Transverse Myelitis

Functional medicine practitioners are often consulted for autoimmune diseases, for a variety of reasons, but I would argue most often because they aren't getting the attention they deserve within conventional medicine. The healthcare system is not efficient, particularly with regards to chronic disease. The average visit with a clinician is about six minutes, largely because patients have to move through the clinic fast enough that the practitioner can bill sufficiently to keep the doors open. I can talk on this for days, but what this means, is disorders such as transverse myelitis, which can be a bit vague in its presentation and particularly in its etiology, may not get the attention they deserve and ultimately, outcomes worsen simply because of a broken system.

Transverse myelitis (TM) is a neurological disorder caused by inflammation of the spinal cord (Salas et al., 2024). There are any number of underlying causes, infection being most common, but conventional medicine tends to treat the symptoms and not really dig deeper into the why, but in scenarios such as this, treating the why is the entire point. We must resolve the issue if we want resolution. This would be like stepping on a tack and because the patient complains of foot pain, we just offer Motrin, but don't look at the underlying cause so the tack remains. In the scenario of spinal cord inflammation, the longer this remains an issue, the greater the damage to the myelin sheath, or the protective material surrounding the nerve cell fibers in the spinal cord.

The site of inflammation in the back is how the symptoms or areas of the body that are impacted are determined. Typically the body is affected from the site of the damage and below. Most often, unfortunately, this occurs in the nerves of the upper back or the thoracic region (Salas et al., 2024), but "transverse" refers to the pattern of symptoms, meaning individuals typically describe a band-like sensation across the trunk of their body and also, sensory symptoms and weakness below that area. It's rare that symptoms impact three or more vertebral segments, but it does occur.

Most do have, at least, partial recovery, with most recovery taking place within the first three months of symptom onset. Some though, do have full recovery, or minor consequence, but this can take many months of healing. Permanent effects, significant enough to impact their ability to perform ordinary daily tasks, does occur. At peak deficit, half of patients are completely paraplegic with virtually all having some degree of bladder and bowel dysfunction (Salas et al., 2024).

Approximately 33% of those who develop TM, 33% recover with no lasting deficits, while another 33% have a moderate degree of permanet disability, and the final 33% are permanently disabled (Salas et al., 2024). Transverse myelitis may reoccur, especially if the underlying cause is autoimmune in origin such as multiple sclerosis.

The incidence of TM is about one to eight people per million, each year (Salas et al., 2024).

Classic Features of Transverse Myelitis

Symptoms can occur rather quickly, even within minutes or over a few days, but it may also present more gradually, over a week or month. Most often individuals will share that they are experiencing a weakness in their legs and it seems to worsen rapidly. If the myelitis affects the upper spinal cord, it affects the arms as well. They may experience partial paralysis in their legs and this can progress to complete paralysis, requiring the use of a wheelchair.

Pain is one of the initial symptoms, usually with lower back pain and sharp, shooting pain that radiates down the legs or arms, or around the person's torso. Burning, tickling, pricking, numbness, coldness, or tingling in the legs is also commonly reported; we call this paresthesias. Some lose sensation in parts of their body, or have abnormal sensations in their torso and genital region. Often, individuals have increased frequency or urges to use the restroom, even incontinence or urinary retention and constipation.

Other symptoms include muscle spasms, a general feeling of discomfort, and loss of appetite. Some people experience respiratory problems, sexual dysfunction, and chronic pain.

Whose at Risk?

Every one of us. Any age. Male and female. All races. It doesn't seem to be genetic or even run in families, but it does impact adolescents and teens most often, or those in their third decade. There are some more common underlying causes however.

In some people, transverse myelitis is the first symptom of an autoimmune or immune-mediated disease such as multiple sclerosis (MS) or neuromyelitis optica spectrum disorder. With MS, our immune cells mistakenly attack the protective coating of myelin in the brain, optic nerves, and spinal cord. Neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein-associated disorder (MOGAD) are disorders that affect the nerves of the eye and spinal cord, and may be the underlying trigger.

