
(L2-4)

1) With the patient lying in

prone position, flex their
knee and extend the hip
2) If positive, pain felt at the
back or in the front of the
thigh
3) If necessary, can be formed
with the patient lying on
their side with their test side
uppermost
iii) Flip test for functional overlay

1. Ask the patient to sit on the end

of the couch with their hips and
knees flexed to 90 deg
2. Examine the knee reflexes
3. Extend to the patient’s knee, as if
to examine the ankle jerk. If
achieved, this put the straight leg
at 90 deg of hip flexion → can
excludes sciatic nerve root
compression, patients with root
compression will lie back (flip)
 Spinal Cord
Compression
Causes
Vertebral (80%) Meninges (15%) Spinal cord (5%)

● Trauma ● Tumors (ie: ● Tumor (glioma,

● Intervertebral disc meningioma, ependymoma)
prolapse neurofibroma)
● Metastatic ● Epidural abscess
carcinoma
● Tuberculosis
● Myeloma
 Clinical features
● Variable onset depending on the etiology Cervical ● UMN signs
above C5 ● Loss of sensation upper
● Tenderness to percussion over the spine
and lower limbs
● Radicular pain
● Diaphragm weakness
● Bilateral paralysis below the affected spinal
segment
● Hyperreflexia C5 - T1 ● LMN signs in upper limb
● UMN signs in lower limb
● Hyporeflexia (when acute)
● Intercostal muscle weakness
● +ve babinski sign
● Ataxia (loss of coordination) Thoracic ● Spastic paraplegia
● Paresthesia , numbness/cold sensation cord ● Weakness of legs
● Sacral loss of sensation
● Loss of extensor plantar
reflexes
 Investigations
IOC - MRI without contrast
Other Imaging investigations
● Spinal X-ray
● CT Myelography
- CSF is taken for
analysis
 Management
Dependent upon the etiology of the spinal cord compression
● Consult neurosurgery for further management on spinal decompression
● Order bladder scan with post voidal residual.
- Catheterise patient -- strict I/O charting
● Manage acute pain with analgesics -- NSAIDs
● IV dexamethasone 10mg
- Patients with marked neurological deficit prior to diagnosis formation
indicates a poor prognosis for functional recovery; otherwise functional
recovery is expected
● Treat underlying cause
Indications for surgical management
● Neurologic deficit worsens despite non-surgical treatment
● Biopsy needed
● Spine is unstable (ie: vertebral #)
● Recurring tumor
● Abscess, subdural or epidural hematoma compressing the spinal cord
Ankylosing
spondylitis
 Spondyloarthritis
1. Ankylosing Spondylitis
2. Reactive arthritis (Reiter’s syndrome)
3. IBD associated Arthritis (Enteropathic arthritis)
4. Psoriatic Arthritis
5. Juvenile onset spondyloarthritis
Common points for all Spondyloarthritis
● Seen in patients <40 years
● M>F
● Characterized by Axial skeleton or
Peripheral skeleton or Axial and peripheral
● skeleton
● Characterized by Sacroiliitis, Dactylitis,
Enthesitis (Inflammation at the site
● where the ligament or tendon attaches to
the bone)
● M/C extra articular manifestation is acute
anterior uveitis
● RF -ve and HLA-B27 +ve
 Ankylosing Spondylitis
Ankylosing Spondylitis is a chronic, progressive inflammatory disease that
primarily affects the axial skeleton, including the sacroiliac joints, spine and
pelvis.
● Male female ratio (3:1)
● It is an axial arthropathy
● Shoulder and hip involvement in AS is associated with bad prognosis
● It presents as sacroiliitis, then ascends upward, finally involving the cervical
spine.
● Fractures are more common in cervical spine.
● Always produces symmetrical sacroiliitis, dactylitis and enthesitis.
● HLA-B27 is seen in more than 90% of AS patients.
 Clinical features
Articular features
1. Episodic inflammation of sacroiliac joint
- Dull lower back pain and stiffness
● Worse in the morning
● Stiffness lasts >30 mins
● Relieved by exercise
● Alternating gluteal pain
2. Tenderness over sacroiliac joints
3. Extraspinal joint pain
- Inflammatory enthesitis
- Dactylitis
- Arthritis outside of spine (ie: knee,
shoulder)
Physical examination
Schober’s test
Aim → to measure spinal stiffness
● In this test marks are made
5cm below and 10 cm above
the sacral dimples.
● The distance between these
marks should increase from
15 cm to at least 20 cm with
lumbar flexion
● The distance less than 5 cm
is abnormal
Approach to making a
diagnosis
 Grade 0 - Normal Grade I - Slight blurring of the cortical Grade II - Definite bilateral sacroiliitis
joints margins of the lower third of each joint characterized by erosion & sclerosis of
each joint

