Transverse myelitis represents an uncommon neurological condition. It arises from inflammation, which is swelling, within the spinal cord. The resulting scars or lesions disrupt the transmission of signals between the nerves within the spinal cord and the rest of the body.

The term ‘Transverse’ indicates that the inflammation spans across the width of the spinal cord. It’s important to note that this term is sometimes used even when the inflammation only affects a portion of the spinal cord’s width.

Signs and Symptoms

• Muscle weakness in the legs, and sometimes the arms: This can range from mild weakness to complete loss of strength in the affected limbs.

• Mobility problems: Difficulty with movement, coordination, and balance can occur.

• Unusual sensations and numbness: These can include tingling, prickling, burning, coldness, or a loss of feeling.

• Bladder problems: Issues may involve difficulty starting urination, inability to empty the bladder completely, frequent urination, or incontinence.

• Bowel problems: This can manifest as constipation, difficulty controlling bowel movements (incontinence), or changes in bowel habits.

• Sexual problems: These can include erectile dysfunction in men, difficulty achieving orgasm in women, or reduced libido.

• Pain: Pain can be localized or widespread, and may be sharp, burning, or aching.

Types of Transverse Myelitis

There are primarily three categories of Transverse Myelitis, which are distinguished by the speed at which symptoms develop:

1. Acute Transverse Myelitis (ATM): This is the most frequently encountered form and is characterized by a rapid onset of symptoms, typically developing over hours to a few days.

2. Subacute Transverse Myelitis (STM): In this type, symptoms tend to progress more gradually, developing over several weeks to months.

3. Chronic Transverse Myelitis (CTM): This refers to cases where the symptoms persist for an extended period, specifically six months or longer.

Causes of transverse myelitis

Autoimmune disease

In some instances, transverse myelitis is triggered by an autoimmune reaction. In autoimmune disorders, the body’s immune system mistakenly identifies its own tissues as foreign invaders and attacks them. This misdirected attack leads to inflammation, subsequently damaging the myelin sheath, which is the protective covering around nerve fibers. Examples of autoimmune diseases associated with transverse myelitis include:

• Neuromyelitis optica (NMO): An autoimmune disease that primarily affects the optic nerves and spinal cord.

• Myelin oligodendrocyte glycoprotein antibody (MOG) associated myelitis: Another autoimmune condition targeting the myelin sheath in the central nervous system.

• Sarcoidosis: A disease involving the growth of inflammatory cells in various parts of the body.

• Sjögren’s syndrome: An autoimmune disorder that affects moisture-producing glands.

• Lupus: A chronic autoimmune disease that can affect many different body systems.

Viral infection

Transverse myelitis can sometimes develop indirectly following a viral infection. The body’s immune response to the virus can sometimes mistakenly attack the spinal cord. Common viral infections linked to transverse myelitis include:

• Echovirus: A type of enterovirus that can cause various illnesses.

• Enterovirus: A group of viruses that can cause a range of symptoms, including respiratory illness and neurological problems.

• Epstein-Barr virus (EBV): The virus that causes mononucleosis.

• Hepatitis A: A viral liver infection.

• Herpes simplex virus (HSV): A common virus that can cause sores and other infections.

• Human immunodeficiency virus (HIV): The virus that attacks the immune system.

• Rubella: Also known as German measles.

• Influenza (flu): A common respiratory infection.

• Varicella zoster virus: The virus responsible for chickenpox and shingles.

Bacterial infection

Certain bacterial infections, such as syphilis, can also be a precursor to transverse myelitis.

Cancer

In rare instances, certain cancers may elicit an unusual immune response that can ultimately lead to transverse myelitis. This is often referred to as a paraneoplastic syndrome.

Diagnosing transverse myelitis

To confirm a diagnosis of transverse myelitis, several diagnostic tests may be necessary:

• Neurological examination: A thorough assessment of the patient’s nervous system function, including reflexes, muscle strength, sensation, and coordination.

• Magnetic resonance imaging (MRI) scan: A powerful imaging technique that uses magnetic fields and radio waves to create detailed images of the spinal cord, helping to visualize inflammation or lesions.

• Lumbar puncture: Also known as a spinal tap, this procedure involves collecting a sample of cerebrospinal fluid (CSF) to analyze for signs of inflammation, infection, or abnormal antibodies.

• Blood tests: Various blood tests can help identify underlying causes such as autoimmune diseases or infections.

Other diagnostic tools may include CT scans, which can provide cross-sectional images of the spinal cord and surrounding structures.

