Does your spine feel like it's going to lose its strength? Let's talk about Transverse Myelitis (TM)!

Have you ever thought about a condition where you suddenly lose control of your legs, feel numb in some parts of your body, or have difficulty controlling your urine and stool? Although these are a little scary, sometimes these symptoms can occur due to an inflammation of our spinal cord , that is, the nerve fibers that run through the spine. That is the condition we are going to talk about today, called Transverse Myelitis (TM) . This is a relatively rare neurological condition.

What exactly is transverse myelitis (TM)?

Simply put, transverse myelitis (TM) is inflammation of your spinal cord , the main nerve fiber that runs down your spine. Think of it this way: it carries messages from your brain to the rest of your body. It's like a telephone cable.

This inflammation causes damage to the protective covering around the nerve cells in the spinal cord, called the myelin sheath . It's like the plastic covering on the top of a cable is damaged. What happens then? Messages from the brain don't get through properly. This causes problems like loss of sensation, numbness, and loss of bladder control.

This condition, called TM, can affect the spinal cord anywhere along the spine. "Myelitis" refers to inflammation of the spinal cord. "Transverse" refers to the pattern of changes in sensation and function. It can feel like a belt is tied around the body, with sensory changes below the belt.

Most of the time, TM is a condition that develops once and then either gets better or stays the same.

Who is most affected by this condition, transverse myelitis (TM)?

In fact, this condition called transverse myelitis (TM) can develop at any age, in anyone. However, when you look at the data, you can see that it develops slightly more in young people between the ages of 10 and 19 and in people between the ages of 30 and 39. Surprisingly, about 25% of those who develop it are children. However, this is not a genetic disease that is passed down through generations. Therefore, there is no need to worry that others will also develop it just because someone in the family had it.

So how common is this situation?

Transverse myelitis (TM) is a very rare condition . Just think, even in a country like America, only one to eight new cases are reported per million per year. That means about 1400 new cases per year. So it is not something that is seen very often in Sri Lanka either.

What are the symptoms of transverse myelitis (TM)?

Transverse myelitis (TM) symptoms can sometimes appear suddenly , within a few hours or days. In other people, these symptoms may gradually develop over a period of one to four weeks. However, it is important to be aware that TM symptoms can worsen quickly .

Symptoms usually appear below the point where your spinal cord is damaged. For example, if the damage is in the middle of your back, below your arms, your legs and bladder/bowel control will be affected. Your arms may not be affected.

TM often affects both sides of the body. However, it can sometimes affect only one side. This type of unilateral weakness is more common in people with diseases such as Multiple Sclerosis (MS) .

Imagine, at the most severe stage of TM, 50% of patients lose all movement in both legs. Between 80% and 94% experience numbness or unusual sensations like pins and needles. Also, almost everyone experiences some degree of urinary discomfort.

For some people, these symptoms will lessen or disappear completely with treatment, but for others, permanent complications may develop.

There are several main symptom groups that can be seen in TM:

• Unusual sensations
• Pain
• Bowel and urinary problems
• Muscle and movement problems
• Sexual function problems
• Other symptoms

Unusual sensations

Depending on where your spinal cord is damaged due to TM, you may experience abnormal sensations (also known as ``Paresthesia'' in medical terms) in certain parts of your body, such as:

• Numbness
• Feeling like pricking (Prickling)
• Burning
• Hypersensitivity to touch or temperature
• Less sensation of heat/cold

Pain

TM can cause pain in certain parts of the body. This pain can be sharp or dull . Sometimes this pain can radiate down the arms and/or legs, or it can feel like it's coming from the chest and abdomen.

Stool and urinary symptoms

TM can cause urinary and bowel problems such as:

• Constipation
• Not emptying the bladder completely when urinating (`(Urinary retention)`)
• Urinary control problems, for example, having to urinate frequently (`(Urge incontinence)`)
• Inability to control urination (`(Urinary incontinence)`)

Muscle and movement problems

People with TM may experience weakness in their legs, which can progress quickly. If the inflammation has affected the spinal cord in some way, it can also affect the arms.

You can see these symptoms:

• Loss of balance in the body
• Difficulty walking (stumbling, dragging legs)
• Muscle spasms
• Partial loss of muscle function, sometimes even leading to paralysis .

Sexual function problems

People with TM may have difficulty achieving orgasm. In addition, men may experience erectile dysfunction.