Sacroiliitis grading according to the modified New York Criteria

Grade III - Joint margins no longer visible due to extensive Grade IV - Joint ankylosis
erosion with pseudo widening of each joint
Investigations
Lab findings

● ESR and CRP are elevated

● HLA B27 +ve

Imaging
X ray of sacroiliac Best initial test to confirm diagnosis + assess severity
joint (PA view) Findings
● Symmetrical
● Erosion and sclerosis of sacroiliac joint
● Ankylosis -- fusion of articular surfaces

X ray of spine (AP Findings

and lateral view) ● Ankylosis of costosternal and costovertebral joints
● Dagger sign -- ossification of vertebral lig.
- Radiodense line running through center of vertebral
bodies
● Bamboo Sign
- Ossification of outer fibers of annulus fibrosus resulting in
ankylosis of intervertebral joint
- Presence of Syndesmophytes
Management
Assess symptom severity

● Severe ongoing symptoms - manage as active disease

● Asymptomatic patient or manageable symptoms for >6 months - manage as stable disease

Supportive management - indicated to all patients

● Provide regular physiotherapy to maintain range of motion and posture

● Refer patients for fall evaluation and counseling, patient education on self management
● Screen patients for osteoporosis
● Advise patients with severe osteoporosis or spinal fusion to avoid spinal manipulation
Active disease management (1st line → NSAIDS, 2nd line → TNF a inhibitors)

Medication Indication

NSAIDS ● 1st line treatment for patients without concurrent IBD or renal impairment
(Naproxen,
indomethacin)

TNF a inhibitors ● 1st line in patients with concurrent IBD or recurrent anterior uveitis
(Infliximab, ● 2nd line in patients with insufficient response to NSAIDs
Adalimumab, Can reactivate latent TB or hep B infection
Etanercept)
Cauda Equina
Syndrome
 Definition
● The collection of nerves at the end of the spinal cord is known as the
cauda equina, due to its resemblance to a horse's tail. The spinal
cord ends at the upper portion of the lumbar (lower back) spine. The
individual nerve roots at the end of the spinal cord that provide motor
and sensory function to the legs and the bladder continue along in the
spinal canal.
● The cauda equina is the continuation of these nerve roots in the
lumbar and sacral region. These nerves send and receive messages
to and from the lower limbs and pelvic organs.
● Cauda equina syndrome (CES) is caused by compression of the
lumbosacral nerve roots of the cauda equina.
● CES is a neurosurgical emergency, and delays in diagnosis and
treatment may lead to permanent disability.
 Causes of CES
Lumbar disc herniation Spinal canal tumor: primary / metastatic
● poor posture, strong rotational movement ● Primary: schwannoma, spinal meningioma
● Metastasis: thyroid, breast, lung, renal, prostate Ca

Lumbar spinal stenosis Inflammatory

● m/c cause thecal sac compression in elderly ● spinal arachnoiditis
● narrowing lumbar vertebral foramen ● chronic inflammatory demyelinating polyneuropathy (CIDP)
● congenital / acquired eg. in Ankylosing spondylitis ● sarcoidosis
(intervertebral disc ossification) ● ankylosing spondylitis

Trauma spine Infections

● vertebral fracture / subluxation (car crash/ gunshot) ● Spinal epidural abscess

