Transverse Myelitis

What is Transverse Myelitis?

Transverse myelitis is a rare, acquired inflammatory disorder of the spinal cord that typically causes weakness, loss of sensation and bladder or bowel problems.^[1] It is not a single disease. It can occur on its own, after an infection, or as part of a wider immune disorder such as multiple sclerosis or neuromyelitis optica spectrum disorder.^{[1, 2]}

Common symptoms

Symptoms usually develop over hours to days and depend on which level of the spinal cord is inflamed.^[3] They can include:

• Weakness or paralysis in the legs, and sometimes the arms
• Numbness, tingling or reduced sensation below the level of the inflammation
• Back pain
• Bladder and bowel problems, such as retention or incontinence^{[1, 3]}

At the worst point, about half of patients are completely paraplegic, and almost all have some bladder or bowel dysfunction.^[1]

Causes and risk factors

Transverse myelitis has many causes, from infections to immune-mediated disease. Examples include sarcoidosis and systemic lupus erythematosus, and in some people the cause is never found (idiopathic).^[2] Blood tests for antibodies against aquaporin-4 and myelin oligodendrocyte glycoprotein help separate the immune-mediated types, which differ in their risk of relapse.^{[2, 4]}

How it is diagnosed and treated conventionally

Diagnosis needs urgent medical assessment. Spinal MRI and spinal fluid analysis are the main tests, and a compressive problem of the spine must be ruled out first because it can look the same and may need emergency surgery.^{[2, 3]}

Treatment depends on the cause. Management for immune-mediated forms includes acute treatment, preventive treatment for types that can relapse, and supportive care, and experts advise a disease-specific diagnosis in place of the general label.^[4] Starting treatment quickly is linked to better outcomes.^[3]

Recovery varies. Roughly one third of patients recover with little lasting deficit, one third have moderate permanent disability, and one third are permanently disabled.^[1]

Why Transverse Myelitis calls for a whole-person approach

Transverse myelitis is treated by neurologists, and the first priority is stopping the inflammation and protecting the spinal cord. After that, many people live with problems that medicine alone does not fully resolve, such as pain, spasticity, bladder and bowel dysfunction, poor sleep and the stress of long-term disability.

Supportive care targets these ongoing problems. It does not treat the inflammation or the underlying cause.

Pain and spasticity

Pain and muscle stiffness after damage to the spinal cord can limit rehabilitation. In one case report, a patient in inpatient rehabilitation for transverse myelitis was struggling to take part because of pain and poor sleep.^[5]

Bladder and bowel function

Almost all patients have some bladder or bowel dysfunction at the worst point of the illness.^[1] These problems need specialist urological and bowel management.

Sleep and stress

Sleep disturbance and mood can interfere with rehabilitation. In the same case report, better control of pain and sleep let the patient take part more fully in therapy.^[5]

Acupuncture as supportive care in Transverse Myelitis

What the research shows

The research on acupuncture in transverse myelitis is very limited. A PubMed search found no randomized trials and no systematic reviews.

The best available study is a prospective observational study of 16 patients with transverse myelitis and bladder or bowel dysfunction, given electroacupuncture for 8 weeks and followed for 6 months. Five regained normal voiding and three partially, and of eight patients with fecal retention, four resumed normal bowel movements and three partially normal ones. There was no comparison group, so the study cannot show that acupuncture caused the changes, and the authors called for randomized trials.^[6] Two case reports describe benefit for pain, sleep, bladder and walking.^{[5, 7]} Case reports cannot show cause and effect.

Evidence from related conditions is also weak. A meta-analysis of 12 trials in spinal cord injury found possible benefit for neurological and motor recovery, but the studies were generally poor quality with evidence of publication bias.^[8] A Cochrane review of non-drug treatments for chronic pain after spinal cord injury found two acupuncture trials and no evidence that acupuncture reduces pain.^[9] A review of acupuncture for spasticity found moderate-quality evidence after stroke, but not enough to conclude it helps in other central nervous system diseases.^[10] These findings are not for transverse myelitis.

For symptoms in general, an individual-patient meta-analysis of 39 trials found acupuncture reduced chronic musculoskeletal, osteoarthritis and headache pain,^[11] and a meta-analysis of 24 trials found that, in 15 trials comparing it with medication, acupuncture improved insomnia scores, with large differences between studies.^[12] Neither involved people with spinal cord inflammation.