Consider though that inflammation can occur in the spinal cord after a virus, any sort of infection, or even post-vaccine. As the body fights the infection, it confuses the invader with our own healthy tissue. Less often this inflammation can occur when we have some type of cancer that damages the nervous system. Something as simple as herpes viruses such as varicella zoster (chickenpox or shingles), herpes simplex, enterovirus, poliovirus, cytomegalovirus, and Epstein-Barr can initiate this response in the body. Flaviviruses such as West Nile and Zika or even common influenza, echovirus, hepatitis B, the mumps, measles, or rubella can also cause transverse myelitis. It's unclear whether direct viral infection or post-infectious response is the real trigger, but either way, there is association.

Bacterial infections are also triggers, including syphilis, tuberculosis, actinomyces, pertussis, tetanus, diphtheria, and Lyme disease (Dumic et al., 2019). Bacterial skin infections, middle-ear infections, campylobacter jejuni gastroenteritis, and mycoplasma bacterial pneumonia have also been associated with transverse myelitis. Fungal infections as well, such as aspergillus, blastomyces, coccidioides, and cryptococcus. Is there potential mold in your home? And we must consider parasites such as toxoplasmosis, cysticercosis, shistosomiasis, and angtiostrongyloids.

Occasionally, individuals actually have a vascular disorder such as arteriovenous malformation or dural arterial-venous fistual, or even intra-spinal cavernous malformations. They could have a spinal cord infarct or even a disk embolism.

If your doctor has called your transverse myelitis "idiopathic" that means they don't know why it is happening, which may be legitimate; however, I would assure proper and thorough testing has actually been done because many clinicians simply don't think about underlying causes. They will simply move to treatment.

Diagnosing and Treating

An MRI will almost always confirm the presence of damage within the spinal cord, also called a lesion. Blood tests can identify or rule out various disorders, including HIV infection and vitamin B12 deficiency. A lumbar puncture and spinal fluid analysis, also called a spinal tap, can help identify infections, and often we'll identify a higher number of protein than usual and an increased number of white blood cells (leukocytes) that help the body fight infections.

In some cases, PET scans can help identify diseased cells and diagnose some possible underlying causes such as sarcoidosis or cancer. The PET scan uses a safe, radioactive tracer.

When we identify the underlying cause, we need to treat this, such as infection. This will ultimately reduce spinal cord inflammation and manage, or reduce symptoms. However, most will be offered intravenous corticosteroid drugs initially, which will decrease swelling and inflammation in the spinal cord and reduce immune system activity. Methylprednisolone or dexamethasone are commonly used, and they do reduce the chance of recurrence.

Plasma exchange therapy (plasmapheresis) is another approach for those who don't respond well to IV steroids. This is a procedure that reduces immune system activity by removing plasma and replacing it with special fluids, essentially removing the antibodies and other proteins thought to be causing the inflammatory reaction. Another treatment that can help reset the immune system is IVIG, or IV immunoglobulin, which is a highly concentrated injection of antibodies pooled from many healthy donors. This will bind to the antibodies that are causing the inflammation and then remove them from circulation.

Pain medications are offered as well, including acetaminophen, ibuprofen, and naproxen. Nerve pain though is often treated with certain antidepressants such as duloxetine, or even muscle relaxants, such as baclofen, tizanidine, or cyclobenzaprine, and anticonvulsant drugs, such as gabapentin or pregabalin.

If a virus is thought to be a trigger, or underlying cause, antivirals may also be offered. Individuals may receive medication treatment for incontinence, painful muscle contractions (tonic spasms), stiffness, sexual dysfunction, or even depression.

After initial therapy, the big or critical focus becomes keeping their body functioning during the recovery period. In rare cases, when breathing is significantly affected, a respiratory may be required, but this is usually temporary.

