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neuro.transverse-myelitis.v1PRODUCTION
neuro.transverse-myelitis.v1

Acute Transverse Myelitis

neurologyacutesubacuteadultpediatric
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Acute / subacute bilateral spinal cord dysfunction with sensory level + inflammation evidence (TMCWG 2002 PMID 12236201); EXCLUDE COMPRESSIVE first via STAT MRI

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TMCWG criteria framework activated

Patient inputs (20)

AQP4-IgG (live cell-based assay) → NMOSD; positive triggers different DMT (eculizumab / satralizumab / inebilizumab / rituximab) (Wingerchuk 2015 PMID 26092914)

MOG-IgG (live cell-based assay) → MOGAD; different DMT consideration (Banwell 2023 PMID 36706773)

Adult TM peaks 10-19 + 30-39; NMOSD female 9:1; MOGAD bimodal peds + young adult; older age + vascular RFs → spinal cord infarct (TMCWG 2002 PMID 12236201)

Cervical (C3-C5 → diaphragm + respiratory) / thoracic / lumbar localization drives respiratory + autonomic risk + intubation threshold

Bowel / bladder dysfunction, sweating asymmetry, hypotension / dysreflexia (cervical/high thoracic) → cord involvement, autonomic risk, ICU consideration

Post-infectious TM after viral / bacterial illness or vaccination (Pidcock 2007 PMID 17470749); also drives infectious workup

Known SLE / Sjögren / sarcoid / Behçet / MS / NMOSD / MOGAD drives autoimmune workup + DMT decisions

Paraneoplastic TM (anti-CRMP5, anti-amphiphysin, anti-Hu) — drives cancer screening

Lyme (tick endemic; CDC PMID 27931077); schistosoma (freshwater bathing in endemic); HTLV-1/2 (Caribbean / Japan); strongyloides (immunosuppression); brucellosis; TB

Pregnancy alters drug selection (steroid OK after first trimester; cyclophosphamide CONTRAINDICATED; rituximab category C; doxycycline CONTRAINDICATED → amoxicillin/cefuroxime for Lyme); ob consult

Max severity within 4 h to 21 d = TMCWG 2002 criterion; <4 h = vascular (cord infarct); >21 d = chronic (dural AV fistula, compressive, demyelinating slow progressive)

STAT MRI cervical + thoracic cord with gadolinium — exclude compressive lesion (epidural abscess, hematoma, mass, fracture, disc — SURGICAL EMERGENCY); document lesion length (≥3 vertebral segments → NMOSD pivot — Wingerchuk 2015 PMID 26092914); cord edema; gad enhancement = active inflammation

MRI brain — rule out MS lesions (T2 white matter, periventricular, Dawson fingers); MOGAD cortical encephalitis (Banwell 2023 PMID 36706773)

CSF cell count (lymphocytic pleocytosis), protein (mildly elevated), glucose (normal), OCB (matched in TM, unmatched in MS), IgG index — TMCWG 2002 inflammation evidence

Baseline glucose before high-dose steroid pulse — steroid-induced hyperglycemia common

Cervical TM (C3-C5) → diaphragm involvement; FVC < 20 mL/kg or NIF magnitude < 30 → intubate

ASIA Impairment Scale A-E (A = complete; B-D = incomplete; E = normal) baseline drives severity + prognosis + PLEX trigger; schema-blocked calculator

Autoimmune + infectious panel — ANA / dsDNA (SLE), SS-A/SS-B (Sjögren), ACE (sarcoid + gallium scan + biopsy), RPR (syphilis), HIV, Lyme (CDC PMID 27931077), B12 (subacute combined degeneration mimic), HTLV-1/2 (HAM/TSP — Caribbean / Japan endemic)

Anti-CRMP5, anti-amphiphysin, anti-Hu → paraneoplastic; drives cancer screening (CT chest/abdomen/pelvis + PET)