How acupuncture may work

How acupuncture might act in transverse myelitis is not known. The authors of one case report state that electroacupuncture has a positive effect on neurological repair after spinal cord disease,^[7] and a review of acupuncture for spasticity describes possible nervous system mechanisms.^[10] These are proposals, not settled facts, and none has been shown in transverse myelitis.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes, with a course of several visits and reassessment. Electroacupuncture, in which a small current is passed through the needles, may be used. The observational study above used sessions five times a week for four weeks, then three times a week for four weeks.^[6]

Because sensation may be reduced below the level of the spinal cord injury, the practitioner will need to know which areas are numb. Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[13] Tell the practitioner first if you take blood thinners, have a bleeding disorder, are pregnant, take immune-suppressing medicines that raise infection risk, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Transverse Myelitis

The Ayurvedic view

Transverse myelitis is a modern diagnosis with no exact classical Ayurvedic equivalent. Weakness, numbness and loss of movement are traditionally associated with Vata imbalance, and paralysis-type conditions are described in classical texts as Pakshaghata or related Vata disorders. This is a traditional explanatory framework, not a biomedical diagnosis.

Therapies that may be used

Care is individualized and would be added only after acute medical treatment. Traditional approaches include:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Gentle warm oil massage, avoiding any areas where sensation is lost, because heat injury is a risk
• Breathing exercises and gentle yoga adapted to your mobility
• Individually prescribed herbs, which may include ashwagandha (Withania somnifera)

Panchakarma, the traditional cleansing program, is not appropriate during acute illness, frailty or pregnancy, and would not be suitable during active spinal cord inflammation. Any such procedure should be discussed with your neurologist first.

What the research shows

No studies of Ayurvedic treatment in transverse myelitis were found. A single case report of cervical spondylotic myelopathy, a compression problem and not inflammation, described improvement with Panchakarma and oral Ayurvedic medicines, but a single case cannot show that the treatment worked.^[14]

For ashwagandha, research in the spinal cord is laboratory-based. A review summarized effects in cell and animal models of neurodegenerative disease and spinal cord injury, which do not show benefit in people.^[15] In people without spinal cord disease, a meta-analysis of 12 trials found ashwagandha reduced stress and anxiety scores compared with placebo, with low-certainty evidence,^[16] and a meta-analysis of five trials found a small improvement in sleep.^[17]

Herbal medicine as supportive care in Transverse Myelitis

Herbs and formulas that have been studied

No clinical trials of Chinese herbal medicine or other herbal medicine in transverse myelitis were found in PubMed. Nothing can be said about herbs for the condition itself. Herbs such as ashwagandha, discussed above, have been studied for stress and sleep in people without this condition.^{[16, 17]}

What the research shows

There is no clinical evidence for herbal medicine in transverse myelitis. Any herbal care would be aimed at symptoms such as stress and sleep, and the evidence for those comes from other populations and is low certainty.^{[16, 17]}

Safety and herb-drug interactions

Herbs can interact with medicines. Reported interactions include bleeding when some herbs are combined with warfarin or aspirin, and lowered blood levels of immune-suppressing drugs such as ciclosporin and tacrolimus with St John's wort.^[18] Many people with transverse myelitis take steroids, immune-suppressing drugs, or medicines for pain, spasticity and bladder control, so every herb needs review by your prescriber first.

Herbal and dietary supplements are a recognized cause of liver injury.^[19] In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding or have liver or kidney disease.

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine would describe weakness and numbness after spinal cord illness as obstruction of qi and blood in the channels, often with deficiency of kidney or liver. Ayurveda would describe a Vata disorder. These frameworks guide how a practitioner chooses points and therapies.

Researchers study biological ideas that loosely parallel them, such as nervous system mechanisms that may affect spasticity and recovery after central nervous system injury.^[10] No study has shown that a traditional pattern matches a specific biological change in transverse myelitis.

How this care fits with your medical care

Supportive care comes only after the condition is under medical management, and works alongside your neurologist, rehabilitation team and urologist. We do not diagnose or manage transverse myelitis. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Please bring your diagnosis, spinal MRI reports, antibody test results, a full list of medicines and supplements, and details of your rehabilitation plan. Do not stop or change steroids, immune-suppressing drugs or any other prescribed treatment without your prescriber. Tell us about areas of reduced sensation, and about any catheter use.

When to seek urgent medical care

Sudden spinal cord symptoms need emergency evaluation because early treatment is linked to better outcomes, and compressive causes of the same symptoms may need urgent surgery.^[3]

• New or rapidly worsening weakness or numbness in the legs or arms
• Sudden loss of bladder or bowel control, or inability to pass urine
• Back pain with new weakness, numbness or a band-like sensation around the trunk
• Fever with back pain or new neurological symptoms
• A relapse of any earlier symptoms, or new vision loss
• Difficulty breathing or swallowing

For any of these, call 911 or go to the nearest emergency department.