Synopsis
Approach acute spinal-cord inflammation as a time-critical syndrome: localise the lesion, exclude compression and vascular disease, identify its cause and protect respiratory, bladder and mobility function.
- Transverse myelitis describes an inflammatory spinal-cord syndrome, not a final aetiological diagnosis; it may be idiopathic, post-infectious or part of MS, NMOSD, MOGAD, systemic autoimmunity, infection or malignancy.
- Typical deficits evolve over hours to days and combine bilateral motor, sensory and autonomic dysfunction attributable to a spinal level, although asymmetry is common early.
- Urgent MRI of the whole spine with contrast is required to exclude compression, epidural infection, tumour, vascular malformation and other structural emergencies before immunotherapy is assumed appropriate.
- A deficit maximal within minutes suggests spinal-cord infarction; a progressive course beyond several weeks raises a compressive, neoplastic, dural arteriovenous fistula, metabolic or degenerative alternative.
- Lesions spanning three or more vertebral segments suggest NMOSD, MOGAD, sarcoidosis or other systemic inflammation more than typical MS, but length is a clue rather than a diagnosis.
- MRI brain and serum AQP4-IgG and MOG-IgG help predict recurrence and determine whether long-term disease-specific treatment is needed.
- High-dose intravenous methylprednisolone is common first-line attack therapy after infection and compression are considered; severe steroid-incomplete disease should prompt early plasma-exchange discussion.
- Bladder overdistension, constipation, venous thromboembolism, pressure injury, neuropathic pain, spasticity and respiratory decline require active treatment from admission.
- Neurological recovery can continue for months, so coordinated physiotherapy, occupational therapy, rehabilitation medicine, continence care and psychological support are core treatment.
- Do not diagnose relapse from symptoms alone when infection, fever, pain, fatigue or an established cord scar could be causing pseudo-worsening.
Key red flags
Weakness and sensory symptoms progress over hours or days, with a band-like truncal boundary and new bladder, bowel or sexual dysfunction. Bilateral findings below one anatomical level are strongly localising.
Arm involvement, weak cough, breathlessness, reduced chest expansion or bulbar symptoms accompany a cervical lesion. Serial respiratory observations and critical-care input may be required before oxygen saturation falls.
Severe local back pain, vertebral tenderness, fever, malignancy, immunosuppression, anticoagulation or recent procedure raises epidural abscess, malignant compression or haematoma and prioritises emergency imaging and surgical pathways.
A maximal deficit within minutes, often with acute back pain and disproportionate loss of pain and temperature, favours spinal-cord infarction over immune myelitis even if early MRI is unrevealing.
Guillain-Barre syndrome can cause ascending weakness and areflexia but does not usually create a clear truncal sensory level or an intrinsic cord lesion; cauda-equina disease produces a different root and sphincter pattern.
Investigation priorities
Confirm intramedullary disease and immediately identify compression, abscess, haemorrhage, tumour or a vascular structural lesion.
Management branches
An acute or subacute bilateral sensorimotor syndrome with autonomic disturbance is identified.
- Perform ABCDE, document sacral and segmental neurology, check respiratory mechanics for cervical disease, scan the bladder and use the emergency spinal-compression pathway when red flags are present.
- Obtain urgent contrast MRI of the whole spine, involving spinal surgery, oncology or infection teams immediately if compression, abscess, haemorrhage or instability appears.
- After structural emergencies are excluded, acquire serum and appropriate CSF samples promptly and agree empiric antiviral or antimicrobial cover when infection remains plausible.
- Start pressure-area care, thromboprophylaxis when safe, catheterisation for significant retention and early rehabilitation assessment on the day of admission.