Acute Spinal Cord Syndromes: Pathology, Etiology, and Diagnosis

Transverse Myelitis. This syndrome of acute segmental spinal cord dysfunction results from inflammatory disease. Initial symptoms include limb weakness, loss of all sensation, and sphincter involvement. Nerve root pain and back pain are common. Early in the course, muscle stretch reflexes are either depressed or absent; spasticity and hyperreflexia subsequently develop.

The disorder may have an autoimmune basis. It occurs in multiple sclerosis, sometimes as the presenting feature, in neuromyelitis optica (a disorder limited to the optic nerve and spinal cord and characterized by the presence of specific circulating antibodies against the aquaporin-4 antigen), and in various connective tissue diseases. In many instances, it is idiopathic. The diagnosis is one of exclusion in a patient who has a complete acute spinal cord syndrome. Involvement of all sensory modalities in acute transverse myelitis differentiates this disorder from spinal cord infarction, in which dissociated sensory loss is present. Spinal MRI shows gadolinium-enhancing signal abnormality, with involvement over one or more segments of the spinal cord. In neuromyelitis optica, these changes extend over at least three or more vertebral segments.

Treatment is of the underlying disorder. Patients with idiopathic transverse myelitis often make a partial recovery with time but may be left with a significant residual disability. Recovery is unlikely if improvement fails to occur within about 3 months.

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