NMOSD female predominant (9:1); SLE / Sjögren female predominant; MOGAD slight female (Banwell 2023 PMID 36706773)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningnmosd_tm
    NMOSD transverse myelitis — AQP4-IgG positive + longitudinally extensive ≥3 vertebral segments + female predominant 9:1 (Wingerchuk 2015 PMID 26092914); different DMT (eculizumab / satralizumab / inebilizumab / rituximab) — NOT MS DMT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsle_tm
    SLE transverse myelitis — ANA + dsDNA positive + part of SLE flare (5% of SLE develop TM); SLE engine drives cyclophosphamide / rituximab — TM engine drives cord workup + steroid pulse + PLEX (route to rheum.sle-flare.core.v1)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningspinal_cord_infarct
    Spinal cord infarct — anterior cord syndrome (bilateral motor + pain/temp loss with preserved dorsal column proprioception/vibration); sudden onset (<4 h to peak); vascular RFs (atherosclerosis, AAA repair, hypotension, hypercoagulable, fibrocartilage embolism); STAT MRI cord; route to neuro.ischaemic-stroke.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereidiopathic_tm
    Idiopathic transverse myelitis — TMCWG 2002 criteria (bilateral cord signs + sensory level + inflammation evidence MRI gad or CSF + max severity 4 h-21 d + EXCLUDE compressive) without identified etiology (TMCWG 2002 PMID 12236201; Beh 2013 PMID 23186897)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremogad_tm
    MOGAD transverse myelitis — MOG-IgG positive (live cell-based assay) + often bilateral simultaneous optic neuritis + brain / cortical encephalitis features (Banwell 2023 PMID 36706773); many monophasic but some relapsing → rituximab / azathioprine / mycophenolate / IVIG
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresarcoid_tm
    Sarcoid-associated transverse myelitis — elevated CSF / serum ACE + gallium scan + biopsy granulomas; longitudinally extensive cord lesion common; steroid + methotrexate / TNF inhibitor maintenance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresjogren_tm
    Sjögren transverse myelitis — SS-A/SS-B positive + Schirmer test + lip biopsy; rituximab + steroid; rheum consult
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparaneoplastic_tm
    Paraneoplastic transverse myelitis — anti-CRMP5 / anti-amphiphysin / anti-Hu / anti-Ma2 positive; underlying cancer (small cell lung, breast, ovary, thymoma); CT chest/abdomen/pelvis + PET cancer workup
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredural_av_fistula_chronic
    Chronic dural arteriovenous fistula — progressive over weeks-months; older male predominant (M:F 4:1); STAT spinal angiography → embolization or surgical disconnection; NOT a steroid-responsive entity
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_infectious_tm
    Post-infectious transverse myelitis — recent viral / bacterial illness or vaccination; pediatric common (Pidcock 2007 PMID 17470749); variable recovery; viral PCR workup mandatory
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

TM acute Rx — high-dose steroid + PLEX for refractory + cyclophosphamide / rituximab for autoimmune + antibiotic for infectious + supportive (TMCWG 2002 PMID 12236201; ApolyDS Magaña 2011 PMID 10589540)
axis: transverse_myelitis_acute_treatmentstep 1 - Step 1 — High-dose IV methylprednisolone (TMCWG 2002 scaffolding; ms-flare ONTT-style; Beh 2013 PMID 23186897)
Selected step "Step 1 — High-dose IV methylprednisolone (TMCWG 2002 scaffolding; ms-flare ONTT-style; Beh 2013 PMID 23186897)" — Acute TM with TMCWG 2002 criteria met (bilateral cord + sensory level + inflammation evidence + 4 h-21 d onset + compressive excluded)
  • methylprednisolone
    first line
    corticosteroid_pulse
    1 g IV daily × 3-5 d (typically 5 d) • IV • daily × 3-5 d (max: 5 g cumulative)
    triggers: confirmed_TM_TMCWG_2002, severe_TM
    First-line for acute TM; reduces inflammation; ONTT-scaffolding (extension from optic neuritis trial); same pulse used for MS flare (ms-flare engine — Beh 2013 PMID 23186897 review)
    rxcui 6902
  • prednisone
    second line
    corticosteroid_oral
    1250 mg PO daily × 3-5 d (then taper) • PO • daily
    triggers: outpatient_no_iv_access
    Oral methylprednisolone-equivalent 1250 mg/day non-inferior to IV for MS flare (Le Page Lancet 2015); reasonable for mild TM with reliable PO + outpatient infusion
    rxcui 8640

outpatient playbook — drug actions (8)

