While all patients are treated as individuals and each case is different, the following are possible transverse myelitis treatment that patients may encounter in the management of acute TM.
Several therapies target the acute signs and symptoms of transverse myelitis:
- Intravenous steroids. You’ll probably receive steroids through a vein in your arm over the course of several days. Steroids help reduce the inflammation in your spinal column.
- Plasma exchange therapy. People who don’t respond to intravenous steroids may need plasma exchange therapy. This involves removing the straw-colored fluid in which blood cells are suspended (plasma) and replacing the plasma with special fluids.
It’s not certain how this therapy helps people with transverse myelitis, but it may be that plasma exchange removes inflammatory antibodies.
- Antiviral medication. Some people who have a viral infection of the spinal cord may be treated with medications to treat the virus.
- Pain medication. Chronic pain is a common complication of transverse myelitis. Medications that may lessen muscle pain include common pain relievers, such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve.)
Nerve pain may be treated with antidepressant drugs, such as sertraline (Zoloft), and anticonvulsant drugs, such as gabapentin (Neurontin, Gralise) or pregabalin (Lyrica).
Medications to treat other complications. Your doctor may prescribe other medications as needed to treat problems such as muscle spasticity, urinary or bowel dysfunction, depression, or other complications associated with transverse myelitis.
Medications to prevent recurrent attacks of transverse myelitis. People who have antibodies associated with neuromyelitis optica need ongoing medications, such as corticosteroids and/or immunosuppressants, to reduce their chances of more transverse myelitis attacks or developing optic neuritis.
Other transverse myelitis treatment:
For those patients who do not respond to either steroids or PLEX who continue to exhibit active inflammation in the spinal cord, other forms of immune-based interventions may be required. The use of immunosupressants or immunomodulatory agents may be required. One of those approaches may include the use of intravenous cyclophosphamide (a chemotherapy drug often used for lymphomas or leukemia). Patients who initially presented with aggressive forms of myelitis or those that are particularly refractory to treatment with steroids and/or PLEX may benefit from aggressive immunosupression with cyclophosphamide. It is very important that an experienced oncology team be involved in the administration of this drug, and patients should be monitored carefully as potential complications may arise from immunosuppression. As with all medications, risks versus benefits of aggressive immunosuppression need to be considered and discussed with your doctor.
The use of other immune-based therapies such as B-cell modulators, anti-TNFα inhibitors or IV immunoglobulins (IVIG) have not been tested and their use in the management of acute or subacute TM is not supported.
Transverse myelitis may be idiopathic in nature, such that a definite cause is not identified. In these cases, it is rare for patients to have a recurrence. For others, TM may be a manifestation of another disorder, such as neuromyelitis optica, multiple sclerosis, sarcoidosis, lupus, to name a few. In these cases, ongoing treatment with medications that modulate or suppress your immune system may be necessary. Either way, aggressive rehabilitation and long-term symptom management are an integral part of the healthcare plan.
Additional therapies focus on long-term recovery and care:
- Physical therapy. This helps improve strength and coordination. Your physical therapist can teach you how to use any needed assistive devices, such as a wheelchair, canes or braces.
- Occupational therapy. This helps people with transverse myelitis learn new ways of performing day-to-day activities, such as bathing, preparing a meal and housecleaning.
- Psychotherapy. A psychotherapist can use talk therapy to treat anxiety, depression, sexual dysfunction, and other emotional or behavioral issues from coping with transverse myelitis.
Individuals with transverse myelitis treatment should be educated about the effect of TM on mood regulation and routinely screened for the development of symptoms consistent with clinical depression. Warning signs that should prompt a complete evaluation for depression include failure to progress with rehabilitation and self-care, worsening fixed low mood, pervasive decreased interest, and/or social and professional withdrawal. A preoccupation with death or suicidal thoughts constitutes a true psychiatric emergency and should lead to prompt evaluation and treatment.
Depression in TM is similar to the other neurologic symptoms patients endure, which are mediated by the effects of the immune system on the brain. Depression is remarkably prevalent in TM, occurring in up to 25% of those diagnosed at any given time, and is largely independent of the patient’s degree of physical disability. Depression is not due to personal weakness or the inability to “cope.” It can have devastating consequences; not only can depression worsen physical disability (such as fatigue, pain, and decreased concentration) but it can have lethal consequences. Suicide is the leading cause of death in TM. Despite the severity of the clinical presentation of depression in TM, there is a very robust response to combined aggressive psychopharmacologic and psychotherapeutic interventions. With appropriate recognition and treatment of TM depression, complete symptom remission is standard.
After the inflammation has begun to resolve after transverse myelitis treatment and the person is medically stable, the next course of treatment for a person who has an inflammatory attack in their spinal cord (ADEM, MOG-Ab disease, NMOSD, MS or TM) involves intensive rehabilitation therapy. Centers devoted to spinal cord injury and disease or stroke offer comprehensive rehabilitation programs for people who have suffered significant spinal cord deficits from the inflammatory attack. Children and adults who have experienced significant muscle weakness or paralysis should be admitted to a specialized rehabilitation hospital, and the program should include an aggressive physical and rehabilitative therapy regimen (as opposed to an exclusive emphasis on independence training).