Rehabilitation and Long-Term Therapy for Transverse Myelitis

There are a number of approaches, and both strength and function can improve even years after the initial episode. However, current understanding is that rehabilitation cannot reverse the physical damage resulting from transverse myelitis. Therapy can help individuals attain their greatest quality of life.

Physiatrists, physical therapists, occupational therapists, vocational therapists, and mental health therapists are typically part of the team. Physical therapy helps retain muscle strength and flexibility, as well as improve coordination, minimize stiffness, and regain bladder and bowel control. Occupational therapy is typically used to help individuals regain their independence by participating in meaningful, self-directed, everyday tasks such as bathing, dressing, preparing meals, and house cleaning. Vocational therapy helps people develop and improve work skills, identify potential employers, and assist in job searches. They can also mediate between employees and employers to secure reasonable workplace accomodations.

Psychotherapy, counseling, and talk therapy can also be an important part of recovery, as this can be a significant life altering even that can challenge our capacity to cope.

There are a number of research trials underway, and if you'd like to join, visit NIH Clinical Research Trials and You or Clinicaltrails.gov.

Thinking Holistically

The first thoughts that come to mind when seeking to address TM from a functional and integrative mindset, are assuring vitamin D3 is at a function level, 60-80, not just above 30. Low vitamin D3 is even more concerning (less than 30), so I'd be aggressive here as appopriate, supplementing as much as 10,000 IU daily with K2.

Vitamin B12 is great for protecting the health of our nervous system, as is alpha lipoic acid. Both of these are easily supplemented over-the-counter, and ALA crosses the blood brain barrier, which would be especially helpful here, although it can lower blood sugar so be mindful.

Fish oils are important for inflammation, and I'd aim for at least one gram daily, but potentially as much as 2 or 3 grams daily. Taking these at night can help minimize fishy burps.

An anti-inflammatory diet can help reduce inflammation, although there is no definitive, evidence-based approach. Increase plant-based foods though, like fruits, vegetables, nuts, legumes, and seeds, while reducing animal proteins and processed foods. Plant foods are much richer in antioxidants, which play a cruical role in reducing inflammation.

Peek at what causes inflammation in your own body though. For some this is gluten, and for others it might be dairy or red meat. The MRT test is my favorite approach, along with LEAP therapy. Keep a food diary and identify triggers. Not all foods are equal in their anti-inflammatory properties. High-antioxidant foods, such as berries and greens, significantly reduce inflammation more effectively than low-antioxidant ones like bananas or lettuce. Additionally, excess fat in the body can increase inflammatory markers, so maintaining a healthy weight is important.

Increasing physical activity also helps reduce inflammation, regardless of weight loss. Eating more fiber from whole plant foods supports the gut, and good bacteria use fiber to produce butyrate, which reduces inflammation. Probiotics can help, but they’re more effective when balanced with fiber.

To further combat inflammation, focus on omega-3-rich foods, antioxidants, and vitamins. Phytochemicals like carotenoids, flavonoids, polyphenols, and sulforaphane from plants have been shown to lower inflammation. Low levels of magnesium, vitamin C, and vitamin D are linked to inflammation, and increasing plant-based foods can help supply these nutrients.

Omega-3s from flaxseeds, walnuts, and fish, along with monounsaturated fats from olive oil, can reduce inflammatory markers. Additionally, spices like turmeric have anti-inflammatory effects. A simple way to improve your diet is by creating a checklist of anti-inflammatory foods to include daily.

References

Dumic, I., Vitorovic, D., Spritzer, S., Sviggum, E. Patel, J., & Ramanan, P. (2019). Acute transverse myelitis - a rare clinical manifestation of Lyme neuroborreliosis. ScienceDirect, 15.

Salas, J. R., Farrell, A., Potts, C., & Robinson, P. (2024). Longitudinally extensive transverse myelitis in a patient with systemic Lupus Erythematosus, recent influenza infection, and nutritional deficiencies in the setting of chronic alcohol use. Cureus, 16(6).