  1. 1. NMOSD DMT (route via ms-flare engine — eculizumab / satralizumab / inebilizumab / rituximab)
    Per drug • IV/SC • per drug
    trigger: Confirmed NMOSD-AQP4+
    Wingerchuk 2015 PMID 26092914; ms-flare engine carries NMOSD regimen scaffolding
  2. 2. MOGAD DMT (rituximab / azathioprine / mycophenolate / IVIG)
    Per drug • IV/PO/SC • per drug
    trigger: Confirmed MOGAD relapsing
    Banwell 2023 PMID 36706773; many MOGAD monophasic — observe vs treat decision
  3. 3. methylprednisolone pulse if recurrence
    1 g IV daily × 3-5 d • IV • as scheduled
    trigger: TM recurrence
    Same scaffold as acute
  4. 4. baclofen / tizanidine (continue)
    Per regimen • PO • TID
    trigger: Persistent spasticity
    Antispasmodic; never abrupt-stop
  5. 5. oxybutynin / tamsulosin / mirabegron (continue)
    Per urology • PO • daily
    trigger: Neurogenic bladder
    Bladder mgmt
  6. 6. sertraline (or other SSRI)
    25-200 mg PO daily • PO • daily
    trigger: PHQ-9 ≥10 — post-TM depression
    Common sequelae; address QoL
  7. 7. gabapentin or pregabalin
    Gabapentin 300 mg PO TID titrate to 1200 mg TID; pregabalin 75 mg BID titrate • PO • TID / BID
    trigger: Neuropathic pain post-TM
    Neuropathic pain mgmt; renally adjusted
  8. 8. tadalafil or sildenafil
    Per regimen • PO • daily or PRN
    trigger: Sexual dysfunction
    PDE-5 inhibitor for neurogenic erectile dysfunction

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Bilateral motor + sensory deficit referable to single spinal cord level (TMCWG 2002 PMID 12236201); Sensory level (clear demarcation between normal and abnormal sensation) — TMCWG 2002 cardinal feature; Bowel / bladder dysfunction (retention, incontinence, urgency) — autonomic involvement; cord pathology.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Transverse Myelitis** (neuro.transverse-myelitis.v1).
Phenotype framing: Idiopathic TM (TMCWG 2002 PMID 12236201) / NMOSD-TM (AQP4+; Wingerchuk 2015) / MOGAD-TM (MOG+; Banwell 2023 PMID 36706773) / post-infectious / sarcoid (Pidcock 2007 PMID 17470749) / SLE / Sjögren / paraneoplastic / spinal cord infarct (anterior cord syndrome; vascular RF) / chronic dural AV fistula (progressive over months; spinal angiography) / radiation myelopathy
Scope: Acute / subacute bilateral spinal cord dysfunction with sensory level + inflammation evidence (TMCWG 2002 PMID 12236201); EXCLUDE COMPRESSIVE first via STAT MRI

No severity triggers fired against current inputs.

Plan

Regimen axis: **TM acute Rx — high-dose steroid + PLEX for refractory + cyclophosphamide / rituximab for autoimmune + antibiotic for infectious + supportive (TMCWG 2002 PMID 12236201; ApolyDS Magaña 2011 PMID 10589540)** — step "Step 1 — High-dose IV methylprednisolone (TMCWG 2002 scaffolding; ms-flare ONTT-style; Beh 2013 PMID 23186897)".
1. methylprednisolone 1 g IV daily × 3-5 d (typically 5 d) IV daily × 3-5 d (corticosteroid_pulse, first line) — First-line for acute TM; reduces inflammation; ONTT-scaffolding (extension from optic neuritis trial); same pulse used for MS flare (ms-flare engine — Beh 2013 PMID 23186897 review)
2. prednisone 1250 mg PO daily × 3-5 d (then taper) PO daily (corticosteroid_oral, second line) — Oral methylprednisolone-equivalent 1250 mg/day non-inferior to IV for MS flare (Le Page Lancet 2015); reasonable for mild TM with reliable PO + outpatient infusion