Iatrogenic Spondylolisthesis
● spinal surgery (direct damage / post-op hematoma) ● displaced lumbar vertebrae (trauma/ surgery)
● epidural hematoma secondary to spinal anaesthesia
● Hematoma in postoperative period with early DVT
prophylaxis
Clinical manifestations

Common symptoms
● back pain (most common): may be initial presenting symptom alone
● unilateral or bilateral leg pain (2nd most common)
● saddle anesthesia : if present should initiate surgery
emergency protocol.
● bladder dysfunction: disruption of bladder contraction and sensation
leads to urinary retention and eventually to overflow incontinence ,
important to document presence of bladder dysfunction prior to
surgery
● unilateral or bilateral sensory changes in legs
● unilateral or bilateral motor weakness in legs
● sexual dysfunction (impotence in men)
● bowel dysfunction
 Types and classification of CES
Acute cauda equina syndrome
● Severe symptoms start suddenly. You’ll likely
need surgery within 24 to 48 hours.
Complete cauda equina syndrome
● Complete cauda equina syndrome causes urinary and/or
bowel retention or incontinence.
● It affects about 60% of people with cauda equina syndrome.
Chronic cauda equina syndrome
● long-lasting cauda equina syndrome.
● If permanent damage persists despite surgery.
Incomplete cauda equina syndrome
● This affects the other 40% of people with cauda equina
syndrome.
● Typical symptoms include loss of urgency or increased
urgency sensation in the bladder and bowels without retention
or incontinence.
Investigations
CES is a neurosurgical emergency
Aim to quickly confirm by MRI with subsequent emergency surgical decompression within 24-48hrs
1. Emergency MRI lumbar spine without contrast
● Gold standard 1st line investigation in suspected CES – confirm diagnosis
2. CT myelography
● study of choice if patient unable to undergo MRI (e.g. pacemaker, MRI-incompatible
implants)
● sagittal and axial reconstructions can reveal space-occupying lesion
● partial or complete blockage of contrast

Laboratory

1. CBC, ESR, CRP

● concern for infectious etiology (i.e. epidural abscess)
2. Urodynamic studies
● preoperative postvoid residual volumes (PVR) (recommended to be obtained prior to
decompression but not at delay of decompression)
● normal post-void residual volume is less than 50 to 100 mL, PVR values > 200 ml - 43%
probability CES
● postoperative post-void residual volume, assessment for return of bladder function
 Management
Emergency surgical decompression
Indications
● clinical symptoms of CES with imaging (MRI) to support diagnosis
Outcomes
● Improved outcomes in bowel and bladder function and resolution of motor and sensory deficits when
decompression performed within 48 hours of the onset of symptoms
● Residual bladder deficits may persist despite successful decompression
● Motor recovery may continue up to 1 year post-op
● Bladder function may continue to improve up to 16 months post-op
Treat the underlying cause
● Ex: antibiotics - in Epidural abscess
Prophylaxis
● VTE : graduated compression stockings/ intermittent pneumatic compression device
● Gastric ulcers: PPI (Omeprazole 20 mg OD) / H2 antagonist (Famotidine 40 mg OD) for 4wk
● Pressure ulcers: regular manual turning for pt on bed rest; if no bed rest encourage mobilize regularly
Physiotherapy
● To help regain strength after surgery
Brown Sequard
Syndrome
 Definition
● A rare neurological condition characterized by a ½ lesion in the spinal cord
- Hemisection
- Unilateral cord lesion
● Most common in cervical region
 Etiology
1. Traumatic injury
● Stab wound
● Blunt trauma
● Cervical vertebral fracture
● Cervical vertebral dislocation

2. Non-traumatic injury
● Cervical and thoracic herniation
● Spinal stenosis
● Tumors
● Epidural hematoma
● Spinal cord ischemia
● Spinal cord infarction
● Neurodegenerative diseases: multiple sclerosis
 Clinical Features
1. Ipsilateral findings
a. At the level of lesion
- Loss of sensory modalities
- Flacid paralysis
b. Below the lesion
- Spastic paraparesis