Management of Transverse Myelitis

The approach to managing transverse myelitis varies. In some cases, the condition may improve spontaneously without specific treatment. However, many patients require interventions to address their symptoms, reduce inflammation, or treat the underlying cause.

Symptomatic Treatment

Various therapies are available to manage the specific symptoms of transverse myelitis.

Muscle weakness

• Physiotherapy: Exercises and techniques designed to improve muscle strength, coordination, and reduce muscle spasms and stiffness. Stretching exercises are particularly helpful for improving restricted movement.

• Muscle relaxants: For more severe muscle spasms, medications such as baclofen, gabapentin, or tizanidine may be prescribed to help relax the muscles. It’s important to discuss potential side effects, such as dizziness, weakness, nausea, and diarrhea, with a healthcare professional to determine the most suitable option.

Mobility problems

Mobility difficulties often stem from muscle spasms, spasticity, muscle weakness, or balance issues. Management strategies include:

• Exercise programme supervised by a physiotherapist: A tailored program to improve strength, balance, and coordination.

• Mobility aids: Devices such as walking sticks or wheelchairs to assist with movement.

• Home adaptations: Modifications to the home environment, such as stairlifts or railings, to improve accessibility and safety.

• Occupational therapist assessment: An evaluation of the home environment to suggest appropriate adaptations to facilitate daily living.

Treatment of the inflammation (swelling)

• Steroids: These medications can be effective in reducing inflammation associated with some types of transverse myelitis. They are typically administered for a short duration to minimize potential side effects, which can include reflux and stomach irritation, increased susceptibility to infection, mood swings, and sleep disturbances.

Bladder problems

• Medication: Drugs may be prescribed to manage an overactive bladder or frequent nighttime urination.

• Continence nurse or physiotherapist advice: Guidance and techniques to help with difficulty emptying the bladder.

• Hand-held external stimulators: Devices that can help some individuals initiate urination or empty the bladder.

• Catheter: A thin tube inserted into the bladder to drain urine. Patients may be taught intermittent self-catheterization (ISC) to manage bladder emptying. In more complex cases, a long-term catheter may be necessary.

Bowel problems

• Dietary changes or laxatives: For mild to moderate constipation.

• Suppositories or enemas: May be necessary for more severe constipation. An enema involves flushing liquid medication through the rectum and large bowel to soften and remove stool.

• Anti-diarrhea medication or pelvic floor exercises: May be helpful for bowel incontinence.

Sexual problems

• Relationship counselling or sex therapy: Can provide support and strategies for addressing decreased libido or difficulty reaching orgasm.

• Medication for erectile dysfunction: Drugs to increase blood flow to the penis may be prescribed for men experiencing difficulties with erections.

Musculoskeletal pain

• Physiotherapy: Exercises and advice on posture and seating to alleviate pain.

• Painkillers: May be prescribed for more severe pain.

• Transcutaneous electrical nerve stimulation (TENS) machine: A device that uses electrical impulses to stimulate nerves and reduce pain.

Neuropathic pain

• Neuropathic painkillers: Medications specifically designed to treat pain caused by nerve damage. Neuropathic pain is often described as sharp, stabbing, or burning, and may involve extreme skin sensitivity.

Complications of Transverse Myelitis

Transverse Myelitis can lead to several potential long-term issues:

• Bladder or bowel dysfunction: Persistent problems with bladder or bowel control.

• Sexual dysfunction: Ongoing difficulties with sexual function.

• Chronic pain: Persistent pain that can significantly impact quality of life.

• Paralysis: Loss of muscle function, which can be partial or complete.

• Respiratory failure: Weakness of the respiratory muscles, potentially requiring breathing support.

Nursing Diagnosis for Transverse Myelitis

• Impaired physical mobility related to muscle weakness, spasticity, or paralysis: Difficulty with movement due to muscle-related issues.

• Risk for impaired skin integrity related to prolonged bed rest, altered sensation, or pressure ulcers: Increased vulnerability to skin damage due to immobility or sensory loss.

• Ineffective airway clearance related to respiratory muscle weakness, paralysis, or impaired cough reflex: Difficulty clearing secretions from the airway due to weakened respiratory muscles.

• Urinary incontinence or retention related to bladder dysfunction: Problems with bladder control or emptying.

• Bowel incontinence or constipation related to bowel dysfunction: Issues with bowel control or infrequent bowel movements.

• Risk for infection related to impaired immune function or catheterization: Increased susceptibility to infections due to a weakened immune system or the use of catheters.

• Chronic pain related to nerve damage or altered sensation: Persistent pain stemming from nerve damage.