Setting playbook (outpatient) — Long-term DMT for NMOSD / MOGAD / MS-spectrum (route to ms-flare engine), rehab 6-12 mo, recurrence surveillance, complications mgmt (spasticity, neurogenic bladder/bowel, pressure ulcers, depression, sexual function, bone health)
3. NMOSD DMT (route via ms-flare engine — eculizumab / satralizumab / inebilizumab / rituximab) Per drug IV/SC per drug — Confirmed NMOSD-AQP4+ (Wingerchuk 2015 PMID 26092914; ms-flare engine carries NMOSD regimen scaffolding)
4. MOGAD DMT (rituximab / azathioprine / mycophenolate / IVIG) Per drug IV/PO/SC per drug — Confirmed MOGAD relapsing (Banwell 2023 PMID 36706773; many MOGAD monophasic — observe vs treat decision)
5. methylprednisolone pulse if recurrence 1 g IV daily × 3-5 d IV as scheduled — TM recurrence (Same scaffold as acute)
6. baclofen / tizanidine (continue) Per regimen PO TID — Persistent spasticity (Antispasmodic; never abrupt-stop)
7. oxybutynin / tamsulosin / mirabegron (continue) Per urology PO daily — Neurogenic bladder (Bladder mgmt)
8. sertraline (or other SSRI) 25-200 mg PO daily PO daily — PHQ-9 ≥10 — post-TM depression (Common sequelae; address QoL)
9. gabapentin or pregabalin Gabapentin 300 mg PO TID titrate to 1200 mg TID; pregabalin 75 mg BID titrate PO TID / BID — Neuropathic pain post-TM (Neuropathic pain mgmt; renally adjusted)
10. tadalafil or sildenafil Per regimen PO daily or PRN — Sexual dysfunction (PDE-5 inhibitor for neurogenic erectile dysfunction)

Non-pharmacologic actions:
- PT / OT / SLP — community-based long-term
- Aquatic therapy if available
- Wheelchair / mobility aids per OT
- Home safety review (grab bars, raised toilet seat)
- Bowel + bladder program (intermittent self-catheterization)
- Pressure ulcer prevention (cushion, q2h turn if non-ambulatory)
- Sexual health counseling
- Caregiver respite + support groups (Transverse Myelitis Association)
- Annual vaccinations
- Bone health (DEXA + vitamin D + calcium; bisphosphonate if osteoporosis)
- Driving evaluation + cessation if cognitive concerns
- Vocational rehab
- Pregnancy counseling + contraception during cyclophosphamide / mycophenolate

AVOID / contraindication checks:
- STAT_MRI_to_exclude_compressive_FIRST (epidural abscess / hematoma / mass / fracture / disc = surgical emergency; time to decompression determines outcome)
- CSF_AQP4_MOG_send_out_BEFORE_steroid (live cell based assay; steroid lowers titer; document AQP4 vs MOG status before treatment)
- Cyclophosphamide_CONTRAINDICATED_in_pregnancy (alkylator; teratogenic)
- Rituximab_HBV_VZV_TB_screen_before_initiation (immunosuppression activation)
- Eculizumab_MANDATORY_meningococcal_vaccine_before_initiation (PREVENT trial Pittock 2019; complement inhibitor = increased meningococcal risk)
- Doxycycline_CONTRAINDICATED_in_pregnancy_and_peds_under_8 (use amoxicillin or cefuroxime for Lyme)
- Baclofen_NEVER_abrupt_stop (withdrawal syndrome with hyperthermia + AMS + autonomic instability)
- DVT_prophylaxis_mandatory_in_immobile_tm (LMWH per renal)
- Bladder_decompression_mandatory_neurogenic_retention (urology consult; intermittent vs indwelling)
- Pressure_ulcer_prevention_q2h_turn_cushion_low_air_loss (high risk in immobile cord injured)

Monitoring

Regimen monitoring:
- Daily neuro exam + ASIA grading (schema-blocked calc)
- FVC + NIF q4h if cervical TM (intubation threshold FVC <20 mL/kg or NIF magnitude <30)
- Bowel + bladder log; urology consult q-week
- Pressure ulcer surveillance q-shift; cushion + turn q2h
- Glucose q6h during steroid pulse
- Mood + sleep (steroid psychosis)
- CBC + LFT q-wk on steroid + cyclophosphamide / rituximab
- CD19 count + IgG levels before rituximab redosing
- AQP4 / MOG result tracking
- DMT-specific labs per ms-flare engine (NMOSD/MOGAD)
- Annual MRI brain + cord if NMOSD / MOGAD / MS-spectrum

Setting (outpatient) monitoring:
- Outpatient neurology / autoimmune q3 mo
- MRI cord + brain annually
- AQP4 / MOG q12 mo
- Urology q6 mo
- Bone health q2 y
- Vaccinations annually