Other symptoms

In addition, TM may also cause the following symptoms:

• Appetite
• Headache (headache)
• Fever
• Breathing difficulties

What causes transverse myelitis (TM)?

Generally speaking, the main cause of transverse myelitis (TM) is inflammation of the spinal cord.

Imagine, when something harmful enters our body, such as viruses, bacteria, toxic chemicals, or when we suffer an injury, our immune system activates.

The immune system releases inflammatory cells and other substances (cytokines) that stimulate other inflammatory cells. These cells are what trigger an inflammatory response that helps to fight off things like bacteria and start healing wounds. While this inflammatory response is often necessary, sometimes our immune system can attack healthy tissue for no reason. Or, the response to that foreign substance can become too strong and damage the body's tissues.

That's what happens in TM. The inflammation damages the myelin sheath that surrounds the nerve cells in the spinal cord.

There are several possible causes of inflammation that lead to TM. These causes can be divided into several main categories:

• Cases where the exact cause is unknown (`(Idiopathic)`)
• Inflammation caused by an infection
• Autoimmune diseases that affect the entire body (`(Systemic inflammatory autoimmune diseases)`)
• Central nervous system diseases (`(Central nervous system diseases)`)

Idiopathic transverse myelitis

``(Idiopathic) TM`` is when no specific cause can be found. Most TM patients fall into this category. Scientists think it happens because our own immune system reacts abnormally and excessively against the spinal cord, causing inflammation and tissue damage. But the exact cause, or trigger, is still unknown.

Infections that can cause transverse myelitis

There are several bacterial, viral, parasitic, and fungal infections that can cause TM. Some of them are:

• Enteroviruses (These are very common viruses, but most often cause mild illness)
• `West Nile virus`
• Herpes viruses, for example genital herpes
• `HIV`
• Varicella-zoster (the virus that causes chickenpox and herpes zoster)
• `Human T-cell leukemia virus type 1 (HTLV-1)`
• `Zika virus`
• Neuroborreliosis (Lyme disease)
• `Syphilis`
• `Tuberculosis`
• Bacterial skin infections
• `Mycoplasma bacterial pneumonia`

Often, it is difficult for doctors to say for sure whether TM is caused by a viral infection itself, or by the immune system's response to an infection.

Autoimmune diseases that affect the entire body, associated with transverse myelitis

Some autoimmune diseases associated with TM are:

• `Ankylosing spondylitis`
• `Antiphospholipid syndrome`
• `Behçet's disease`
• `Mixed connective tissue disease`
• `Rheumatoid arthritis`
• `Sarcoidosis`
• `Scleroderma`
• `Sjogren's syndrome`
• `Systemic lupus erythematosus (SLE)`

Central nervous system diseases that can cause transverse myelitis

Autoimmune diseases of the central nervous system that can cause TM include:

• `Multiple sclerosis (MS)`
• Neuromyelitis optica spectrum disorder (NMOSD) - This is also called Devic's disease .
• `Myelin oligodendrocyte glycoprotein antibody disorders (MOGAD)`
• `Acute disseminated encephalomyelitis`

For some people, transverse myelitis may be the first symptom of an autoimmune disease of the central nervous system, such as multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD) .

"Partial" myelitis, which affects only one side of the body, is common in MS.

If someone with NMOSD develops myelitis, it is more likely to be "complete," meaning it causes severe paralysis and numbness on both sides of the body. Myelitis in people with NMOSD can be more severe and less likely to heal than in people with MS.

Can vaccines cause transverse myelitis (TM)?

Very rarely, people have reported developing transverse myelitis within two days to three months of receiving a vaccine. Scientists are still not sure why this happens, but one theory is that some people’s immune systems may be triggered by the vaccine and start an autoimmune process. But here’s an important point: Vaccines have been shown to be safe in extensive research. This association with TM could be a coincidence or a very rare complication.

How is transverse myelitis (TM) diagnosed?

If you have symptoms of transverse myelitis (TM), your doctor will review your medical history and perform a physical examination.

If these tests suggest a problem with the spinal cord, further tests will be ordered. Why is that?

• Make sure that the spinal cord is not affected by something other than inflammation, for example , a spinal tumor , a herniated disc , or compression caused by an abscess .
• Confirm that there is abnormal inflammation inside the spinal cord.
• If possible, find out what is causing this unusual inflammation.

