MRCP PACES Cord Syndromes Transverse Myelitis
  • Acute cord transection will cause spinal shock (flaccid paraparesis, urinary retention, diminished reflexes)
  • Thereafter, clinical picture is:
    • Sparing of the cranial nerves
    • Increased tone (velocity-dependent)
    • Hyperreflexia below the level of the lesion
    • Upgoing plantars
    • Power
      • If mechanical, may have LMN weakness at the level of lesion
      • Otherwise, pyramidal weakness bilaterally below the level of lesion
    • Sensation
      • Sensory level in a dermatomal distribution
      • Both pinprick and temperature affected
    • Look for wheelchair
    • Look for surgical scars over the back
  • Causes
    • Trauma
    • Transverse myelitis
      • Demyelinating
        • Multiple sclerosis
        • Neuromyelitis optica
        • Idiopathic transverse myelitis
        • Acute disseminated encephalomyelitis
      • Inflammatory
        • Systemic lupus erythematosus
        • Sjögren’s syndrome
      • Infection
        • Bacterial: Lyme, mycoplasma, tuberculosis, syphilis
        • Viral: HSV, VAV, CMV, HIV, HAV, echovirus, influenza virus
    • Tumours
    • Epidural abscess
    • Degenerative spondylosis
  • Investigation
    • Magnetic resonance imaging of the spinal cord to look for lesions separated in space
    • Lumbar puncture
      • Unpaired oligoclonal bands (MS)
      • Cytology
      • CSF VDRL
      • Elevated CSF protein
      • Angiotensin converting enzyme (neurosarcoidosis)
    • Serology
      • NMO antibody (anti-aquaporin-4 antibody) – sensitivity 70%, specificity 100%
      • Antinuclear antibody, anti-dsDNA (SLE)
      • Anti-Ro/SSA and anti-La/SSB antibodies (Sjogren’s syndrome)
  • Management (inflammatory myelitis)
    • Multidisciplinary team approach
    • Patient education
    • IV methylprednisolone
    • For severe disease
      • IV cyclophosphamide
      • Plasma exchange, especially if failed methylprednisolone
    • If no improvement after PLEX, some evidence for
      • IV immunoglopulin (ADEM)
      • Rituximab (NMO)
      • Azathioprine (SLE)
      • See section on multiple sclerosis
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