2. Contralateral findings
a. Below the lesion
- Loss of pain
- Loss of temperature
 Investigation
● Diagnosis is made on the basis of history and physical examination.
● Laboratory study is not necessary (useful in non-traumatic etiologies: infectious or
neoplastic causes)

1. X-Ray
- Traumatic causes: vertebral fracture and dislocation
2. MRI (Diagnostic)
- Identify structures involved
- Non-traumatic etiologies
3. CT
- When MRI contraindicated
- Findings: destruction of nerve tissue localised to one side of the spinal cord
 Management
1. Surgical therapy
- Stabilize and reduce spine
- Surgical decompression
2. Physical therapy
- starts in the acute care phase of treatment. Therapy goals include the
following:
● Maintaining strength in neurologically intact muscles
● Maintaining range of motion in joints
● Preventing skin breakdown by proper positioning and weight shifting
● Achieving early mobilization to increase tolerance of the upright position
● Providing emotional and educational support for the patient and his/her
family
Transverse
Myelitis
 Definition

Transverse myelitis is an acute inflammatory disorder that are characterized by acute or subacute
motor, sensory, and autonomic (bladder, bowel, and sexual) spinal cord dysfunction.

Epidemiology
● Bimodal distribution
● 10-19 years old ; 30-39 years old
 Etiology
● Idiopathic
● Para-infectious autoimmune inflammatory response (may follow viral infection or
immunization)
● Systemic inflammatory disorders (SLE,Sjogren’s,sarcoidosis)
● Infection (varicella zoster,EBV,HIV,tuberculosis,syphilis)
● Multiple sclerosis
● Vascular disorders (ischemic or hemorrhagic events affecting spinal cord)
 Clinical Features
Clinical features depend on the extent of spinal cord involvement as it varies among individuals

Symptoms and signs of transverse myelitis typically evolve over the course of hours to days and are usually
bilateral; however, unilateral or markedly asymmetric presentations can occur

1. Pain
● Severe neck or back pain initially
● May radiates down to the legs , arms or around torso
2. Motor
● Sudden onset of weakness or paralysis depending on the location of lesion
● Respiratory failure if involve high cervical lesion
3. Sensory
● Paresthesias (tingling or numbness) at the level of lesion
4. Dysfunction of autonomic nervous system
● Bowel and bladder dysfunction including urinary retention or incontinence
 Investigations
1. MRI of the entire spine
● To rule out presence of structural lesions
● IV gadolinium administration can enhance the intrinsic cord
lesion in acute phase of myelitis
● Hyperintense on T2-weighted images
2. Lumbar puncture w CSF analysis
● Pleocytosis
● Elevated IgG index
● Increase protein levels
3. Blood test
● Serological tests for infectious causes (HIV,VDRL,IGRA)
● Serum autoimmune antibody testing (antinuclear
antibodies,anti-aquaporin 4 antibodies)

T2 sagittal MRI image of the spine showing hyperintense signal at

the T6-T10 levels
Diagnostic Criteria

Adapted from Frohman EM, Wingerchuk DM. Clinical practice. Transverse

myelitis. N Engl J Med. 2010 Aug 5;363(6):564-72. doi: 10.1056/NEJMcp1001112.
 Management
1. Corticosteroids
● are the standard first-line treatment,high-dose intravenous regimens are typically used
(e.g,1000 mg of methylprednisolone daily, generally for 3 to 5 days).
● Oral regimens may be used in the case of patients with relatively mild episodes of myelitis
who do not require hospitalisation
2. Plasma exchange
● benefit patients who do not have a response to corticosteroids
● Hypotension, electrolyte imbalance, coagulopathy, thrombocytopenia, catheter-related
thrombosis, and infections are recognized complications of plasma exchange.
3. Supportive treatment
● Urinary catheter insertion for urinary incontinence
● Intubation for respiratory failure
● Physical therapy to maintain muscle strength and function
Thank You!