Doctors conclude that TM is present when spinal symptoms have been present for several days and no other cause for the spinal cord problem can be found on an MRI (Magnetic Resonance Imaging) scan or other test.

What tests are done to diagnose transverse myelitis?

Your doctor may order tests like these to diagnose TMJ and its cause:

• MRI (Magnetic Resonance Imaging) scan of the entire spine: An MRI is a painless test. It uses a large magnet, radio waves, and a computer to make clear pictures of organs and structures inside the body. You may need to have two MRI scans of your spine - one with a special substance called gadolinium contrast and one without. This will help your doctor distinguish between compressive and non-compressive lesions.
• Brain MRI scan: Your doctor may also order an MRI scan of your brain (with or without gadolinium contrast) to look for lesions in your brain. A brain MRI can give clues about other underlying causes, especially multiple sclerosis (MS) .
• Lumbar puncture (also known as spinal tap): In this procedure, the doctor inserts a needle into your lower back and takes a sample of cerebrospinal fluid (CSF) . CSF is the clear fluid that surrounds your brain and spinal cord. The CSF sample is then tested in a lab to see if there are too many white blood cells, an elevated IgG index, or oligoclonal IgG bands in the CSF. These inflammatory markers are commonly seen in TM.
• Blood tests: The doctor will likely order several blood tests to check for infections and immune system-related causes that could be causing TM.

Depending on the possible cause of TM, additional tests may be done. If none of these tests can find a specific cause, it is assumed that you have idiopathic transverse myelitis.

How is transverse myelitis (TM) treated?

There are several main goals in treating transverse myelitis (TM):

• If possible, treat the cause of TM (e.g., an infection).
• Reducing inflammation in your spinal cord.
• Relieve or reduce symptoms such as pain.
• Managing long-term complications.

When treating TM, short-term treatment is provided for the inflammation and its cause, as well as long-term management of the complications that may arise from TM.

Short-term treatment for transverse myelitis

The first-line treatment for transverse myelitis is intravenous (IV) glucocorticoids . If your doctor suspects TM, they will start high-dose intravenous (IV) glucocorticoids as soon as possible.

Glucocorticoids are a type of steroid hormone that belongs to a class of drugs called corticosteroids . These are powerful drugs that fight inflammation and work with your immune system. In transverse myelitis, glucocorticoids help reduce inflammation in the spinal cord. You may need to take these medications for three to five days, or longer.

Additional treatments for TM may include:

• Plasma exchange therapy (Plasmapheresis): This is a procedure that "cleans" your blood. In this treatment, your doctor removes the liquid part of your blood (plasma) and replaces it with plasma from a healthy person or a plasma substitute. This removes antibodies and other proteins thought to be causing the inflammatory reaction. This treatment may help people with TM who have acute central nervous system demyelinating disease that has not responded to glucocorticoid treatment.
• Intravenous Immune Globulin (IVIG): This is a treatment made from antibodies. It is given through a vein. This treatment can bind to the antibodies thought to cause TM and reduce the inflammatory response in the spinal cord.
• Immunosuppressant drugs: For TM patients who have not responded well to glucocorticoids, plasma exchange, or IVIG treatments, doctors use drugs such as rituximab and cyclophosphamide . These drugs have immunosuppressive properties.
• Medications to manage other symptoms: Your doctor may prescribe other medications to manage symptoms such as pain, muscle spasms, urinary problems, or depression .

Long-term management for transverse myelitis

After you have received treatment for an acute episode of transverse myelitis (TM), you will need rehabilitative care to improve your functional abilities and prevent secondary complications that may occur due to TM.

Although rehabilitation cannot reverse the physical damage caused by TM, it can help people with severe paralysis to be as independent as possible and live as good a quality of life as possible.

Long-term management of transverse myelitis may include:

• Urinary function management: People with TM often experience urinary problems. Solutions include timed voiding, medications, condom catheters, clean intermittent catheterization, and padded underwear.
• Managing bowel function: Constipation is a common problem for people with TM. It can be managed with special diets, the strategic use of stool softeners and dietary fiber, and rectal stimulation.
• Treatment of sexual dysfunction: The most commonly prescribed erectile dysfunction drugs are sildenafil (`sildenafil` - Viagra®) , vardenafil (`vardenafil` - Levitra®) , and tadalafil (`tadalafil` - Cialis®) . Although these drugs are less effective in women, they have also been shown to improve sexual function.
• Preventing skin cracks and pressure injuries (bedsores): If your skin is under pressure for a significant period of time, it can become cracked. To prevent this, you should change your position at least every 15 minutes. Wheelchairs with power recline or tilt-in-space mechanisms that can change the way your weight is distributed can also help. There are various types of wheelchair cushions that can reduce the pressure that occurs when you sit.
• Managing muscle spasticity: Stretching practices and the use of braces and splints can help manage or prevent muscle spasticity. Strength-building exercises and muscle relaxants may also help.
• Mobility management: Physical therapists can provide exercises to improve mobility. Mobility aids such as canes, walkers, crutches, and wheelchairs can help you become more independent.
• Managing daily activities: People with TM can find it very difficult to perform daily tasks such as dressing, bathing, cleaning themselves, and eating. Discussions with adaptive equipment and occupational therapists can help find ways to make these tasks easier and more effective.
• Pain Management: It is common to experience some pain after TMJ. Muscle pain can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetaminophen (Tylenol®) , naproxen (Naprosyn®, Alleve® or Motrin®) , or heat and cold therapy. Nerve pain can be more challenging to treat. Some antidepressants or anticonvulsants may help.
• Mental health management: Depression is common among people with TM. If you have symptoms of depression or other mental health conditions, it is important to see a therapist or psychologist. Medication can also help treat depression.

Can transverse myelitis be cured?

Yes, transverse myelitis (TM) can be cured. However, the recovery process varies from person to person.

Healing from TM may be complete, partial, or nonexistent. Healing usually begins within one to three months of the first treatment. Most people recover from TM within three months. For some, it can take months or even years to heal.

Some people recover from arthritis with little or no long-term complications, while others recover with moderate or severe disability.

People who may have a reduced chance of recovery are:

• Those with rapid onset of symptoms.
• Those whose symptoms have not improved within the first three to six months of treatment and recovery.

What is the prognosis of transverse myelitis (TM)?

The outlook/prognosis for people with transverse myelitis varies:

• Approximately 33% of people recover with little or no long-term complications.
• Approximately 33% of people recover with moderate disabilities, such as bowel problems and difficulty walking.
• Approximately 33% of people recover with permanent disabilities, such as paralysis.

Most people only get transverse myelitis once. However, some people with an underlying condition, such as multiple sclerosis (MS), can have it come back (`(recur)`). If you have TM affecting only one side of your body, you may be more likely to develop MS in the future.

How do I take care of myself, or someone with transverse myelitis (TM)?

If you have transverse myelitis, it's important to make sure you're getting the right medical care to prevent or treat TM complications, such as bowel and bladder problems and muscle stiffness. You may also want to consider joining a support group to meet others who can relate to your experiences. It's also important to seek help from a therapist or psychologist if you're feeling depressed or anxious because of TM.

If you are caring for someone with TM, it is important that you advocate for them to make sure they receive the best medical care, mobility devices, and therapies that will help them become more independent.

It can be difficult for you and your family to adjust to the mental and physical effects of TM. In the early stages of recovery, it is essential to educate your family and develop a plan to deal with the challenges to independence.

When should I see a doctor about transverse myelitis (TM)?

If you experience symptoms of transverse myelitis, such as sudden and severe muscle weakness and pain, go to the nearest hospital as soon as possible .

If you have been diagnosed with TM, you should meet with your medical team regularly to receive treatment and monitor for possible complications.

Understanding your or your loved one's diagnosis of transverse myelitis (TM) can be overwhelming. But your medical team will provide you with a strong treatment and rehabilitation plan tailored to your or your loved one's symptoms. It's important to make sure you get the love and support you need throughout your recovery journey, and to stay alert to any new symptoms that may arise.

The most important things to keep in mind (Take-Home Message)

Okay, so now you have a better idea of ​​what transverse myelitis (TM) is. Remember, even though it is a rare condition, it is very important to seek medical advice immediately if you experience symptoms.

The main thing is, if you experience sudden weakness, numbness, or urinary control problems, don't ignore it. See a doctor immediately.

TM can have many causes, and sometimes no cause can be found. However, with proper treatment and rehabilitation, most people can achieve some level of recovery. Some people recover completely.

When living with a condition like this, it's important to stay mentally strong and to have the support of your family and doctors. So, don't be afraid to talk to your doctor about any concerns you may have.

` Transverse myelitis, TM, spinal cord, neuropathy, inflammation, myelin, symptoms, treatment