Follow-up plan: Rehab 6-12 mo (PT / OT / SLP); NMOSD / MOGAD DMT initiation if AQP4+/MOG+ (route to ms-flare engine for regimen scaffolding); MS clinic q3 mo if MRI brain demyelinating lesions; autoimmune clinic if SLE / Sjögren / sarcoid; recurrent TM warning (NMOSD 60% in 1 y untreated; Wingerchuk 2015 PMID 26092914); bladder mgmt + bowel regimen + spasticity Rx + pressure ulcer surveillance + sexual function counseling + psych follow-up
- Close-out criterion: Long-term plan documented + rehab arranged

Monitoring phase: Daily neuro exam + ASIA grading; FVC/NIF q4h if cervical; bowel/bladder log; pressure ulcer surveillance; glucose q6h on steroid; mood/sleep (steroid psychosis); DMT-specific labs if NMOSD/MOGAD treatment started (CBC, CD19, IgG levels for rituximab; meningococcal vaccine for eculizumab)

Disposition

Current setting: outpatient — Long-term DMT for NMOSD / MOGAD / MS-spectrum (route to ms-flare engine), rehab 6-12 mo, recurrence surveillance, complications mgmt (spasticity, neurogenic bladder/bowel, pressure ulcers, depression, sexual function, bone health)

Disposition criteria:
- Continue indefinite autoimmune / neurology + rehab + urology + psych follow-up
- Hospice referral if severe ASIA A-B + life-limiting comorbidities

Escalation triggers (move to higher acuity):
- New weakness / sensory level / vision loss / bowel-bladder change → ED + STAT MRI (recurrence)
- New infection during immunosuppression → urgent visit + abx
- Pressure ulcer stage 2+ → wound care + nutrition
- Severe depression / suicidality → urgent psych
- Severe spasticity / baclofen withdrawal symptoms → ED
- DVT signs → ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] NMOSD transverse myelitis — AQP4-IgG positive + longitudinally extensive ≥3 vertebral segments + female predominant 9:1 (Wingerchuk 2015 PMID 26092914); different DMT (eculizumab / satralizumab / inebilizumab / rituximab) — NOT MS DMT
- [LIFE_THREATENING] SLE transverse myelitis — ANA + dsDNA positive + part of SLE flare (5% of SLE develop TM); SLE engine drives cyclophosphamide / rituximab — TM engine drives cord workup + steroid pulse + PLEX (route to rheum.sle-flare.core.v1)
- [LIFE_THREATENING] Spinal cord infarct — anterior cord syndrome (bilateral motor + pain/temp loss with preserved dorsal column proprioception/vibration); sudden onset (<4 h to peak); vascular RFs (atherosclerosis, AAA repair, hypotension, hypercoagulable, fibrocartilage embolism); STAT MRI cord; route to neuro.ischaemic-stroke.v1

Citations

- 2002 Transverse Myelitis Consortium Working Group (TMCWG) Clinical Criteria + 2015 Wingerchuk NMOSD Diagnostic Criteria + 2023 Banwell MOGAD Diagnostic Criteria + 2011 ApolyDS Magaña PLEX Class I AAN + CDC Lyme Borreliosis + Pidcock 2007 Post-Infectious TM + Beh 2013 TM Review Neurol Clin [PMID:12236201](https://pubmed.ncbi.nlm.nih.gov/12236201/)
- Cited evidence (PMID 26092914) [PMID:26092914](https://pubmed.ncbi.nlm.nih.gov/26092914/)
- Cited evidence (PMID 36706773) [PMID:36706773](https://pubmed.ncbi.nlm.nih.gov/36706773/)
- Cited evidence (PMID 10589540) [PMID:10589540](https://pubmed.ncbi.nlm.nih.gov/10589540/)
- Cited evidence (PMID 27931077) [PMID:27931077](https://pubmed.ncbi.nlm.nih.gov/27931077/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2002 Transverse Myelitis Consortium Working Group (TMCWG) Clinical Criteria + 2015 Wingerchuk NMOSD Diagnostic Criteria + 2023 Banwell MOGAD Diagnostic Criteria + 2011 ApolyDS Magaña PLEX Class I AAN + CDC Lyme Borreliosis + Pidcock 2007 Post-Infectious TM + Beh 2013 TM Review Neurol Clin — PMID:12236201
  • Cited evidence (PMID 26092914) — PMID:26092914
  • Cited evidence (PMID 36706773) — PMID:36706773
  • Cited evidence (PMID 10589540) — PMID:10589540
  • Cited evidence (PMID 27931077) — PMID:27931077